40-minute practical approach

1. Long case: Comprehensive environmental assessment of allotted family

A. Identification and family profile

• Name of head of family, address, religion/caste if relevant
• Type of family: nuclear, joint, three-generation
• Number of family members, age-sex composition
• Occupations, education, per-capita income or socioeconomic status
• Identify vulnerable members: under-five child, pregnant woman, elderly person, adolescent girl, person with chronic disease/disability

B. House and residential environment

1. Site and surroundings

• Rural or urban setting, location and accessibility
• Is the house near a main road, industry, stagnant water, open drain, garbage dump, cattle shed, or overcrowded settlement?
• Nuisance from smoke, dust, noise, foul smell, mosquitoes, flies, rodents
• Drainage around house: adequate, covered/open, stagnant water?
• Availability of nearby school, anganwadi, health facility, market, transport

2. Structure of house

• Kutcha, semi-pucca, or pucca
• Ownership: owned/rented
• Number of rooms and use of rooms
• Floor: mud/cement/tiled
• Walls and roof: condition, leakage, cracks, dampness
• Separate kitchen present or not
• Separate cattle shed, if applicable

3. Overcrowding

• Record number of persons and number of living/sleeping rooms.
• Comment on overcrowding using:
  • Persons per room criterion
  • Sex-separation criterion, where appropriate
  • Adequacy of privacy and sleeping arrangements
• Note if children, adolescents, or adults of opposite sex are sharing rooms inappropriately.

4. Ventilation and lighting

• Number, size and position of doors/windows
• Cross-ventilation present or absent
• Natural light adequate or inadequate
• Artificial lighting source
• Smoke accumulation in kitchen
• Whether rooms feel stuffy, dark, damp, or poorly ventilated

C. Water supply

• Main source: piped supply, hand pump, tube well, protected well, tanker, surface water
• Whether source is protected and functioning
• Sufficiency and regularity of water supply
• Distance and time needed to collect water
• Storage: covered vessel, narrow-mouthed container, ladle used, cleanliness
• Drinking-water treatment: boiling, filtration, chlorination, none
• Separation of drinking water from water for other domestic uses

D. Excreta disposal and personal hygiene

• Toilet available? Functional? Household/shared/community/open defecation?
• Type of latrine, water availability, cleanliness
• Handwashing facility near toilet and kitchen
• Soap/ash available?
• Handwashing after defecation and before preparing/eating food
• Disposal of child faeces

E. Solid waste and wastewater disposal

• Household refuse: covered bin or open heap
• Frequency/method of disposal: municipal collection, compost pit, burning, open dumping
• Presence of flies, stray animals, rodents
• Kitchen wastewater and bathing wastewater disposal
• Presence of soak pit, closed drain, open drain, stagnant pools

F. Kitchen and food hygiene

• Separate kitchen and ventilation/chimney/exhaust
• Type of fuel: LPG, electricity, biomass, kerosene
• Indoor smoke exposure, especially for women and children
• Safe food storage, covered cooked food
• Refrigeration if available
• Cleanliness of utensils and preparation area
• Milk/infant feeding practices when relevant

G. Vector and animal-related assessment

• Mosquito breeding sites: coolers, tanks, tyres, flower pots, stagnant drains
• Mosquito-control measures: nets, screens, repellents, source reduction
• Flies, cockroaches, rats
• Domestic animals/cattle and their location
• Dog vaccination and bite history where relevant

H. Health-service use and preventive practices

• Immunization status of children and pregnant women
• ANC/PNC, institutional delivery, family planning
• Growth monitoring, ICDS/anganwadi use
• Screening or treatment for hypertension, diabetes, tuberculosis, anaemia as applicable
• Health insurance, nearby subcentre/PHC, access barriers
• Tobacco, alcohol, nutrition, exercise, menstrual hygiene and waste disposal, where appropriate

2. How to present positive and negative findings

“The family lives in a ___ type house with ___ rooms for ___ members. The house is/is not overcrowded. Natural lighting and ventilation are adequate/inadequate. Drinking water is obtained from ___ and stored ___. A sanitary toilet is present/absent. Solid waste is disposed by ___. There is/is no stagnant water or vector breeding. The kitchen uses ___ fuel, with/without adequate ventilation. Vulnerable family members include ___.”

Positive findings

• Pucca house, adequate rooms, no overcrowding
• Good cross-ventilation and natural lighting
• Protected piped water supply and covered storage
• Functional sanitary latrine and handwashing with soap
• Proper drainage, no stagnant water
• Covered waste bin/regular waste collection
• Separate smoke-free kitchen using LPG
• Complete immunization and regular use of health services

Negative findings

• Overcrowding, poor privacy, dampness
• Poor ventilation/light or indoor smoke exposure
• Unsafe water source or unsafe storage
• Open defecation or poorly maintained toilet
• Open drains, stagnant water, mosquitoes or flies
• Open garbage dumping
• Poor food hygiene
• Unimmunized child, missed ANC, untreated chronic illness

3. Give health advice according to the problems found

Short case

4. Present the summary of the index case

“Mr/Ms ___, ___ years old, resident of ___, belonging to a ___ socioeconomic-status family, presents with ___ for ___ duration. Relevant positive history includes ___. Relevant negative history includes ___. On examination, the important findings are ___. The provisional clinical diagnosis is ___.”

1. Identification details
2. Chief complaints and duration
3. Relevant history: past, personal, family, treatment and exposure history
4. Examination findings
5. Investigations, if available
6. Provisional diagnosis and differential diagnosis if needed

5. Formulate a clinico-social diagnosis

1. Clinical diagnosis
2. Severity/complication, if any
3. Relevant epidemiological or social determinants
4. Family/environmental risks
5. Health-service or adherence issue

Template

“A case of ___ in a ___-year-old ___, with/without ___ complication, occurring in the setting of ___ socioeconomic condition, ___ environmental risk, and ___ behavioural/health-service-related factor.”

Examples

• “Pulmonary tuberculosis in an adult male, with household exposure risk and possible treatment-adherence concerns in an overcrowded, poorly ventilated dwelling.”
• “Hypertension in a middle-aged woman with obesity, high salt intake, low physical activity and irregular follow-up.”
• “Acute diarrhoeal disease in an under-five child, likely associated with unsafe water storage, poor hand hygiene and inadequate sanitation.”

6. Management plan for the index case

A. Clinical management

• Immediate treatment/referral as required
• Investigations and confirmation of diagnosis
• Disease-specific treatment according to programme/guidelines
• Management of complications and danger signs

B. Preventive management

• Prevent complications, recurrence and transmission
• Immunization/chemoprophylaxis/screening as relevant
• Nutritional advice and personal hygiene
• Follow-up schedule and adherence monitoring

C. Family management

• Screen household contacts where indicated
• Identify high-risk or vulnerable members
• Counselling on disease transmission/prevention
• Immunization, nutrition, reproductive and child-health needs

D. Social and environmental management

• Correct the environmental risks identified during the home visit
• Link the family with ASHA, anganwadi, ANM, subcentre/PHC and relevant national health programme
• Address affordability, transport, literacy, stigma, adherence, housing, sanitation or food-security barriers
• Arrange home follow-up where needed

Suggested final closing statement

“The family has both protective factors and modifiable environmental risks. Priority interventions are improvement of safe water and sanitation, proper waste and wastewater disposal, vector control, a smoke-free and ventilated kitchen, and completion of preventive health services. The index case requires disease-specific clinical care together with family screening, counselling, environmental correction and scheduled follow-up.”

1. Criteria for healthful housing

1. Provide physical protection and shelter.
2. Provide adequately for cooking, eating, washing and excretory functions.
3. Be designed, constructed, maintained and used to prevent the spread of communicable diseases.
4. Protect occupants from hazards due to noise and pollution.
5. Be free from unsafe construction/maintenance arrangements and from toxic or harmful materials.
6. Encourage personal and community development, promote social relationships, respect ecological principles and thereby promote mental health.

2. Ventilation

Definition

Standards of ventilation

Natural ventilation

1. Wind: perflation and aspiration
2. Diffusion
3. Inequality of temperature

• Provide doors and windows on opposite walls for cross-ventilation.
• Back-to-back houses are unsuitable because they do not permit cross-ventilation.
• Use properly placed doors, windows, ventilators and skylights.

3. Lighting: requirements of good lighting

1. Sufficiency
   • Light should enable the eye to see the object and surroundings clearly without strain.
   • Basic minimum for satisfactory vision: 15-20 foot-candles.
   • 1 foot-candle = 10.76 lux.
2. Uniform distribution
   • Light should have similar intensity throughout the field of work.
   • Avoid marked contrasts and uneven illumination.
3. Absence of glare
   • Avoid direct glare from light sources and reflected glare from polished surfaces.
   • Glare causes discomfort and reduces critical vision.
4. Absence of sharp shadows
   • Sharp, contrasting shadows interfere with vision and should not fall in the working field.
5. Steadiness
   • Light should be constant and should not flicker.
   • Flickering causes eye strain and may cause accidents.
6. Colour of light
   • Intensity is more important than colour.
   • Artificial light should approximate daylight colour as far as possible.
7. Appropriate surroundings and reflection
   • Ceiling/roof reflection factor: 80%
   • Walls: 50-60%
   • Furniture: 30-40%
   • Floor: not more than 15-20%

4. Overcrowding

Definition

A. Persons-per-room criterion

B. Floor-space criterion

C. Counting of persons

• Infant under 12 months: not counted
• Child aged 1-10 years: counted as half a person
• Person over 10 years: counted as one person

D. Sex-separation criterion

Practical outline: Comprehensive nutritional assessment of the index case

A. Opening and identification

1. Introduce yourself, obtain consent and ensure privacy.
2. Identify the index case:
   • Name, age, sex
   • Family position and occupation/school status
   • Physiological state: under-five child, adolescent, pregnant/lactating woman, adult or elderly person
3. Record family details:
   • Family type and size
   • Socioeconomic status, education, occupation and income
   • Food security, ration card/PDS use
   • Vulnerable family members: young children, pregnant/lactating women, elderly persons, chronic disease patients.

B. Nutritional history

1. Present and past history

• Loss or gain of weight, appetite, fatigue, weakness
• Fever, recurrent diarrhoea, worm infestation, tuberculosis, recurrent infections
• Vomiting, abdominal pain, altered bowel habits
• Excess thirst/urination, hypertension, diabetes, thyroid disease
• Chronic kidney, liver, heart or gastrointestinal disease
• Medication use, especially drugs affecting appetite or absorption
• Menstrual history in adolescent girls/women: heavy menstrual bleeding, regularity
• Pregnancy details: ANC, iron-folic acid and calcium intake, deworming, weight gain
• Breastfeeding and complementary feeding, if the index case is an infant/young child

2. Food and dietary history

Ask for a 24-hour dietary recall

• Early morning
• Breakfast
• Mid-morning snack
• Lunch
• Evening snack/tea
• Dinner
• Bedtime intake

• What was eaten?
• Quantity: katori, glass, chapati, ladle, number of pieces
• Ingredients and cooking method
• Oil, ghee, sugar, salt and packaged food use
• Food eaten outside home

Food-frequency questions

• Cereals and millets
• Pulses, dals, beans, soy
• Milk/curd/paneer
• Egg, meat, fish, chicken
• Green leafy vegetables
• Other vegetables and fruits
• Nuts and oilseeds
• Visible fats/oils/ghee/butter
• Sugar, sweets, sweetened beverages
• Fried food, bakery foods, packaged snacks and fast food

C. Positive and negative food-related practices

Positive practices to look for

• Regular meals without skipping breakfast
• Breastfeeding and timely, adequate complementary feeding in children
• Use of a varied diet with cereals, pulses, milk/animal-source food, vegetables and fruits
• Daily green leafy vegetables and seasonal fruits
• Adequate use of iodized salt
• Safe food storage, handwashing and hygienic preparation
• Limited sugar, salt, fried foods and ultra-processed foods
• Use of clean drinking water
• Avoiding tobacco and excessive alcohol
• Regular physical activity

Negative practices to look for

• Monotonous cereal-based diet with little pulse, milk, fruit or vegetables
• Frequent meal skipping or low meal frequency
• Low intake of protein-rich foods
• Poor complementary feeding, delayed feeding or diluted feeds
• Excess tea/coffee with meals, which may worsen iron absorption
• Excess junk food, sweets, soft drinks, fried food, salt or visible fats
• Very low fruit and vegetable intake
• Food taboos during pregnancy/lactation or illness
• Not using iodized salt
• Poor food hygiene, uncovered food or unsafe storage
• Alcohol, tobacco or low physical activity

D. Clinical nutritional examination

1. General examination

• General build and nourishment
• Pallor
• Icterus
• Oedema, especially bilateral pitting pedal oedema
• Dehydration
• Hair, skin, nails, eyes, mouth and tongue
• Lymph nodes and thyroid enlargement
• Blood pressure
• Signs of systemic disease

2. Deficiency signs to look for

E. Anthropometric assessment

For every index case

• Weight in kg
• Height/length in cm or m
• Body mass index (BMI)

• Waist circumference for abdominal obesity and cardiometabolic risk
• Hip circumference, if required
• Waist-hip ratio, if required

If the index case is an under-five child

• Weight-for-age
• Height/length-for-age
• Weight-for-height
• Mid-upper arm circumference, especially in 6-59 months
• Bilateral pitting oedema
• Plot on the appropriate WHO growth chart where available.

• Low weight-for-age: underweight
• Low height-for-age: stunting
• Low weight-for-height: wasting
• High weight-for-height/BMI-for-age: overweight

If the index case is an adolescent

• Weight, height and BMI-for-age
• Look for anaemia, menstrual problems, unhealthy dieting, excess junk-food intake and obesity.

If the index case is pregnant

• Pre-pregnancy/booking weight if known
• Current weight and gestational weight gain
• Height, BMI where applicable
• Pallor, oedema, BP
• IFA, calcium, deworming, diet diversity and ANC use.

F. Biochemical and functional assessment

• Haemoglobin: suspected anaemia
• Peripheral smear, serum ferritin, vitamin B12/folate if clinically indicated
• Blood glucose/HbA1c: obesity, diabetes risk or symptoms
• Lipid profile: obesity, hypertension or cardiovascular risk
• Thyroid function tests if indicated
• Stool examination for worms if relevant
• Serum vitamin D/calcium only if clinical suspicion exists

G. State your nutritional assessment

“The index case is a ___-year-old ___ with a BMI of ___ kg/m². Dietary assessment shows ___ meal pattern, ___ dietary diversity, and inadequate/excess intake of ___. On examination, there is/is no ___ clinical sign of nutritional deficiency. Anthropometric assessment indicates ___. The likely nutritional problems are ___, associated with ___ food-related practices and socioeconomic/health factors.”

Examples

• “An adolescent girl with probable iron-deficiency anaemia, inadequate intake of iron-rich foods, frequent tea intake with meals and possible excess menstrual blood loss.”
• “An adult male with overweight/central obesity, excess intake of fried foods and sweetened beverages, low fruit and vegetable intake and physical inactivity.”
• “An under-five child with underweight/wasting, inadequate complementary feeding frequency and recurrent diarrhoeal illness.”

H. Management plan

1. If undernutrition/protein-energy malnutrition is present

• Increase meal frequency and energy density.
• Include cereal plus pulse combinations, milk/curd, egg, groundnut, soy, dal, seasonal fruits and vegetables according to affordability.
• Advise one extra meal/snack for children, adolescents or pregnant/lactating women as appropriate.
• Treat contributing illness: diarrhoea, worms, infections, tuberculosis or chronic disease.
• Assess for danger signs, oedema, severe wasting or poor appetite and refer urgently if severe acute malnutrition is suspected.
• Link eligible children to anganwadi/ICDS services and growth monitoring.

2. If anaemia or probable iron deficiency is present

• Refer for haemoglobin estimation and appropriate treatment.
• Encourage green leafy vegetables, pulses, beans, jaggery, groundnuts, sesame, egg/meat where acceptable.
• Combine iron-rich food with vitamin C sources such as lemon, amla, guava, orange or tomato.
• Avoid tea/coffee with or immediately after meals.
• Ensure IFA supplementation and deworming where indicated under national programmes.

3. If overweight/obesity or dietary excess is present

• Reduce fried foods, bakery foods, packaged snacks, sweets and sugary beverages.
• Reduce excess oil/ghee, salt and refined carbohydrate.
• Increase vegetables, fruits, pulses, whole grains and fibre-rich foods.
• Encourage regular physical activity suited to age and health status.
• Screen for blood pressure, diabetes and dyslipidaemia where indicated.
• Set a practical target and schedule follow-up rather than suggesting crash diets.

4. If vitamin A, iodine, calcium/vitamin D or other deficiency is suspected

• Give food-based counselling.
• Refer for confirmation and treatment when clinical signs are present.
• Reinforce iodized salt use and proper storage.
• Ensure age-appropriate supplementation programmes where applicable.

I. Suitable health advice: final counselling message

1. Eat diverse foods from all food groups daily.
2. Improve the deficient food group identified in the diet survey.
3. Limit excess salt, sugar, oil, fried and packaged foods.
4. Maintain meal regularity and safe food hygiene.
5. Continue age- and condition-appropriate supplementation and preventive services.
6. Review weight/growth, diet adherence and laboratory tests after an appropriate interval.

Short case: Summary, clinico-social diagnosis and management

1. Case summary

“___ is a ___-year-old ___ from a ___ socioeconomic-status family, presenting with ___. Relevant history includes ___. Dietary history shows ___. On examination, important findings are ___. Anthropometry shows ___. The provisional diagnosis is ___.”

2. Clinico-social diagnosis

“A case of ___ in a ___-year-old ___, associated with ___ nutritional deficiency/excess, ___ dietary practice, and ___ socioeconomic, environmental or health-service-related factor.”

Examples

• “Iron-deficiency anaemia in an adolescent girl associated with poor dietary iron intake, tea consumption with meals and heavy menstrual bleeding.”
• “Obesity with increased cardiometabolic risk in a middle-aged adult associated with high-calorie processed-food intake, sedentary lifestyle and irregular health screening.”
• “Underweight in an under-five child associated with inadequate complementary feeding, recurrent diarrhoea and low household food security.”

3. Management

• Clinical care: investigate, treat and refer if required.
• Nutritional care: specific diet correction and supplementation.
• Family care: counsel caregiver/family, improve food allocation and screen other vulnerable members.
• Social/programme linkage: anganwadi, ASHA, ANM, ICDS, Poshan-related services, IFA/deworming, growth monitoring and follow-up.

Consumption unit (CU) for dietary survey

• 1 CU = adult sedentary male = 2,400 kcal/day in the traditional ICMR/PSM practical table.
• Assign a CU to every family member, add them, then calculate the family's dietary intake per consumption unit.

Example

Use in practical