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DEPARTMENT OF COMMUNITY HEALTH

ST. JOHN’S MEDICAL COLLEGE
FAMILY STUDY – PROFORMA
Know the following about the slum when you introduce the family/slum
 Health centres (Private; public)
 Anganwadis and schools
 Mahila Mandals and stree shakthi groups
 NGOs working in the area
 Public distribution system

Q. Why should we study family?

A. Family is the basic unit of a society

 It is a cultural, biological and an epidemiological unit.
 A family’s health may reflect the health of the community

Q. What are the objectives of a family study?

A. The following are the objectives of a family study

 To assess health status of the family/members

 To identify vulnerable individuals
 To identify the health problems, health needs and health demands of the family
 To make a comprehensive community diagnosis
 And to suggest corrective measures which are socially and culturally compatible and
acceptable and economically feasible for the family

Every question and reasoning during the family study should be relevant to health

Q. What is the difference between a clinico-social case presentation and family study

Sl. Variable Clinico social case Family study

No. presentation
1. Aims An individual Health of the family and the community
2. Covers Curative aspects in detail Comprehensive health aspect
3. Benefits to The individual and the family The whole family and the community
4. Vulnerable Not the focus of our action Are the focus of our action
age groups
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Q. What is the difference between vulnerable group and high risk group?

Vulnerable group At risk or high risk group

Potential to have problem; may or may not have Have or has a predisposing factor

GENERAL INFORMATION

1. Name of the head of the family:

 Who takes decisions in the family with respect to health seeking, health expenditure,
marriages, preparation of food items etc
 HOF need not be the person who is the oldest (by age) or higher earning capacity or
even the gender

2. Name of the person interviewed and his/her relation to the head of the family

 Because tells us the quality/reliability of information provided.

 Helps to clarify any issue at a later date if need be.

3. Residing at: (the complete address is a must) Current, Correct, Complete and Clear
address with landmark (also take the phone number if available)

Why?
 Geographic distribution of diseases/Medical geography
 Certain areas/regions are endemic for some diseases
 May also shed some information on health services availability and accessibility
 Cultural aspects which may impact health

4. Duration of stay at this address:

 Relate migration, uprooting, relocation etc... to the health problems identified or

proneness for a health problem as a consequence
 Where were they staying before moving to this location?

5. Religion and caste:

Why?
 Certain religious practices may have a role to play with certain health aspects,
diseases, health beliefs or health seeking behaviour.
 Knowing the religion and caste may also help understanding the reasons for a health
problem
 Govt has specific schemes for the socially oppressed (OBCs, SCs and STs etc)
 Knowing the religion would also help make culturally sensitive recommendations.

Q. What do you mean by Vital Statistics?

The science of numerical facts dealing with vital events in life is called vital statistics. The
application of vital statistics is very important in policy making.
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Q. Uses and applications of Vital statistics?

Vital statistics provide answers to important health related questions such as:
1. What are the leading causes of mortality and morbidity? What are their trends over a
period as regards severity and prevalence?
2. What is the age, sex, class and area wise distribution of various variables?
3. What is the composition of the population and what are the future trends?
4. Which health program should be given priority and what are the needs for the same?
The answers to these questions then help in policy making.

Q. Sources of vital statistics

1. Census enumeration
2. Registration of births and deaths
3. Notifiable disease records
4. Hospital and health centre records
5. Sample registration system
6. Adhoc surveys
7. Records of the insurance companies
8. Reports of other surveys and other voluntary organizations

FAMILY STRUCTURE AND ECONOMICS

1. Type of the family: Joint/Nuclear/Three generation
 Role of the type of family in health and diseases.
 Advantages of a particular type of family with respect to health

Q. What is a family?
A family is the primary unit in any society.
It is defined as a group of individuals related biologically or by the institution of
marriage living together and eating from the same kitchen.
i. Biological unit – The individuals share a pool of genes
ii. Social unit – They share a common physical and social environment
iii. Cultural unit – The family reflects the culture of the wider society of which it is a
part and determines the behaviours of its members.
iv. It is also an epidemiological unit

Q. What is the difference between a family and a household?

A household is where the individuals may not be related biologically. E.g. Servants
The census of India 2001 defines:
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. However, if a group of
unrelated persons live in a census house but do not take their meals from the common
kitchen, then they are not constituent of a common household. Each such person was to be
treated as a separate household. The important link in finding out whether it is a
household is to see if there is a common kitchen. There may be one member
households, two member households or multi-member households.
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Q. What are the different types of family you know?

i. Joint family
ii. Nuclear family / elementary family
iii. Three generation family

Q. What is a nuclear family / elementary family?

A nuclear family is the one which consists of married couple living with their
children while the children are still regarded as dependent on the couple.
i. They share a common dwelling place
ii. Husband plays a dominant role usually
iii. Greater burden in terms of responsibilities for child rearing.
iv. More intimate relationship between husband and wife
v. ‘New’ families are the nuclear families that are less than 10 years old

Q. What is a joint family/extended family?

A joint family is the one where in a number of married couples and their children live
together live in the same house. The men are all related by blood and the women
are their wives, unmarried girls and widows of their family kinsmen.
i. The property is held in common. There is a common purse to which all the
money goes and the family expenditure is met with by that common purse.
ii. The most senior male member is the head of family and takes all the decisions.
His wife is the head of the women folk in the family.
iii. Familial relations enjoy primacy over marital relations.

This is a lateral extension of the nuclear family

Q. What is a three generation family?

It is a family where representatives of three generation are living together.
Young married couples continue to stay with their parents and have their own
children as well.
i. This is fairly common in countries like India where married couples find it difficult
to find separate accommodation.
ii. It has some of the advantages of the joint family with regards to the responsibility
in upbringing of the children
iii. In urban areas with working women it has more relevance; the grand parents can
take care of children in the absence of their parents.
iv. Also, senior citizens of the family stay with the young couple; they are also taken
care of, thereby supporting them.

This is a linear extension of the nuclear family.

Q. What do you mean by family of orientation and family of procreation?

The family into which individuals are born is called the family of orientation.
The family that the individual creates after he/she marries and thus ‘procreates
into’ is called the family of procreation.
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2. Number of family members:

a. Adults Males:
Females:
b. Children Boys:
Girls:

3. Profile of individual family members

Sl. Name of the Relation Age Sex Ocupn Edu Income Comments
No. family member to the (p.m.) / Remarks
HOF
1 Head of the family
2 Wife of H O F
3 Children

 Age and sex composition of the family will help identify vulnerable age groups and
health needs
 This in turn will help prioritizing the needs and direct resources to most vulnerable
groups
 Will also enlist current health problems and health needs

Q. Why should you know the educational status of an individual?

 It is known that better the educational status, better is the knowledge regarding a
particular disease.
 Better the educational status, more reliable and better is the history.
 To give suitable recommendations which the person can understand and follow.

Q. Who is a literate?
 A person aged 7 years and above who can both read and write with understanding
in any language has been taken as literate. (Census 2001)

 It is not necessary for a person to have received any formal education or passed any
minimum educational standard for being treated as literate. People who are blind
and can read in Braille are treated as literates.

Q. Who is an illiterate?
 A person, who can neither read nor write or can only read but cannot write in any
language, is treated as illiterate. All children of age 6 years or less, even if going to
school and have picked up reading and writing, are treated as illiterates.

Q. What do you mean by Consanguinity?

The literal translation of the word is:
Con = Similar
Sanguin = Blood
This indicates that two people are related by blood.
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Q. What are the various degrees of consanguinity?

Four degrees of consanguinity have been identified.
1st degree = Marriage between siblings (Incest)
2nd degree = Marriage between uncle and niece (girl marrying her mother’s brother)
3rd degree = Marriage between first cousins (girl marrying her uncle’s son)
4th degree = Marriage between second cousins or between people with a relationship
beyond second cousins or a far off relationship all fall under this category.

Q. What is the importance?

In these areas consanguineous marriages are very common. Equally common are
congenital malformations such as congenital deafness, congenital blindness, cleft lip, cleft
palate, any form of disability and other genetic malformations. It has been proven that there
is a strong association between congenital malformations and consanguineous marriages.
Hence, to identify such problems in the family, we should know the state of consanguinity.

4. Total Income of the family:

Per capita income:

5. Socioeconomic status:
Socio economic status is an important determinant of health, morbidity and mortality of a
family. The variables that affect the socio economic status are different in rural settings as
compared to urban areas and hence different scales are available for rural and urban
areas.

Q. What are the different socio-economic scales that are used in India? How do you classify?
Urban Area Rural Area Can be used in both settings
 Modified  Modified B G Prasad’ s  Standard of living index
Kuppuswamy’s classification – (parasuraman et al)
scale  Pareekh and Kulashreshta’s  BPL/APL
classification  Wealth Index

Q. What is an Urban Area?

According to the Census of India 2001, an urban area is the one which fulfils the following criteria:
a) All statutory places with a municipality, corporation, cantonment board or notified town area
committee, etc. OR
b) A place satisfying the following three criteria simultaneously:
i. A minimum population of 5,000;
ii. At least 75 per cent of male working population engaged in non-agricultural
pursuits; and
iii. A density of population of at least 400 per sq. km. (1,000 per sq. mile)

Q. What is a rural area

According to the Census of India 2001, all those areas which do not fulfil the criteria for urban area
are grouped as rural areas
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Q. What is a slum?
According to the Census of India 2001, slum areas broadly constitute:
1. All specified areas in a town or city notified as ‘Slum’ by State/Local Government and
UT Administration under any Act including a ‘Slum Act’.
2. All areas recognized as ‘Slum’ by State/Local Government and UT Administration,
Housing and Slum Boards, which may have not been formally notified as slum under
any act;
3. A compact area of a population of at least 300; or about 60-70 households of poorly built
congested tenements, in unhygienic environment usually with inadequate infrastructure
and lacking in proper sanitary and drinking water facilities.

The UN habitat defines a slum as an area lacking the following facilities:

a. Access to improved water
b. Access to improved sanitation
c. Security of tenure (the right to effective protection by the state against arbitrary, unlawful
eviction)
d. Durability of housing (including living in a non - hazardous location)
e. Sufficient living area (no overcrowding).

6. Expenditure pattern:
 Tells us the prioritization of the family: health promotion related expenditure such as
on Diet/ Immunisation/ Water filter/ refrigerator etc...
 Tells us the amount of money a family spends on health and the role an illness plays
in impoverishing the family
 Direct and Indirect expenditure on Health (Micro economics of health and diseases)

1 What Proportion of the family income is spent on Medical needs

2 What Proportion of the family income is spent on food
3 Savings
4 Debts

7. Vital events in the family in the past 1 year

Births/ Deaths/ Marriage/ Migration

Q. What do you mean by vital events?

Vital events are defined as those important events in human life such as birth, death,
sickness, marriage, divorce, adoption, legitimization, recognition, separation etc… which
have a bearing upon an individual’s entrance into or from life together with changes in civil
status which may occur to him during his life time.
This therefore will affect the family structure and thereby affecting the demographic
characteristics of the family, a community and the country.

Q. What are the implications of vital events on a family?

The vital events have a very important bearing on the family.
 Birth/Marriage: heralds the entry of a new person into the family which increases the
needs of the family. It also leads to the neglect of the other children and the other
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vulnerable groups in the family. Marriage is a change of environment for the girl and
this might have an adverse effect on her.
 Death: leads to a void in the family. It may decrease the burden on the family to
some extent. However, it might take away a ‘decision maker’ or an ‘earning member’
from the family which definitely has adverse effects on the other family members.
 Migration: indicates a change in the environment for all the family members and thus
might have ill effects.

8. Health care utilization

 Availability, Accessibility, Affordability and Utilization of Health Services for
common/simple and complicated problems.
 Also make a note of Anganwadi, PDS, Government school which the family accesses
 Why do they go to this particular physician (Traditional/ ISM/ Allopathic/ Quack)?
 What are the transport facilities available to the family? During a health emergency do
they have an access to some form of transport facility?
 Recreation facilities: Radio/ TV/ Magazine/ Cinema/Drama others.
(Why should we know about the recreational facilities? What role does that have on the
health of the family/members of family?)
 Communication facilities available in the community

SOCIO ENVIRONMENTAL HISTORY OF THE FAMILY

A. Macro environment
a. Draw a map of the area as you enter the area
b. Locate the house in the community

Q. Why should you locate the house in the community?

 To assess the accessibility to and from the house.
 To identify any health problem that might be associated with the location
 To assess its distance from important centres such as PDS, Anganwadis, Health centres,
Schools etc...

c. Describe the external environment of the house – any accident prone area, open
drains, vector breeding sites, waste disposal area, stray animals, or any other
significant observations
d. Also describe the solid waste management in the area

B. Micro environment
a. Housing
 Type of the house
a. Attached/Detached
b. Pucca/ Kacchha/ semipucca/ semikacchha
c. Owned/Rented/Leased out
d. Dampness – present/ absent
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Q. What do you mean by attached house?

An attached house is the one which shares one or more walls with another house. This decreases
the ventilation, cross ventilation and lighting in the house. Also, there are chances that the
family gets to hear what the other family is speaking and that is a nuisance to the family.
In urban areas, high rise apartments and flat systems pose a similar problem. However, if
ventilation, cross ventilation and lighting are adequate then it should be considered adequate.

Q. What is pucca house? Kutcha house? Semi pucca house? Semi kutcha house?
Census classifies houses into 2 classes: pucca and kutcha. Therefore it defines a pucca house
and a kutcha house. It has identified the materials which are used to construct pucca house and
kutcha house. (the table below describes the same)

Variable Pucca Kutcha

1 Durability Long lasting Short lasting
2 Definition A house is called pucca if it is A house is called kucchha if it is
constructed using the following constructed using the following
materials materials
Wall Roof  Un burnt bricks
 Burnt bricks  Tiles  Bamboos
 Stones  G.I/Metal  Mud
 Concrete  Asbestos  Grass
 Cement  Concrete  Reeds
 Timber  Bricks  Thatch
 Stone  Loosely packed stone
 Timber

A pucca house is long lasting and does not allow rain water, insects, snakes etc…to come into the
house. It gives good shelter to the inmates. It protects against cold, heat, and dampness.

 House Plan – preferably draw a rough sketch

 Size of the house
a. Floor space of the house
b. Per capita space in the house
 Number of living rooms
 Other rooms
 Overcrowding: (why should you know about overcrowding? Privacy, movement,
rest, sleep, irritability, frustration, psychosomatic problems, physical proximity
might lead to spread of communicable diseases)
 Windows-doors space and its relation to the floor space of the family
Ratio of the window space to the floor area
a. 1/5th of the floor area: Yes/ No
b. Doors and Windows combined would it be 2/5th of the Floor area: Yes / No
 Ventilation including cross ventilation
 Lighting
 Any other important finding
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b. Kitchen
 Separate/Attached
 Platform: present/absent
 Platform used for cooking or not?
 Fuel used for cooking
(If fuel is used for cooking is kerosene then ask details about it)
 Smoke vent: present/absent
 Smokeless chullha
 Washing area for utensils
 Storage of cooked food, raw food items including vegetables

c. Water (for drinking purposes and for other purposes)

1. Source (mention all the different sources and preferably its use): Piped or un-
piped; Bore water/ Open well/ Hand pump/ River/ Tank/ any other. Also mention
the distance of source of water.
2. Collection and storage methods including frequency, method of collection,
method of transport, storage of water
3. Purification methods
4. Utilization of water: filter, drum, tumbler with or without a handle,

{Also know the following: Is the source of water safe? Is it protected from pollution? Is it protected
from unauthorized access to human /animals? If possible assess the source of water}

Q. What are the different types of water sources and their definitions? (source – NFHS 3)

Piped water into Pipe connected with in-house plumbing to one or more taps, e.g. in the
dwelling kitchen and bathroom. Sometimes called a house connection. In-house
pipes connected to a public or private water distribution system.
Piped water to Pipe connected to a tap outside the house in the yard or plot (and the
yard/plot water is coming from a public or private water distribution system).
Sometimes called a yard connection.
Public Public water point from which community members may collect water (and
tap/standpipe the water is coming from a public or private water distribution system). A
standpipe may also be known as a public fountain or public tap. Public
standpipes can have one or more taps and are often made of brickwork,
masonry or concrete.
Tubewell or A deep hole that has been driven, bored or drilled with the purpose of
borehole reaching ground water supplies. Water is delivered from a tubewell or
borehole through a pump which may be human, animal, wind, electric,
diesel or solar-powered.
Protected dug A dug well that is (1) protected from runoff water through a well lining or
well casing that is raised above ground level and a platform that diverts spilled
water away from the well and (2) covered so that bird droppings and
animals cannot fall down the hole. Both conditions must be observed for a
dug well to be considered as protected.
Unprotected A dug well which is 1) unprotected from runoff water; 2) unprotected from
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dug well bird droppings and animals; or (3) both.

Protected spring A spring protected from runoff, bird droppings, and animals by a “spring
box” which is typically constructed of brick, masonry, or concrete and is
built around the spring so that water flows directly out of the box into a
pipe without being exposed to outside pollution.
Unprotected A spring that is subject to runoff and/ or bird droppings or animals.
spring Unprotected springs typically do not have a “spring box”.
Rainwater Rain that is collected or harvested from surfaces by roof or ground
catchment and stored in a container, tank or cistern.
Tanker truck Water is obtained from a provider who uses a truck to transport water into
the community. typically the provider sells the water to households.
Cart with small Water is obtained from a provider who transports water into a community
tank using a cart and then sells the water. The means for pulling the cart may
be motorized or nonmotorized (e.g., a bullock).
Surface water Water located above ground and includes rivers, dams, lakes, ponds,
streams, canals, and irrigation channels
Bottled water Water that is bottled and sold to the household in bottles

d. Sanitation
1. Describe the bathing area – anything identified which could be detrimental to
the health of the family members
2. Defecation
 Toilet facilities: (this activity should be preferably documented by
inspection or observation and not only by asking questions)
 A toilet within the house/attached to the dwelling unit.
 Does the toilet have soap and water?
 Public/ Community toilets; If available
o utilized or not
o are they sufficient
o are children encouraged to use these toilets
o are they allowed or encouraged to defecate/ micturate near the
house
 How far are these toilets located from dwelling unit
 Are they well maintained, water available, lighting available in the toilets
 Type of latrine: Flushable/ water seal present/ Connected to a septic tank/
Pit/ others/ municipal sewerage system
3. Hand washing practices: with soap/ without soap/ with ash/ with clay/ with
mud/ only water. Remember the five `F`s and sanitation barrier
 Before eating, before feeding the infant/child, before collecting water for
drinking from the vessel, after defecation and after washing the bottom of
the new born/infant/child
4. Disposal of wastes (solid/ liquid/ sullage/ sewage/ garbage and refuse
disposal)
 Segregation of wastes in to bio degradable and non bio degradable
 Waste containers in the house: Lid/No lid
 Where do they deposit the waste generated at home?
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 Is a common waste container provided for the locality/street etc?

 How far is it located from house?
 How frequently is the waste collected from here
 Describe the common waste collection point/container/access to animals
etc.
 Sullage disposal?

5. Domestic pets in the house: Present/ absent

DIETARY PRACTICES
a. Type of diet – Vegetarian/Non vegetarian
b. Staple diet – Rice/Ragi/Wheat/Maize
c. Procurement of raw food: Cereals, vegetables, fruits and groceries
d. Calculate the consumption units for the family
e. Method used for dietary survey: Stock Inventory method/ 24 hr dietary recall
f. Dietary co efficient is defined as the energy requirement of an adult male sedentary
worker i.e. 1 D C = 1 adult consumption unit = 2400 kcal
(ICMR Recommendation)

Energy
Category Type of work Dietary Co efficient
Requirement
Adult Male sedentary worker 1.0 2400
moderate worker 1.2 2800
heavy worker 1.6 3900
sedentary worker 0.8 1900
Adult female moderate worker 0.9 2200
heavy worker 1.2 2800
Adolescents 12 – 21 yrs 1.0 2400
10 – 11 yrs 0.8 1900
8 – 9 yrs 0.7 1700
6 – 7 yrs 0.6 1440
Children
4 – 5 yrs 0.5 1200
1 – 3 yrs 0.4 1000
< 1 yr 0.3
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g. For one consumption unit the following is the balanced diet prescribed

Cereals 460 g
Pulses 40 g
Green Leafy vegetables 40 g
Other vegetables 60 g
Roots and tubers 50 g
Milk 150 g
Fat/Oil/Ghee 40 g
Sugar/ Jaggery 30 g

 Estimate the amount of food items used by the family per day.
 Estimate the amount they should actually be using according to the RDA
 Then compare the above two and calculate the deficiency or excess; and
comment
 Also calculate the energy and protein deficiency or excess for the entire family
i.e. 2400 k cal per consumption unit (+ 300 kcal for pregnancy; + 550 kcal
for the first 6 months of lactation; + 400 kcal for 6 – 12 months of lactation)
AND protein of 1 g/kg of body weight

h. Cooking and food handling practices

 Vegetables washed thoroughly and not merely rinsed in water
 Storage of vegetables/ perishables and not perishables
 Cooked food consumption/ storage / reheating etc.
 Cleaning of kitchen utensils and inspection of few of the commonly used
vessels for cooking and serving, to ascertain the cleanliness of the vessels.
 Inspect the utensils used for infant feeding (including feeding bottle for
cleanliness/smell/and grease.

CULTURAL PRACTICES OF THE FAMILY

Note down the specific cultural practices prevalent in the family such as:
1. Withholding food items during antenatal period
2. Delivery at home itself
3. Pre lacteal feeds
4. Withholding colostrum
5. Application on the umbilical cord
6. Branding
7. Withholding food items during postnatal period
8. Method of preparation of certain foods
9. What do they do when a child has chicken pox

KAP REGARDING HEALTH AND DISEASE

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Questions may include aspects on age at marriage, age at first child birth, family size, women’s
education and employment, food taboos, knowledge regarding diseases causation and cure
 What do you think the age of marriage should be?
 What do you think the age at first child birth should be?
 Do these have an impact on health?
 Outlook on causes of disease: Rational/ Deistic/ Demonic/ Supernatural
 Outlook on prevention and cure of diseases: Rational / Religious/ Fatalistic/ Stoic
 Sources of health related information for the family is from: Radio/ TV/ Newspaper/ Health
worker/ AWW/ any other

SUMMARY:

HEALTH STATUS OF THE MEMBERS OF THE FAMILY (available for examination)

Sl. No. Name History Anthropometry Other examination
1
2
3

INDEX CASE: Neonate/ Infant/ Under five/ Adolescent/ Antenatal woman/ Postnatal woman/
Geriatric/ any specific disease
Relevant history:

Examination:
a. General
b. Systemic

COMPLETE DIAGNOSIS/COMPREHENSIVE PROBLEM LIST (in the order of priority)

This is the family of Mr. X residing in..................... (an urban slum) belonging to ......
socioeconomic status. The health problems, health demands and health needs of this family
are.............................
The vulnerable individuals identified in this family are.... (Why are they vulnerable?).
Any medical diagnosis in a particular individual has to be mentioned in the end.

RECOMMENDATIONS
1. To the family on the whole
2. To specific individuals/ index case
3. To the community at large