Family health care manual 2016

Family Health Care Manual
[Updated on January 2016]
Department of Community Medicine
North Bengal Medical College
Sushruta Nagar, Darjeeling

COMPLETION CERTIFICATE
This is to certify that Mr./Ms.
Name of the student:
Roll No.:
University Roll No:
Session:
Registration No:
Completed his/her Family Health Care Program.
Teacher-in-charge Head of the Department:

List of contributors of 1st Edition
Prof. Manasi Chakraborty
Prof. R.N. Bhattacharya
Prof. Dilip Kumar Das
Dr. Romy Biswas
Dr. Aditi Aikat
Dr. Priti Bikas Haldar
Dr. Partha Pratim Pal
Dr. Tapas Kumar Sarkar
Dr. Kuntala Ray
Dr. Jayanta Kumar Roy
Dr. Sharmistha Bhattacherjee
Dr. Fasihul Akbar
Dr. Kingsuk Sarkar
Dr. Louis Tirkey
Dr. Nilanjana Ghosh
Dr. Anamika Verma
Dr. Maumita De
Dr. Sasthi narayan Chakraborty
Dr. Abir Bandyopadhyay
List of contributors in updated version
Prof. Samir Dasgupta
Dr. Tushar Kanti saha
Dr. Abhijit Mukherjee
Dr. Kaushik Ishore
Dr. Pallabi Dasgupta

Dedicated to the
Students and the Community

Chapter 1: FAMILY HEALTH CARE PROGRAM
I. INTRODUCTION
The principle of community medicine is to ameliorate individual's life in his or her family through
their own efforts in a supportive environment. Community physician plays a significant role in
creating this supportive environment. The clinical knowledge and experience and his or her
understanding of epidemiology of diseases and social medicine are the basic components of
package of services that is offered to the sufferer or ignorant person in his/her family.
There are three steps in making proper diagnosis. The first is to establish the clinical features by
history taking, physical examination and appropriate investigations. This is clinical database. The
second step is studying the human ecology by taking history of other family members and of those
who are vulnerable. This includes the nutritional history, social problem history and environmental
history. The third step is interpretation of these data in terms of disordered function an structure
within individual and family, and then in terms of pathology including social pathology. Similarly
solution of the problem needs to be more comprehensive involving not only treatment of sufferer
but also handling other associated factors in the family and community.
Objectives of Family Health Care Program:
1. To understand that health has the components of physical, mental and social well-being and
not merely an absence of disease or infirmity.
2. To study the natural history of the disease or condition in the perspective of the community
and family
3. To learn environmental, socio-economic, behavioral and cultural factors which may have an
influence on health.
4. To study the health care-seeking behaviors including the utilization of health services and
attitude towards the services provided to them.
5. To develop communication skills of medical students and their ability to establish doctor-
patient relationship
6. To learn the management of patient in the family environment with locally available
resources.
7. To develop the ability to identify health problems and needs of the community
8. To arrive at a family diagnosis and take appropriate measures.
9. To deliver comprehensive health care to the people
10. To develop the qualities of confidence, self reliance, sense of responsibility and leadership in
medical students.
11. To learn the qualities of a good family physician.

Points to remember during family visit:
 Be presentable and wear an apron during family field visits.
 Introduce yourself.
 Tell the purpose of your visit.
 Be polite, modest and friendly with the community and the family.
 Never make false promises to the family members during the work period.
 In case of non-cooperation and any difficult consult your guide immediately.
 Always carry stethoscope, sphygmomanometer, weighing machine, hammer, tape, torch etc
when visiting the family.
 Give them adequate information about the available services and allow them to express
themselves.
 In case of minor ailments diagnosed during your visit, suggest appropriate treatment.
 Counsel for dietary intake, feeding practices, hygiene, immunization, pregnancy care,
contraception etc. as relevant for the family
 If any family member has any clinical condition requiring intervention at NBMCH, try to help
and facilitate the services from NBMCH.
 Respect the family members and try to learn from them.

Important Definitions:
Family: It is a group of individuals living together related either biologically or by marriage or by
adoption and eating from a common kitchen
Types of families:
 Nuclear family: It consists of the married couple and their dependent children.
 Joint family: It consists of married couples and their children living in the same household.
 Three generation family: It is a household where there are representatives of 3 generation-
consisting of parents, their married children and grand children.
Household: An aggregate of persons, generally but not necessarily bound by ties of kinship, which
live together under the same roof and eat together or share in common the household food.
Members comprise the head of the household, relatives living with him/her, and other persons who
share the community life for reasons of work or other consideration.
Community: A group of individuals and families living together in a defined geographic area,
comprising a village, town or city and usually linked by common interests. The characteristics of a
community are:
 People live together
 People co-operate to satisfy basic needs
 There are common organizations like: markets, schools, stores, bank and hospitals
Thus a Community is a network of human relationships and a major functioning unit of society.
Community Diagnosis: The pattern of disease in a community described in terms of the important
factors which influence this pattern. It is based on collection and interpretation of relevant data
such as age and sex distribution of the population, vital statistics rates, incidence and prevalence of
important diseases in the community of the area.
Society: It may be defined simply as an organization of member agents. The outstanding feature is a
system of social relationship between individuals. It is dynamic and changes over time and place. It
controls and regulates the behavior of the individual both by law and customs.
Health Care: Multitude of services rendered to individuals, families or communities by the agents of
health services or professions, for the purpose of promoting, maintaining, monitoring or restoring
health.
Medical Care: Refers chiefly to those personal services that are provided directly by physicians or
rendered as a result of the physician's instruction. Medical care is a subset of health care system.
Primary health Care: Essential health care based on practical, scientifically sound and socially
acceptable methods and technology made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and the country can
afford to maintain at every stage of their development in the spirit of self determination.

Chapter 2: COMMUNITY SURVEY
Name of the village:
Block: District:
Distance from North Bengal Medical College:
Demography:
Age group Population
Sex Ratio:
Vital Events in last one year:
 Total Deaths :
 Total Live Births :
 Total Infant Deaths :
 Total Maternal Deaths:
Environmental Sanitation:
 Refuse disposal : Dumping / Manure pit / Others (specify)
 Drainage facility : Kutcha / Pucca / Mixed / Absent
 Water-logging : Present / Absent
 Water supply :
 Main Source : Wells / River / Tubewells / Others (specify)
Common health problems in this community:
Health Services:
 Subcentre :
 Anganwadi Centre :
 Hospital :
 PHC/BPHC:

Other facilities:
 Schools : Present / Absent
 Playground : Present / Absent
 Parks : Present / Absent
 Electricity: Present / Absent
Comment:
SCHEMATIC MAP OF THE VILLAGE:

Chapter 3: GENERAL SOCIO-ECONOMIC CHARACTERISTICS OF
THE FAMILY
3.1. IDENTIFICATION:
Name of the head of the family:________________________________ Type of family: Nuclear / Joint
Address:____________________________________________________________________________
Religion: ____________________________________ Caste:____________________
Place of Origin:______________________________ Length of stay:________
Particulars of the family members:
S.No.
Names
Begin with Head of the family
(HOF)
Relation
toHOF
Age
Sex
Marital
status
Education
Occupation
Physical
activity
Physiologic
alStatus
HOF
3.2. MONTHLY INCOME OF THE FAMILY: (in rupees) ___________________________
Per capita monthly income: __________________________
3.3 MONTHLY EXPENDITURE OF THE FAMILY: (in rupees)
Food ………………………………………
Fuel ………………………………………
Clothing ………………………………………
Education ………………………………………
Electricity ………………………………………

Housing (Rent / maintenance / taxes) ……….................................
Social functions (marriage, festivals etc. ) ……....................................
Health & Illness ………………………………......
Travel / Transport ………………………………......
Recreation (Cinema, games etc) ………………......................
Any other expenditure …………………………...........
Total : __________________
Make pie diagram for expenditure of the family:
3.4. BALANCE OF INCOME OVER EXPENDITURE: Rs. ______________________
3.5. USING STANDARD SCALE, DETERMINE THE S.E.S. OF THE FAMILY
3.6. AMENITIES AND RECREATIONAL FACILITIES:
 Source of information: Newspaper / Radio /TV /Group meeting / Others (specify)
 Possession of: Bicycle / Motorcycle / Electricity / Fan / Radio / TV / Mobile / Telephone
/ Others (specify) …………………………………
 How do they pass their free time?
3.7. SOCIAL PROBLEM in the family (If any):

GUIDELINES FOR CHAPTER 3
Head of the family (HOF): A person who is the principal earning member of the family
Place of origin: If the family is staying in the present area for less than 30 yrs.
Particulars of family members:
Age: For under-five children, record age in completed months, and for others, in completed years.
Sex: Record as M=male or F=female.
Marital Status: Unmarried/Married/ Divorced/ Widow / Widower
Education level:
 Illiterate: A person more than 7 yrs who cannot read or write with understanding in any
language.
 Literate Non-formal: Those who can read or write but have no formal schooling.
 Literate with formal schooling: Mention the highest education status attained.
Occupation: The occupation that is considered to be principal by the respondent.
 Unemployed: If any person of 14- 60 years of age and not engaged in any paid work
 Professionals: The highest social status is for professions like legal, medical or engineering.
 Business: Traders who maintain petty shops and are engaged in small trade and business
activities.
 Skilled workers: Occupations like tailors, carpenter, blacksmith, washer man, potter, beedi
worker etc. can be included. Usually include artisans who follow their family occupation.
 Unskilled workers: Those who are casual workers and are engaged by others on wages. Usually
they get wages on daily basis and maintain their family on such income.
Physical activity: Mention type of activity as sedentary/moderate/heavy. Examples would be:
 Sedentary: Teachers, doctors, lawyers, executives, students, clerks, shopkeepers, tailors,
barbers, shoemakers, priests, landlords, postmen, nurses, housewives etc.
 Moderate: Fisherman, basket-makers, weavers, potters, goldsmiths, carpenters, masons,
agricultural laborers, rickshaw-pullers, electricians, fitters, turners, welders, industrial laborers,
coolies, drivers, maid-servants, beedi-makers etc.
 Heavy: Wood-cutters, stone-cutters, blacksmiths, miners, gang-men etc.
Physiological status:
For women of reproductive age group: P = pregnant, L = lactating, NP & NL = non-pregnant and non-
lactating

DETERMINATION OF SOCIO ECONOMIC STATUS OF THE FAMILY:
Socio-economic status can be defined as the position that the individual or family occupies with
reference to the prevailing average standard of culture and material possession income and
participation in a group activity of the community. Socio-economic standard of people is conventionally
expressed in terms of various social classes in which people are distributed which are referred to as
social stratification. Social stratification is a horizontal division of society in to several socio-economic
layers: each layer or social class has a comparable standard of living, status and life style. Social class is
determined on the basis of three parameters of development, namely education, occupation and
income.
Socioeconomic scales commonly used are:
1. Modified Kuppuswamy’s Scale: For urban areas
Education of the
head of the family
Score Occupation Score Family Income per
month
Score
Professional degree 7 Professional 10 >21,660 12
Graduate 6 Semi-professional 6 10830-21659 10
Intermediate/Diploma 5 Clerical/shop/farm 5 8122-10829 6
High school 4 Skilled worker 4 5415-8121 4
Middle school 3 Semi skilled 3 3249-5414 3
Primary 2 Unskilled 2 1093-3248 2
Illiterate 1 Unemployed 1 <1093 1
Total score Class Description
26-29 I Upper class
16-25 II Upper middle
11-15 III Lower middle
5-10 IV Upper lower
Below 5 V Lower
2. Modified Prasad’s Scale: Dr. B G Prasad’s social classification was developed in 1961 and is
based on per capita per month income. There are five classes, as follows- Upper class (per capita
per month income Rs 100 and above); Upper middle ( 50-99); Lower middle ( 30-49); Upper
lower ( 15- 29); and Lower (below 15). The income group can be recalculated by multiplying the
above mentioned income as mentioned in Prasad’s classification with P Kumar’s conversion
factor i.e.
Conversion factor = (Value of CPI X 4.93) ÷ 100
For example, the AICPI for December 2015 was 857 (rural labor). Thus the conversion factor will
be (4.93 X 857) ÷ 100 =42.3

Per capita monthly income limits (Rs.):
Social class Prasad classification 1961 Prasad classification for Dec 2015
I 100- above ≥ 4230
II 50-99 2115-4229
III 30-49 1269- 2114
IV 15-29 635- 1268
V Below 15 < 635
3. Pareek’s Scale: The Socio-Economic Scale (rural) developed by Pareek attempts to measure
socio-economic status of a rural family. It is based on the nine items as follows : Caste;
Occupation of head of family; Education; Levels of social participation; Land holding; Farm
power (prestige animals); Housing; Material possessions; and, Family type. The combined score
for the nine items is graded to indicate socio-economic class categories.
Examples of Social Problems:
 Addiction: Cigarette /beedi, khaini, betel leaves with zarda, alcohol.
 Illiteracy :
 Unemployment :
 Working mother without any caregiver of the children :
 Teenage Pregnancy :
 Child labor: Below 14 years of age, if a child is engaged in a work (inside the family or
outside).
 School dropout: within the age of schooling (5 to 14 years), if a child is absent from
school for three consecutive months except vacation.

Chapter 4: ENVIRONMENTAL CHARACTERISTICS OF THE
FAMILY
4.1. HOUSING:
Site:
Type: Pucca / Kutcha / Kutcha-pucca:
Number of living rooms:
Total area of living rooms (floor space):
Per capita floor space:
Set Back:
Comment on overcrowding:
Cross-ventilation: present / absent
Lighting: adequate / inadequate.
Kitchen: in a separate room / in living room / on verandah.
Smoke Outlet: present / absent
Type of fuel used:
Storage of food: proper / improper.
Domestic animals: cattle / goat / sheep / fowl.
Location of animal shelter (if any):
Kitchen garden: present / absent.
If present, does the family consume / sell / do both with the produce?
Comment on drainage system in and around the house:
Comment on drainage of household wastewater:

4.2. WATER SUPPLY
Source of water:
 Drinking purpose: Tube well / Dug well/ tap (personal/public)/ pond / river /others
(specify).
 For other domestic purpose: Tube well / Dug well/ tap (personal/public)/ pond / river
/others (specify).
 Distance of drinking water source (if outside house) :
 Duration of supply: continuous / intermittent.
 Adequacy of supply: adequate / inadequate.
 Comment on drinking water :
o Source
o Carriage
o Storage :
o Special treatment (if any) :
4.3. EXCRETA DISPOSAL
 Latrine:
o Within house / outside house / not present:
o Sanitary / unsanitary
o No. of users :
 Where the family members (including children) go to defecate: Sanitary latrine / open
field / others (specify).
4.4. REFUSE DISPOSAL:
 How do people dispose of refuse: throw indiscriminately / common pit / collected in
container / burning /composting / municipal service/others (specify).
 How is the kitchen waste disposed :
 Fly nuisance: present / absent. (Observe and comment on breeding places of mosquito)

HOUSING: “Housing refers not only to the physical structure providing shelter, but also the immediate
surroundings. “Human settlement” is defined as “all places in which a group of people reside and
pursue their life goals”. The size of the settlement may vary from a single family to millions of people.
Housing may be of the following types:
 Pucca house: Floor: paved, Walls: Stone or brick built, Roof: Tin, asbestos or concrete
 Kutcha house:Floor: Packed earth, Walls: Dried mud or thatched, Roof: Thatched/ slate/stones.
 Kutcha Pucca house: Any combination of the two types
CRITERIA FOR HEALTHFUL HOUSING
1. Healthful housing provides physical protection and shelter.
2. Provides adequately for cooking, eating, washing and excretory functions.
3. Should be designed, constructed and maintained and used in such a manner such as to prevent
the spread of communicable diseases.
4. Free from unsafe physical arrangements due to construction or maintenance and from toxic or
harmful materials. Provides protection from hazards of exposure from noise and pollution.
5. Encourages personal and community development, promotes social relationships, reflects a
regard for ecological principles and by these means promotes mental health.
CRITERIA FOR OVERCROWDING
It refers to a situation where more people are living within a house than there is space for. This leads to
restricted movements, loss of privacy, rest and sleep becomes difficult. Infectious disease spread rapidly
in conditions of overcrowding. There are also psychosocial effects like irritability, frustration, anxiety,
violence and mental disorders. Overcrowding may be expressed in 3 parameters.
A. PERSONS PER ROOM: The accepted norms with respect to overcrowding are:
 1 Room: 2 persons.
 2 Rooms: 3 persons.
 5 or more rooms: 10 persons (additional 2 for each further room)
B. FLOOR SPACE: The accepted standards are-
 110 sq. ft. (11 sq. m.) or more: 2 persons.
 90-100 sq. ft. (9-10 sq. m.): 1 ½ persons.
 70-90 sq. ft. (7-9 sq. m.): 1 person.
 50-70 sq. ft. (5-7 sq. m.): ½ person.
 Under 50 sq. ft. (5 sq. m.): nil.
A baby under 12 months is not counted, children between 1 to 10 years are counted as ½ unit.
C. SEX SEPARATION: Overcrowding is considered if 2 persons over 9 years of age, not husband and
wife, of opposite sexes are obliged to sleep in the same room.

CRITERIA FOR SANITARY LATRINE:
1. Excreta should not contaminate the ground or surface water
2. Excreta should not pollute the soil
3. Excreta should not be accessible to flies, rodents, animals and other vehicles of transmission
4. Excreta should not create a nuisance due to odor or unsightly appearance
SANITARY WELL
A sanitary well is one which is properly located, well constructed and protected against contamination
with a view to yield a supply of safe water. The following points should be taken into consideration
while constructing sanitary wells:
(1) Location: To avoid bacterial contamination, the well should be located not less than 15m (50feet)
from likely sources of contamination. The well should be located at a higher elevation with respect
to a possible source of contamination.
The distance between the well and the houses of the users should also be considered. The well
should be so located that no user will have to carry water for more than 100m (100yards).
(2) Lining: The lining of the well should be built of bricks or stones set in cement upto a depth of at least
6m (20feet). The lining should be carried 60-90 cm (2-3 feet) above the ground level.
(3) Parapet Wall:
There should be a parapet wall up to a height of at least 70-75cms (28inches) above the ground.
(4) Platform
There should be a cement-concrete platform round the well extending at least 1m (3feet) in all
directions. The platform should have a gentle slope outwards towards a drain built along its edges.
(5) Drain
There should be a pucca drain to carry off spilled water to a public drain or a soakage pit.
(6) Covering
The top of the well should be closed by a cement concrete cover.
(7) Hand-Pump
The well should be equipped with a hand-pump for lifting the water, in a sanitary manner.
(8) Consumer Responsibility
Strict cleanliness should be enforced in the vicinity of the well; Personal ablutions, washing of
clothes and animals, and the dumping of refuse and wastes should be prohibited. Ropes and buckets
from individual homes should not be used for drawing a supply from the well. Water from the well
should be carried in clean sanitary vessels.
(9) Quality
The physical, chemical and bacteriological quality of water should conform to the acceptable
standards of quality of safe and wholesome water.

Chapter 5: FAMILY'S KNOWLEDGE AND PRACTICE ON HEALTH
AND UTILIZATION OF HEALTH CARE SERVICES
5.1. COMMON COMMUNICABLE DISEASES:
DIARRHOEA: Knowledge Practice
Signs and symptoms
Causation &
Transmission
Modes of Prevention
Care seeking behavior
ARI: Knowledge Practice
Signs and symptoms
Causation &
Transmission
Modes of Prevention

TUBERCULOSIS Knowledge Practice
Signs and symptoms
Causation &
Transmission
Modes of Prevention
MALARIA: Knowledge Practice
Signs and symptoms
Causation &
Transmission
Modes of Prevention

LEPROSY: Knowledge Practice
Signs and symptoms
Causation &
Transmission
Modes of Prevention
HIV/AIDS: Knowledge Practice
Signs and symptoms
Causation&
Transmission
Modes of Prevention
Care seeking behaviour

5.2. NON COMMUNICABLE DISEASES:
HYPERTENSION Knowledge Practice
Signs and symptoms
Risk Factors
Modes of Prevention
DIABETES Knowledge Practice
Signs and symptoms
Risk Factors
Modes of Prevention
ANY OTHER DISEASE Knowledge Practice
Signs and symptoms
Causation & Transmission
Modes of Prevention

5.3. MICRONUTRIENT DEFICIENCY DISORDERS
IODINE DEFICIENCY DISORDERS Knowledge Practice
Signs and symptoms
Causation
Modes of Prevention
NUTRITONAL ANAEMIA Knowledge Practice
Signs and symptoms
Causation
Modes of Prevention
VIT. A DEFICIENCY DISORDERS Knowledge Practice
Signs and symptoms
Causation
Modes of Prevention

5.4. Knowledge and Practice of Reproductive and Child Health
5.4. I. Infant feeding practices:
Knowledge Practice
Importance of colostrums
Initiation of breast feeding
Prelacteal feeding
Exclusive breast
feeding
Importance
Duration
Timely Complementary
Feeding
Importance
Duration
Continuation of breast feeding
Feeding during illness
5.4.II. Antenatal, natal and postnatal care:
Knowledge Practice
Antenatal Importance of regular check up.
Iron & Folic acid prophylaxis.
Tetanus Toxoid
Diet.
Rest
Natal Safe delivery
Post natal Number of visits & Importance
5.4.III. Immunization:
Knowledge Practice
Common vaccine preventable diseases
Importance and timing of immunization
5.4.IV. Contraception & family planning:
Knowledge Practice
Ideal age of marriage (for boys and girls)
Age at pregnancy.
Interval between pregnancies.
Number of children, etc
Family Planning methods

5.4.V. Awareness and Utilization of National Programs
Awareness Utilization
ICDS
JSY/ JSSK
Social Assistance Schemes
IPPI
NIPI
RBSK
Sarva Shiksha Abhiyan
Any Other (Specify)
5.4. VI. Enquire about and comment on the following:
Reasons for non-utilization / discontinuation of family planning methods (if any)
Reasons for non-immunization / partial immunization (if any)
5.4. VII. Visit to Health Centers / Hospitals:
Frequency: Regular / Frequent / Occasionally / None.
Purpose of visit: Treatment / FP services / MCH care / Immunization / Others (specify)
If health facilities are not visited regularly, what are the reasons?
 Time consuming
 Inconvenient timing
 No faith
 Staff not cooperative
 Staff not available
 No supply of medicines
 Others (specify).

GUIDELINES FOR CHAPTER 5:
Communicable diseases:
Diarrhoea: Diarrhoea is defined as passage of liquid/watery stools. The recent change in the consistency
and character of stools is the most important feature rather than the frequency of stool. It is usually a
symptom of gastrointestinal infection, which can be caused by a variety of bacterial, viral and parasitic
organisms. Infection is spread through contaminated food or drinking-water, or from person to person
as a result of poor hygiene.
 Acute watery diarrhea: Starts suddenly and may continue to a no. of days, but not more than 14
days. Usually self-limiting, may last for 3-7 days
 Dysentery: Acute watery diarrhea with visible blood in stool.
 Persistent diarrhea: Begins acutely but is unusually of long durations, lasting more than 14 days
Pasty stool in a breast fed baby and passage of a stool during or immediately after feeding should not be
considered as diarrhea.
Acute Respiratory Infections: An acute infection of any part of the respiratory tract and related
structures including paranasal sinuses, middle ear and pleural cavity. It includes all infections of less than
30 days duration, except otitis media where the duration of an acute episode is less than 14 days.
Tuberculosis: is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most
commonly affects the lungs. It is transmitted from person to person via droplets from the throat and
lungs of people with the active respiratory disease. Any person with
 Cough of more than 2 weeks duration and with at least 1 of 2 initial sputum smear examinations
(direct smear microscopy) positive for AFB. Often associated with
o Fever
o Wt loss
 X-ray may show infiltration/ fibrocavitary changes
 Laboratory criteria for diagnosis:
o Sputum positive for AFB in 1 out of 2 sputum smear examination
o Sputum positive for AFB in at least 1 out of 2 smear examination with X-ray evidence of
TB
o Sputum culture grows Acid Fast Bacilli
Malaria: Malaria is caused by a parasite called Plasmodium, which is transmitted via the bites of
infected mosquitoes. Malaria should be considered in any patient who presents with Fever and any 2 of
the following.
 Chills, Sweating, Jaundice, Splenomegaly
 Convulsions, Coma, shock, pulmonary edema and death may be associated in severe cases
 Laboratory criteria for diagnosis
o Demonstration of Malaria Parasite in blood film OR
o Positive Rapid Diagnostic Test for Malaria

HIV/AIDS: The human immunodeficiency virus (HIV) is a retrovirus that infects cells of the immune
system, destroying or impairing their function. The most advanced stage of HIV infection is acquired
immunodeficiency syndrome (AIDS).
HIV is transmitted through unprotected sexual intercourse (anal or vaginal), transfusion of
contaminated blood, sharing of contaminated needles, and between a mother and her infant during
pregnancy, childbirth and breastfeeding.
Reproductive and Child Health Services:
A. MATERNAL HEALTH
i. ANTE NATAL CARE: constitutes screening for health and socioeconomic conditions likely
to increase the possibility of specific adverse pregnancy outcomes, providing
therapeutic interventions known to be effective; and educating pregnant women about
planning for safe birth, emergencies during pregnancy and how to deal with them.
1. All pregnancies have to be registered at least before 12 weeks by health worker.
2. Pregnant woman must be given two doses of tetanus toxoid immunization.
3. Pregnant woman must be given Iron & Folic Acid tablets for prevention & treatment
of anemia.
4. Pregnant woman must be given three antenatal check ups other than registration.
ii. INTRANATAL CARE:
1. Institutional Deliveries must be encouraged by skilled birth attendant in safe &
hygienic surroundings (7 cleans).
2. Referrals should be made to First Referral Units for management of obstetric
emergencies
iii. POST NATAL CARE: Begins after third stage of labour till 6 weeks after delivery
Pregnant woman must be given 2 postnatal checkups. Spacing of at least three years
between children must be encouraged. Advice on breast feeding and immunization of the
child.
B. CHILD CARE:
 Essential Newborn Care:
1. Breathing:
 If the baby is crying vigorously or breathing adequately, then no intervention
If the baby is not breathing or gasping, then skilled care in the form of positive pressure
ventilation etc. (i.e. RESUSCITATION) would be required as needed.
FOUR basic needs at birth:
 Normal breathing
 Thermal protection
 Protection from infection
 Breast milk

2. Thermal Protection:
3. Protection from infection:
 T.T. immunization of the mother
 Clean & safe delivery practices
 No prelacteal feeds & exclusive breast feeding
 Immunization
4. Feeding of Infants
 Initiation of breastfeeding within the first hour of life
 Exclusive breastfeeding for 6 months
 Breastfeeding on demand – that is as often as the child wants, day and night
 Continue breastfeeding for up to 2 years of age or beyond
 No use of bottles, teats or pacifiers
WARM CHAIN- 10 interlinked procedures to prevent hypothermia
 Ensure the delivery room is warm (>25o
C), with no draughts
 Dry the baby immediately; remove the wet cloth
 Warm resuscitation
 Immediate skin to skin contact
 Initiate breast feeding
 Postpone bathing/ sponging for 24 hrs
 Wrap the baby with clean dry cloth
 Keep the baby close to the mother
 Warm transport
 Professional alert
SUCCESSFUL BREAST FEEDING
Key points of positioning
 Mother:
o Make the mother sit in a comfortable and convenient position
o Ensure that she is relaxed and comfortable
 Baby:
o Baby’s head and body are in a straight line
o Baby’s whole body is supported
o Baby’s face is opposite the nipple and the breast
o Baby’s abdomen touches mother’s abdomen
Key points of good attachment
 Baby’s mouth is wide open
 Baby’s chin touches the breast
 Baby’s lower lip is curled outward
 The lower portion of the areola is not visible

SOME IMPORTANT DEFINITIONS
 Colostrum is the special milk that is secreted in thefirst 2–3 days after delivery. Colostrum is
rich in white cells and antibodies, especially IgA, and it contains a larger percentage of protein,
minerals and fat-soluble vitamins (A, E and K) than later milk. WHO universally recommends
colostrum, a mother's first milk or the 'very first food', as the perfect food for every newborn.
 Exclusive breastfeeding: It means that except for breast milk or expressed breast milk no other
food or fluid including water and prelacteal feeds should be given to the child till 6 months of
age Medicines can be given, if indicated.The baby should not even have a pacifier or dummy.
 Predominant breastfeeding: In addition to breast milk, the infant may also have received water
and water-based drinks (sweetened and flavored water, teas, infusions, etc.), fruit juice; oral
rehydration salts solution (ORS), drop and syrup forms of vitamins, minerals and medicines,etc.
 Timely Complementary Feeding: Introduction of semisolid feeding for infants at the age of 6
months in addition to the usual breast milk, not merely change from one milk to another.
 Artificial Feeding: the infant is given breastmilk substitutes and not breastfeeding at all.
 Replacement Feeding: is the process of feeding a child who is not breastfeeding with a diet that
provides all the nutrients the child needs until the child is fully fed on family diet
 Partial Breastfeeding or Mixed Feeding: the infant is given some breast feeds and some
artificial feeds, either milk or cereal, or other food or water.
 Bottle-Feeding: the infant is feeding from a bottle, regardless of its contents, including
expressed breast milk.

Chapter 6: NUTRITIONAL PROFILE OF THE FAMILY
Calculate the number of consumption units in the family:
6.1. Schedule for Oral Questionnaire (Recall) Method of Diet Survey:
Food groups Food Items Quantity
[gm. / ml.]
Intake of food
group per CU per
day[gm/ml]
RDA of food group
per CU per
day[gm/ml]
Remarks
CEREALS Rice
Wheat
PULSES 1.
2.
GREEN LEAFY
VEGETABLES
(specify)
1.
2.
3.
ROOTS & TUBERS
(specify)
1.
2.
3.
OTHER
VEGETABLES
(specify)
1.
2.
3.
FRUITS 1
MILK & MILK
PRODUCTS
1.
2.
FLESH FOODS 1.Egg.
2.Fish
3.Meat
FATS & OILS
(specify)
1.
2.
SUGAR & JAGGERY 1.Sugar
2.Jaggery
NUTS &
OILSEEDS
1.Groundnut
2.Coconut
MISCELLEANEOUS 1.
2.

6.2. NUTRIENT INTAKE SHEET:
Foodstuffs Quantity
gm or ml
Calories Protein Iron Vit A
(Carotene)
Thiamin Riboflavin Vit C
Total consumption

6.3. DAILY NUTRITIONAL REQUIREMENTS OF THE FAMILY
Person Calories
(Kcal)
Protein
(gm)
Iron
(mg)
Vit.A
(mcg)
Thiamin
(mg)
Riboflavin
(mg)
Vit.C
(mg)
ADULTS:
1.Male
2.Female
3.Pregnant Women
4.Lactating women
ADOLESCENTS
10 – 12 B
G
13 –15 B
G
16 – 17 B
G
INFANTS & CHILDREN
< 1 Yr.
1 – 3 Yr.
4 – 6 Yr.
7 -- 9 Yr.
Total daily
requirements
Total daily
consumption
Deficit/
Surplus
Qty
wise
% wise

METHODS FOR NUTRITIONAL STATUS ASSESSMENT
a. Clinical examination for nutritional deficiency signs
b. Anthropometry or body measurements
c. Diet surveys
d. Biochemical tests
e. Vital statistics such as mortality and morbidity rates
Out of these, first 3 methods are usually suitable for application in field conditions.
CLINICAL EXAMINATION
This is one of the simplest techniques to assess malnutrition and is relatively inexpensive. But the
method can detect only small number of clinically manifest cases while large numbers of clinically in
apparent cases of malnutrition remain unidentified in the community.
ANTHROPOMETRY OR BODY MEASUREMENTS
It is the most widely used means to assess nutritional status (particularly in children). The most
commonly used and simple body measurements are – weight, height and mid-arm circumference. Using
these measurements, following parameters are usually calculated:
 Weight for age
 Weight for height
 Height for age, etc.
However, use of anthropometric measurements depends on two factors:
 Accurate assessment of age
 Appropriate reference values for comparison/ growth charts
DIET SURVEY
IMPORTANCE: Diet has a far reaching influence on health status. It is essential to have an idea of dietary
pattern in the community along with their nutritional assessment.
PURPOSE:
 To know what people eat – both quantitatively and qualitatively.
 To know inadequacies in existing dietary pattern.
 To find out relationship, if any, between health status and diet consumed by the family.
 To suggest improvement of existing pattern of diet of the family.

METHODS:
 Weighment method – a. Raw food b. Cooked food
 Method is accurate and gives a definite idea of dietary consumption pattern of the family.
 Time consuming and dependent on cooperation of the people surveyed. Unless people are
properly motivated they will not give requisite cooperation.
 In Indian culture most of the families would not like cooked food to be weighed before
consumption. So weighing of cooked food is culturally unacceptable.
 Questionnaire method:
 Family: Family members are asked to recall intake of individual food items in last 24 hours.
 Individual: for assessment of individual intake, a set of standardized measured utensils (e.g.
a set of cups, vessels, spoons etc.) are used to assess intake of different food items.
Merits and demerits:
 One-day recall method of dietary survey is usually practiced in field conditions as it is easier,
less time consuming and provides reasonably good results, provided enquiries are made in
details.
 Depends on ability of family members to correctly recall foodstuffs consumed by them.
 Inventory method (Food listing method):
 It is only an estimate of previous week’s store of foodstuffs – not a direct measurement.
 Illiteracy is a constraint – not suitable in developing countries where literacy status is
generally poor and purchase of food items by the family does not follow any regularity.
 Suitable method for hostels where food items are purchased and stored for weeks or
months in advance.
Some important points related to diet survey:
1. The day of survey should be planned in such a way that festive holidays are not included.
2. In case of any unknown or uncommon food prepared and consumed by the family, it is better to
record the total amount of the constituents only required for the preparation of that food.
3. Collect information on meals /snacks taken outside the home as well as quantity of supplements
from any feeding programs, for the calculation of food items consumed by the family.
4. The dietary intake may be expressed in terms of consumption unit per day or per person per
day.
5. Age and sex composition of all members in the family should be recorded, as requirement and
intake of nutrients may vary accordingly.
6. Number of absentees/servants/guests in the family should be taken into account for calculation
of total consumption unit in the family. Number of pregnant /lactating women in the family as
well as exclusively breast-fed infants should be noted for the purpose of calculation of nutrient
requirements.

CONSUMPTION UNIT: The energy consumption of an average male doing sedentary work is
taken as 1 CU and coefficients of other individuals are calculated on the basis of the calorie
requirements relative to that of the sedentary male.
1 CU= 2320 Kcal/day
GROUPS CONSUMPTION UNIT
Adult male sedentary worker 1
Adult male moderate worker 1.18
Adult male heavy worker 1.5
Adult female sedentary worker 0.82
Adult female moderate worker 0.96
Adult female heavy worker 1.23
16-17 yrs Boys 1.3
Girls 1.05
13-15 yrs Boys 1.18
Girls 1.04
10-12 yrs Boys 0.94
Girls 0.86
7-9 yrs 0.72
4-6 yrs 0.58
1-3 yrs 0.45
Pregnant Women 0.97
Lactating women 0-6 months 1.08
6-12 months 1.04

Chapter 7: HEALTH CHECK UP OF INDIVIDUAL FAMILY MEMBERS.
7.1: Under 5 child check up
7.1.1 Identification
Name of the child:___________________________________Sex: _______Age: _____________
7.1.2. Birth history:
Date of birth: ………………… Birth weight:. …………… Pre-term/ Full term: ………….
Place of delivery: …………………………….. Type of delivery: ………………………………….
Any congenital malformation? (specify): ……………………………………………………………
7.1.3. Feeding:
 Type of food first offered: ……………………………………………………………
 Any prelacteal feed: .......................... If yes, give reasons ________________________________
 When was breast feeding started after delivery? _____________________
 Was colostrum given to the baby? _______
 If no, give reasons: ………………………………………………………………
 When was breastfeeding started after delivery: ……………………………………………….
 Exclusive breastfeeding continued for: __________ months.
 If EBF continued for less than 6 months mention the reason/s:……………………………..
 Any liquid supplementation: ____________ If yes, what and when started________________
Reason/s: ____________________________________________________________________
 Any artificial feeding: ___________ If yes, give reasons _____________________________
 Is breastfeeding continuing till date? ______ If no, breast feeding continued upto____________
 Semisolid / solid food supplementation started from: _________ months.
 If started before 6 months or beyond 7 months, mention reason/s…………………………
 Type of semisolid/ solid food first offered: ……………………………………………..
 Type of food currently taken by the child: ……………………………………………………
 Frequency of meals(current practice): ____________ times per day
 Feeding Pattern during illness:
 Type: …………………………………………
 Amount: Same as before / increased / decreased.

7.1.4. IMMUNIZATION STATUS OF THE CHILD: BCG scar mark: Present/ Absent
Vaccine Age at vaccination (month) Place of vaccination
BCG
DPT-1/ Pentavalent-1
DPT- Booster
DPT- 2nd
Booster
OPV-0
OPV-1
OPV-2
OPV-3/ IPV
OPV-B
Hepatitis B-1
Hepatitis B-2
Hepatitis B-3
MCV and JE
MCV 2/ JE 2
Pulse Polio(number of doses)
Others
7.1.5. Nutritional Assessment:
7.1.5. A. Anthropometry:
Weight (kg)
Height (cm)
Mid-arm Circumference(cm)
7.1.5. B. Clinical examination:
Parameter Observation
1. General appearance
2. Hair/ Face/ Eyes
3. Lips/ Tongue/ Teeth/ Gums
4. Skin/ Nails
5. Glands/ Thyroid

6. Oedema/ visible wasting
7. Rachitic changes
8. Organomegaly
9. Calf tenderness
10. Ankle / Knee jerks
7.1.5. C. GROWTH MONITORING: (Attach growth chart)
7.1.6. CHIEF COMPLAINTS
7.1.7. HISTORY OF PRESENT ILLNESS:
7.1.8. HISTORY OF SIGNIFICANT PAST ILLNESS:
7.1.8. FINDINGS ON CLINICAL EXAMINATION:
General Survey:
Developmental milestones:
Systemic Examination:
7.1.9. LABORATORY INVESTIGATION (if any):
7.1.10. PROVISIONAL DIAGNOSIS:
7.1.11. MANAGEMENT:

7.1: Under 5 child check up
7.1.1 Identification
Name of the child:___________________________________Sex: _______Age: _____________
7.1.2. Birth history:
Date of birth: ………………… Birth weight:. …………… Pre-term/ Full term: ………….
Place of delivery: …………………………….. Type of delivery: ………………………………….
Any congenital malformation? (specify): ……………………………………………………………
7.1.3. Feeding:
 Type of food first offered: ……………………………………………………………
 Any prelacteal feed: .......................... If yes, give reasons ________________________________
 When was breast feeding started after delivery? _____________________
 Was colostrum given to the baby? _______
 If no, give reasons: ………………………………………………………………
 When was breastfeeding started after delivery: ……………………………………………….
 Exclusive breastfeeding continued for: __________ months.
 If EBF continued for less than 6 months mention the reason/s:……………………………..
 Any liquid supplementation: ____________ If yes, what and when started________________
Reason/s: ____________________________________________________________________
 Any artificial feeding: ___________ If yes, give reasons _____________________________
 Is breastfeeding continuing till date? ______ If no, breast feeding continued upto____________
 Semisolid / solid food supplementation started from: _________ months.
 If started before 6 months or beyond 7 months, mention reason/s…………………………
 Type of semisolid/ solid food first offered: ……………………………………………..
 Type of food currently taken by the child: ……………………………………………………
 Frequency of meals(current practice): ____________ times per day
 Feeding Pattern during illness:
 Type: …………………………………………
 Amount: Same as before / increased / decreased.

7.2. ANTENATAL / POST-NATAL CARE:
7.2.1. ANTENATAL AND DELIVERY RECORD:
7.2.1.A. IDENTIFICATION AND MENSTRUAL HISTORY:
Name: _______________________________ Date of registration:___________
Age: ________________ Married for ______________ Age at menarche_____________
Gravida______________ Para___________
LMP____________ EDD______________
7.2.1.B. HISTORY OF PREVIOUS PREGNANCIES
Order of
pregnancy
Age at
pregnancy
Outcome: Live
birth/ Still birth/
Abortion
Type of
delivery
Conducted
by
Complications,
if any
Present
state of
health
child/
7.2.1.C. HISTORY OF PRESENT PREGNANCY
Vomiting / Headache / Blurred vision / High BP / Swelling of feet.
Bleeding / Convulsion / Fever / Others (specify)
7.2.1.C. RELEVANT MEDICAL, SURGICAL, OBSTETRIC AND FAMILY HISTORY:

7.2.1.D. ANTENATAL CARE:
Parameter Visit-1 Visit-2 Visit-3
Date
Gestation period(weeks)
Height
Weight
Pallor
Oedema
B.P.
Fundal height
Lie
Presentation
FHS
Tetanus toxoid
Haemoglobin
Urine examination
Risk factors
Advice
7.2.2. POST NATAL CARE
7.2.2.1: MOTHER:
Day Date Pulse B.P. Temperature Lochia Fundal
Ht.
Breast Bowels Advice &
Treatment
7.2.2. 2. NEWBORN
Day Date Cord Eyes Feeding Stool Bath Any
problems
Advice &
treatment

Adolescent Health Check Up
7.3.1. IDENTIFICATION:
Name:_________________________________ Sex:_________________ Age:_____________
7.3.2 Classification: Early (10-13 yrs)/ Mid (14-16 yrs)/ Late (17-19 yrs)
7.3.3 COMPLAINTS WITH DURATION:
7.3.4 HISTORY OF PRESENT ILLNESS:
7.3.5 HISTORY OF SIGNIFICANT PAST ILLNESS:
7.3.6 PERSONAL HISTORY (Addiction/ Physical changes):
7.3.7 MENSTRUAL HISTORY:
7.3.8 VACCINATION HISTORY: JE/ TT/ HPV
7.3.9 FINDINGS ON CLINICAL EXAMINATION:
GENERAL SURVEY:
NUTRITIONAL ASSESSMENT:
SYSTEMIC EXAMINATION:
7.3.10 PROVISIONAL DIAGNOSIS:
7.3.11 MANAGEMENT:
KNOWLEDGE & PRACTICE OF ADOLESCENTS:
KNOWLEDGE PRACTICE
Adolescent Health Issues
Stress
Menstrual hygiene
RTI/STI
Contraception
Available health services
Adolescent clinic
WIFS
Deworming in school/ AWC

OTHER FAMILY MEMBERS
Name:_________________________________ Sex:_________________ Age:_____________
7.3.2. COMPLAINTS WITH DURATION
7.3.3 HISTORY OF PRESENT ILLNESS
7.3.4. HISTORY OF SIGNIFICANT PAST ILLNESS
7.3.5. MENSTRUAL HISTORY:
7.3.6. FINDINGS ON CLINICAL EXAMINATION
GENERAL SURVEY:
7.3.7. LABORATORY REPORTS (if any):
7.3.9. MANAGEMENT:
7.3. OTHER FAMILY MEMBERS
Name:_________________________________ Sex:_________________ Age:_____________

GENERAL SURVEY:
7.3.9. MANAGEMENT:
7.3. OTHER FAMILY MEMBERS
Name:_________________________________ Sex:_________________ Age:_____________
GENERAL SURVEY:
7.3.9. MANAGEMENT:

GERIATRIC HEALTH CHECK UP
Name:_________________________________ Sex:_________________ Age:_____________
7.3.2 Classification: Young old (60-75 yrs)/ Old old (above 75 yrs)
7.3.3 COMPLAINTS WITH DURATION:
7.3.4 HISTORY OF PRESENT ILLNESS:
7.3.5 HISTORY OF SIGNIFICANT PAST / CHRONIC ILLNESS:
7.3.6 PERSONAL HISTORY (Addiction/Sleep, appetite, bladder and bowel habit):
7.3.7 VACCINATION HISTORY (If any):
7.3.8 FINDINGS ON CLINICAL EXAMINATION:
GENERAL SURVEY:
SYSTEMIC EXAMINATION: Presence of any disability:
GERIATRIC HEALTH ISSUES:
Visual, auditory, locomotors problem if any:
7.3.10 MANAGEMENT:
KNOWLEDGE & PRACTICE OF THE GERIATRIC PERSON:
Available health services Knowledge Practice
Old age pension scheme
Schemes for widows

Chapter 9. MEDICO-SOCIAL DIAGNOSIS

Chapter 10. ACTIONS TAKEN BY THE TEAM

CHILDREN UNDER 2 MONTHS OF AGE

CHILDREN FROM 2 MONTHS TO 5 YEARS OF AGE

Adolescent health services under ARSH
“Our Family and community – a circle of strength
and health”
Department of Community Medicine

Family health care manual 2016

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