FAMILY VISIT

Comprehensive Guide for Community Health Field Visits

By Dr. Shuvro Bhattacharya
(i) FAMILY:
A group of people related biologically, by marriage or adoption, living under the same roof and
sharing a common kitchen.
It differs from ‘Household’. Household members are not all biologically related as for e.g., servants.
(ii) COMMUNITY:
A group of individuals or families who share common characteristics and/or interests like language,
culture norms, moral values etc. in a defined geographical area.
(iii) TYPES OF FAMILY:
• A) Nuclear family
• B) Joint family
(iii) NUCLEAR FAMILY:
A married couple with or without their dependent, unmarried children.
(iv) JOINT FAMILY:
Families which do not satisfy the criteria of nuclear family.
Head of Family (HOF):
The member chosen as principal decision maker by the family members themselves.
(Always not dependent upon age, sex, education or income)

Age:
Under-five in completed months, others by completed years.

Gender:
• Male – M
• Female – F
• Others – O

Marital status:
• Married – M
• Unmarried – UM
• Widow/widower – W
 • Divorced/Separated – D

Education:
In table mention last class passed.
• Illiterate (I): A person more than seven years age who cannot read/write in any language with
understanding.
• Below Primary (BP): Before passing Class V
• Primary (P): Class V passed
• Middle School (M): Class VIII passed
• Secondary (S): Class X passed
• Higher Secondary (HS): Class XII passed
• Graduate (G)
• Post Graduate & above (PG)
• Non-formal (NF): Literate, not attended school

Occupation:
• Unemployed: Not engaged in any gainful employment at age of 15 years & above excluding
students & housewives.
• Unskilled: Work not requiring education and/or training. e.g., Peon, watchman, coolie,
maid/servant, agricultural labour, construction labour etc.
• Semi-skilled: Need some training to do routine job efficiently. e.g., Factory labour, workshop
labour, laboratory attendant, library attendant, car cleaner.
• Skilled:
1. Specific training in complicated work. e.g., Mason, carpenter, mechanic, driver,
telephone operator, plumber, etc.
2. Training in arithmetic/reading/writing with repetitive work. e.g., Clerk, typist,
accountant.
3. Farm owner, Elementary school teacher, shopkeeper, station master, guard, news
correspondent, salesman, insurance agent.
• Semi-professional: Post High School/College education, jobs of routine nature.
e.g., High school teacher, lecturer in college, junior administrator, insurance inspector,
musician, research assistant.
- Professional:
Involve in decision making, formulating & executing policies.
e.g., Doctors, lawyers, engineers, chartered accountants.
- Others:
e.g., Students (S), Retired person (R), Home maker (HM)

Nature of work:
Based on occupation:
1. Sedentary:
Teacher, tailor, barber, executive, cobbler, priest, retired person, landlord, postman, all
professionals, home maker, nurses, students, etc.
2. Moderate:
Fisherman, basket-maker, potter, goldsmith, farmer, carpenter, mason, rickshaw puller,
electrician, fitter, turner, welder, industrial worker, coolie, weaver, driver, maid/servant, etc.
3. Heavy:
Stone cutter, blacksmith, miner, wood cutter, gangman, etc.

Income:
• Total family income: Include income of all family members from all sources.
• Total family members:
• Per capita income (PCI):

Special groups:
• Under-five children (U-5)
• Adolescent (A)
• Pregnant (P)
• Lactating (L)
• Non-pregnant non-lactating (NPNL)
• Geriatric (G)
4. SOCIOECONOMIC CHARACTERISTICS
Socioeconomic status is an important determinant of health status of family and community.
Standard scales used to determine socioeconomic status of the family:
• Modified Kuppuswamy scale – used for urban families
• Udai Pareek scale – used for rural families
• Modified B.G. Prasad’s scale – used for both urban & rural families
Some important references:
1. Type of house:

Type Floor Wall Roof

Pucca Paved (cement/tiles/marbles) Stone or brick built Concrete, asbestos, tin

Kuccha Packed earth Dried mud or thatched Thatched, slate or other stones

Mixed Any combination of above two types

2. Ventilation:
• Cross ventilation should be present
• Window area should be 20% of floor area
• Door and window combined should be 40% of floor area

3. Adequate natural light:

After opening all the doors and windows of a room, if anyone can read the smallest letter of a
newspaper at the center of the room without the help of any artificial light source, then we can say
that natural light is adequate in that room.
4. Overcrowding:

Person per Per capita

Sex separation
room floor space

1 room – 2 ≥110 sq. ft. – 2

persons persons

2 rooms – 3 90 – 110 sq. ft.

persons – 1½ persons

3 rooms – 5 70 – 90 sq. ft. –

persons 1 person

Overcrowding is considered to exist if 2 persons over 9 years of

4 rooms – 7 50 – 70 sq. ft. –
age, not husband and wife of opposite sex, are obliged to sleep in
persons ½ person
same room.

5 rooms – 10
persons

<12 months –
not counted

1 – 10 years: ½
unit

5. Criteria for safe & wholesome water:

a. Free from pathogenic agents
b. Free from harmful chemical substances
c. Pleasant to the taste—free from color and odor
d. Usable for domestic purposes
6. Daily need of water:
• For survival, water is required in the amount of 2 liters/head/day.
• For urban areas, adequate daily water requirement is (for all domestic purposes): 150–200
liters/capita.
• Rural minimal daily water supply target in India (for all domestic purposes): 40 liters/capita.

7. Location of water source:

a. The water source must be located at least 15 meters (50 feet) away from the possible source of
contamination.
b. The water source must be located at a higher level with respect to a possible source of
contamination.
c. If the source is providing intermittent supply instead of continuous supply, the following problems
may arise:
 • The water may not be available at required time and so the water needs to be held, carried,
and stored in containers.
• The containers must be clean and the water must be stored in covered containers to avoid
contamination.
• Usage of long-handled mug instead of short-handled one prevents fingers dipping in the
stored water and thus prevents contamination.
• When the water supply goes off and if there is micro leakages in the pipe system of the water
source, then the negative suction effect may draw contaminants from surrounding areas.
• If water is stored for longer duration in uncovered containers, then it may become breeding
ground of mosquitoes.

8. Sanitary latrine: sanitary latrine must fulfill the following criteria:

a) Excreta should not contaminate the ground or surface water.
b) Excreta should not pollute the soil.
c) Excreta should not be accessible to flies, rodents, animals and often vectors for transmission.
d) Excreta should not create nuisance due to odor or unsightly appearance.

9. Solid wastes:
The term solid waste includes:
a. Garbage (food waste)
b. Rubbish (paper, plastic, wood, metal, glass, throw away containers)
c. Demolition products (bricks, masonry, pipes)
d. Sewage treatment residue
e. Dead animals, manure and other discarded materials
8. NUTRITIONAL ASSESSMENT
Method of nutritional assessment:
a) Anthropometry
b) Biochemical assessment
c) Clinical examination
d) Diet survey
e) Ecological studies
f) Functional assessment
g) Vital statistics

Method of diet survey:

a) 24 hours recall method (Questionnaire method)
b) Food balance sheet method
c) Inventory method
d) Weighment method
e) Food frequency questionnaire method
Balanced diet:
A balanced diet is one which provides all the nutrients in required amount and proportions.
It can easily be achieved through a blend of the three basic food groups.
• A balanced diet should provide around 50–60% of total calories from carbohydrates
(preferably complex carbs)
• 10–15% from protein
• 20–30% from fat
In addition, a balanced diet should provide dietary fibre, vitamins, and minerals which bestow positive
health benefits.

Steps of 24 hours recall method:

• Go to the family on Day 1; ask for the family member who is mainly conducting the
procurement of food and its preparation (cooking, preparing meals for children, etc.)
• Decide another date for data collection regarding food consumption; enquire whether that day
is fast day or feast day. If yes, skip that day.
• Do not tell the family that you are going to take food consumption data on the 2nd day as that
may impair regular food consumption behaviour
• On the day of data collection, start from breakfast and collect data regarding all food
consumed by all family members including outside food
• Breakdown the consumed meal into food stuffs
• Calculate the amount consumed by the following method:
Amount Consumed/day = Amount purchased / Number of days that is consumed

Alternatively, consider the following measures:

• 1 Glass: 200 ml
• 1 Table spoon: 15 ml
• 1 Tea spoon: 5 ml
• 1 Katori: 250 ml
• 1 Egg: 60 gms
• 1 Litre oil: 910 gms
• 1 Litre milk: 1.03 kgs

In the next step, nutrient consumption and RDA will be calculated as per guidelines of National
Institute of Nutrition (NIN).
• Vitamin A should be calculated in the form of Beta carotene (from plant sources).
 • In animal sources, Vitamin A is present as Retinol.
• Retinol to Beta carotene conversion formula:
Retinol × 8 = Beta Carotene
Only visible fat is considered for fat consumption, which is present in edible oils.
RDA Summary (Sample)

Vit A
β-Carotene Thiamin Riboflavin Niacin Pyridoxin
Group Particulars (Retinol,
(µg/day) (mg/day) (mg/day) (mg/day) (mg/day)
µg/day)

Sedentary
Man 600 4800 1.2 1.4 16 2.0
work

Moderate
600 4800 1.4 1.6 18 2.0
work

Heavy work 600 4800 1.7 2.1 21 2.0

Sedentary
Woman 600 4800 1.0 1.1 12 2.0
work

Moderate
800 6400 1.1 1.3 14 2.5
work

Heavy work 800 6400 1.4 1.7 16 2.5

Pregnant 950 7600 +0.3 +0.4 +2 —

Lactating — — +0.2 +0.3 +4 —

This table continues to include nutrients such as:

• Ascorbic acid
• Folate
• Vitamin B12
• Magnesium
• Zinc
• And more for infants, children, adolescents, and both sexes
Antenatal Care:
It is the systemic supervision (examination & advice) of women during pregnancy to monitor the
progress of fetal growth and to ascertain the well-being of the mother and the fetus.

Parity:
Denotes a state of previous pregnancy beyond the period of viability.
Gravida:
Denotes a pregnant state, both present and past, irrespective of the period of gestation.

LMP (Last Menstrual Period):

Refers to the first day of the woman’s last menstrual period.
LMP is used to calculate the gestational age at the time of check-up and to estimate EDD.

EDD (Expected Date of Delivery):

It is based on the assumption that the menstrual cycle of the woman was regular before conception
and followed a 28–30 day cycle.
Formula:
EDD = Date of LMP + 9 months + 7 days

Ascertaining LMP:
• Ensure the woman is not referring to the date of the first missed period. This can lead to
miscalculation of EDD by approximately 4 weeks.
• Help her recall using events, festivals, or any notable occurrence.
• If the exact date is unknown and pregnancy is advanced, ask when she first felt fetal
movements (quickening, around 20 weeks).
• Correlate with fundal height to estimate gestational age.
• If uncertain, ask her how many months pregnant she believes she is and compute from there.
o Example: A woman visits on 20th September, says she completed 8 months 10 days
ago → 9th month starts on 10th October, and EDD becomes 17th October.

LBW (Low Birth Weight):

An infant with a birth weight <2.5 kg, regardless of gestational age.

Abortion:
The expulsion or extraction from the mother of an embryo or fetus <500 gms or not capable of
independent survival.

Stillbirth:
Death of fetus after 28 completed weeks of pregnancy, or delivery of a dead fetus weighing >1000
gms or >35 cm body length.
Home-based neonatal care visit by ASHA:
Visit no. Home Delivery Institutional Delivery

1st 1st day Not applicable

2nd 3rd day 3rd day

3rd 7th day 7th day

4th 14th day 14th day

5th 21st day 21st day

6th 42nd day 42nd day

Post-partum visit by SBA (Skilled Birth Attendant):

Visit no. After Home Delivery After Institutional Delivery

1st 1st day (within 24 hours) Not applicable

2nd 3rd day after delivery 3rd day after delivery

3rd 7th day after delivery 7th day after delivery

4th 6 weeks after delivery 6 weeks after delivery

Early Initiation of Breastfeeding:

• Breastfeeding should begin as early as possible after birth, ideally within the first hour, even
in caesarean births.

Colostrum:
• The milk secreted in the first 2–3 days.
• Must not be discarded—should be fed to the newborn.
• Rich in protective immunoglobulins and cells.
• No pre-lacteal fluid should be given to the newborn.

Prelacteal Feeding:
• Any food given to a newborn before initiation of breastfeeding.
• In some regions, sugar water or honey is commonly used.

Exclusive Breastfeeding for the First 6 Months:

• Infant receives only breast milk (from mother, wet nurse, or expressed).
• No other liquids or solids, not even water.
 • Exceptions: ORS, oral vaccines, vitamins, minerals, and medicines.

Complementary Feeding:
• Begins after 6 months.
• Introduces solid/semi-solid food alongside breast milk.
• After 6 months, breast milk alone is insufficient for nutritional needs.
• Breastfeeding should continue with complementary feeds for at least 2 years.

Active Feeding:
• Must be done for children during and after illness.

Measurement of Mid Upper Arm Circumference (MUAC):

Tools:
• Use insertion-type MUAC tape.
Steps:
1. Locate tip of shoulder
2. Identify tip of shoulder and tip of elbow
3. Place tape at tip of shoulder
4. Pull tape past tip of bent elbow
5. Mark midpoint of upper arm
This midpoint is where MUAC is measured to assess nutritional status in children.
Developmental Milestones for 2–36 Months

Sl. Age (in

Developmental Milestones Danger Signs (at upper age limit)
No months)

- No social smile
- Recognises mother
- No eye contact when interacted with
- Social smile
- Continuous squinting after 2 months
- Eye contact
- No response to sudden loud sound
1 2–3 - Raises head when on abdomen
- Hypertonia, trunk in hyperextension
- Moves hands & feet on both sides
(bowing)
- Hands extended on both sides at
- Thumb always in flexion and opposed
right angle
to palm

- Head upright - Head wobbly or absent control

2 4–6 - Sits with support - Cannot sit with support
- Turns head to sound - No reach for objects
- Reaches for objects - No babbling a, e, u
Sl. Age (in
Developmental Milestones Danger Signs (at upper age limit)
No months)

- Laughter with sound - No tracking of moving objects

- Babbles (a, e, u) - Cannot raise head on abdomen
- Regards self in mirror

- Cannot turn from stomach to back or

- Turns body side to side
vice versa
- Holds with palmar grasp
- Cannot sit without support
- Turns head to reach for toys
3 7–9 - No head turn to sound
- Searches for hidden toys (object
- No babble monosyllables (ma, pa, da)
permanence)
- Lopsided head when looking at
- Responds to name
objects

- Reaches while seated - Absent pincer grasp

- Reaches to be lifted up - Doesn’t reach to be lifted
4 10–12 - Crawls to reach toys - No response to name
- Says 1–2 words - Doesn’t look for hidden toys
- Obeys simple commands - Doesn’t play peek-a-boo

- Cannot stand without support

- Stands without support
- Shows hand preference
- Walks few steps
- Doesn’t interact with caregiver
5 13–18 - Waves & claps
- Cannot put objects in box
- Puts objects in box
- Doesn’t point at toys
- Identifies simple pictures
- Doesn’t say bisyllables (mama, dada)

Developmental Milestones (continued)

Sl. Age
Developmental Milestones Danger Signs (at upper age limit)
No (months)

- Cannot balance while pulling toys

- Cannot scribble
- Walks without support
- Cannot speak 2-word phrases (e.g., "my
- Pulls toys while walking
6 19–24 toy", "want water")
- Mimics household chores
- Does not wave goodbye
- Identifies & shows body parts
- Does not understand or obey simple
commands

- Drinks from a cup

- Cannot self-feed with spoon
- Identifies primary colours, shapes
- No role-play
- Names common objects
7 25–36 - Continuous drooling
- Climbs up/down stairs
- Cannot climb stairs
- Speaks in 3+ word sentences (e.g., “I
- Repetitive or ineffective communication
want to play”)

Instructions:
 • Select the Sl. No. block based on the child’s age.
Example: If child is 5 months old → Sl. No. 2 (4–6 months)
• Tick all milestones achieved in that block.
• Assessment should be done via observation, examination, and interviewing the caregiver.
• If child is at the upper limit of the age block and has not achieved all milestones,
then only check the column of danger signs.
• If any danger sign is present, record in provisional diagnosis and refer to a pediatrician
for further evaluation.
Recommended Complementary Feeding Practices

Amount per Meal (in

Age Frequency per
Texture / Consistency addition to breast
Group Day
milk)

Start with thick porridge, mashed Start with 2–3

2–3 meals +
6–8 roti/rice/bread/biscuit with sweetened undiluted tablespoons, increase
frequent
months milk or thick dal with oil/ghee. Mashed potato, up to ½ of a 250 ml
breastfeeding
banana, mango, papaya, etc. bowl

Start with ½ of a 250

3–4 meals +
9–11 Finely chopped or mashed food; food the baby ml bowl, gradually
breastfeeding ± 1–
months can pick up. increase to ¾ of the
2 snacks
bowl

3–4 meals +
12–23 Family food, finely chopped or mashed as ¾ to 1 full 250 ml
breastfeeding ± 1–
months needed. bowl
2 snacks

As the Baby Grows Older:

• Gradually increase frequency, amount, texture, and variety of food.
• Offer locally available, affordable, acceptable foods: vegetables, fruits, legumes, animal
food.
• Up to 12 months, food should be served on mother’s lap, after that, child should eat by the
side of caregiver.
• Encourage child to finish the serving.

Non-Breastfed Babies:
• Add 1–2 extra servings of food or snack.
• Add 1–2 cups of undiluted milk per day.

Demand Feeding:
 • Feed patiently and encourage active feeding.
• Use a separate bowl to monitor quantity eaten.

Hygiene:
• Food should be freshly prepared, served in clean utensils and spoon.
• Both caregiver and child must wash hands with soap and water before meals.

Feeding During Illness:

• Continue feeding in frequent, small servings.
• After recovery, increase food/breastmilk intake.

Continued Breastfeeding:
• Should continue through 1st and 2nd year of life along with complementary food.
C. ADOLESCENT HEALTH
Definition:
People in the age group of 10–19 years are considered adolescents.
Adolescence is the bridge between childhood and adulthood, marked by pubertal changes.
Adolescence is sub-classified into:
• Early: 10–13 years
• Mid: 14–16 years
• Late: 17–19 years
(Considerable overlap and individual variations exist.)

Changes of Adolescence:
• a) Physical
• b) Psycho-sexual
• c) Cognitive

Medical Problems in Adolescence:

Girls:
• a. Early or Delayed Menarche
• b. Menstrual Bleeding issues:
o Irregular (Polymenorrhoea, Oligomenorrhoea, Metrorrhagia)
 o Excessive (Menorrhagia) or scanty
o Painful cramps (Dysmenorrhoea)
• c. Polycystic Ovarian Disease
• d. Eating disorders, distorted body image (more common in girls)
Boys:
• Nightfall, road traffic accidents, falls, injury
• Violence, harmful substance use
Common to Both Sexes:
• Anemia, Undernutrition
• RTI/STI
• Overweight/Obesity
• Mental health problems, Self-harm
• Acne

Social Issues Related to Adolescence:

• Teenage marriage
• Teenage pregnancy
• High-risk sexual behavior
• Homosexuality
• Juvenile delinquency
• Dropping out of school
• Poor coping skills
• Gender identity disorder
• Lack of family support

Health Programmes for Adolescents:

• Rashtriya Kishore Swasthya Karyakram (RKSK)
• Kanyashree
• Beti Bachao, Beti Padhao
• Kishori Shakti Yojana of IMCDS
• Nutrition Programme for Adolescent Girls (NPAG)
• Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (RGSEAG) – Sabala
Scheme
D. GERIATRIC
National Policy on Older Persons
Adopted in January 1999 by the Government of India.
Defines ‘senior citizen’ or ‘elderly’ as a person aged 60 years or above.
Common Health Conditions in the Elderly:
• Hearing loss
• Cataracts and refractive errors
• Diabetes
• Hypertension
• Obesity
• Depression
• Dementia
• Osteoarthritis
• Chronic obstructive pulmonary disease (COPD)
Programs:
The National Programme for Health Care of the Elderly (NPHCE) was launched in 2010–11 to
address these health problems.

JNC 7 Criteria for Diagnosing Hypertension

Classification Systolic BP (mm Hg) & / or Diastolic BP (mm Hg)

Normal < 120 & < 80

Pre-hypertension 120–139 &/or 80–89

Stage 1 Hypertension 140–159 &/or 90–99

Stage 2 Hypertension ≥ 160 &/or ≥ 100

Note: Once diagnosed and started on treatment, a patient is considered hypertensive regardless of
current BP.
• If systolic and diastolic BP fall into different categories, the higher category is used.
• Isolated systolic hypertension = systolic BP ≥ 140 mmHg with diastolic BP < 90 mmHg.
• Start medication in age ≥60 years if BP ≥ 150/90 mmHg and target BP < 150/90 mmHg.

Diagnostic Criteria for Diabetes (WHO)

BMI Classification (WHO):

BMI (kg/m²) Nutritional Status

• BMI <17.0: thinness

• BMI <18.5: underweight
• BMI 18.5-24.9: normal weight
• BMI ≥25.0: overweight
• BMI ≥30.0: obesity.

• BMI = Weight (kg) / Height (m²)