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CM1.1-10 | Foundations of Health, Disease and Prevention — PBL Case

CLINICAL SETTING

Dr. Priya Menon has just completed her MBBS and is three weeks into her rural posting at Sundarpura PHC, 60 km from the nearest district hospital in Chhattisgarh. Her predecessor left a one-line handover note: 'High diarrhoea load in monsoon — give ORS and refer complications.' In her first week, Dr. Priya notices that the same families return with diarrhoeal illness every monsoon. The village has a bore-well and a covered overhead tank — both installed five years ago under a government scheme — yet the incidence seems unchanged. The ASHA worker, Savitribai, tells her quietly: 'The tank is covered, Doctor, but the pipeline leaks at two points near the temple. And the women still wash pots in the pond where the buffaloes drink.' Dr. Priya pulls the PHC records. She finds: - IMR in the catchment area: 58 per 1,000 live births (state average: 44) - MMR: not reliably captured — most deliveries are home births - CBR: 27 per 1,000 mid-year population - TFR: estimated 3.4 from ASHA records - Diarrhoeal disease incidence: 112 per 1,000 population in June-August She also notices that the PHC has no functional growth monitoring register — children are weighed during immunisation visits only, and no follow-up is done for those below the third centile. There have been two deaths in the under-5 age group this year, both documented as 'fever with loose motions.' Dr. Priya decides to present a root-cause analysis and prevention plan at the next monthly block health officer meeting. She begins by mapping the problem.

Trigger 1: Trigger 1 — Mapping the Burden

Dr. Priya pulls together the available data: - IMR 58 (above state average 44) - CBR 27, TFR 3.4 (above replacement level of 2.1) - Monsoon diarrhoea incidence: 112 per 1,000 - Two under-5 deaths documented as 'fever + loose motions' — no post-mortem or verbal autopsy done - Savitribai's field report: pipeline leaks + shared pond use for domestic water - PHC growth monitoring: functional but inconsistent — no follow-up for faltering children She has 48 hours to draft the opening section of her presentation. She asks herself: **What is the actual burden here, and what frameworks should I use to understand the cause?**

DISCUSSION POINTS

Interpret each indicator Dr. Priya has collected. What is the correct formula/denominator for IMR, CBR, and TFR? What does each tell you — and what does the pattern across all three indicators suggest about this community's health?
Apply the epidemiological triad to the diarrhoeal disease problem in Sundarpura. What are the specific Agent, Host, and Environmental factors operating here? What would a 'web of causation' look like for this situation?
What additional data would Dr. Priya need to complete her picture? Consider: morbidity indicators, environmental health data, nutritional data, socio-economic factors. How would she collect them with PHC-level resources?

Click to reveal Trigger 2: Trigger 2 — The Hidden Iceberg (discuss previous trigger first!)

Trigger 2: Trigger 2 — The Hidden Iceberg

The block health officer responds to Dr. Priya's preliminary data with surprise: 'Two deaths is not alarming — we have a diarrhoea load every monsoon everywhere.' But Savitribai pulls Dr. Priya aside: 'Doctor, there are many children in the village whose stomachs are always swollen. The parents don't come because they think it's normal. They only come when there is blood in the stool.' Dr. Priya arranges a door-to-door survey with the ASHA workers. In a sample of 82 children under 5, they find: - 14 with weight-for-age below -2 SD (stunting + underweight combined) - 6 children with recurrent diarrhoea (>3 episodes in last 3 months) who had never visited the PHC - 2 with visible wasting — one severely so The children's families had not attended the PHC because, in the words of one grandmother: 'Thin children are normal here. You feed them what you have.' Dr. Priya now understands she is seeing the clinical TIP of a much larger problem.

DISCUSSION POINTS

Apply the iceberg phenomenon to this case. What is visible (clinical cases) versus hidden (subclinical burden)? How does this change Dr. Priya's understanding of the actual disease burden from what the PHC registers captured?
Using the natural history of disease framework, at which phase are most of these children? What does this tell you about the timing and type of interventions needed?
The grandmother's statement — 'thin children are normal here' — reflects a community knowledge-attitude-practice (KAP) pattern. What are the specific knowledge gaps, attitudes, and practices that Dr. Priya needs to address? How would you apply the health belief model to understand why families delay care-seeking?

Click to reveal Trigger 3: Trigger 3 — The Prevention Plan (discuss previous trigger first!)

Trigger 3: Trigger 3 — The Prevention Plan

Dr. Priya now presents her full root-cause analysis to the block meeting. The BHO says: 'Your analysis is good. Now give me a concrete plan — what do we do at each level of prevention, and how do we communicate the change? I also want you to think about what our data systems missed.' The BHO adds one more constraint: 'We have limited funds for capital infrastructure — we cannot replace the pipeline immediately. Everything else must be done with what the PHC and community already have.' Dr. Priya designs a tiered prevention and communication plan using existing PHC resources, ASHA networks, and community involvement.

DISCUSSION POINTS

Design a prevention plan with one specific, feasible intervention at each of the four levels (primordial, primary, secondary, tertiary) for the diarrhoeal disease + malnutrition complex in Sundarpura. For each: name the intervention, state the level, and explain its position in the natural history of the disease.
Design a 2-minute IEC/BCC interpersonal counselling script for Savitribai to use when she visits households with malnourished children. Use the KAP framework. Include how Savitribai would use the teach-back method at the end of the session to verify that the mother understood the action she needs to take.
What data gaps in Dr. Priya's PHC registers contributed to the delayed recognition of this problem? What specific health indicators should be routinely tracked at PHC level, and which national data system (SRS, NFHS, or HMIS) would provide state-level benchmarks for comparison?

Group Task Assignments

Group 1: Epidemiological analysis and burden quantification

Calculate and interpret all indicators provided (IMR, CBR, TFR) with correct formulas and denominators
Construct a detailed epidemiological triad map for diarrhoeal disease in Sundarpura
Propose additional indicators Dr. Priya should track and identify the appropriate data collection tool for each

Competencies: CM1.3, CM1.7, CM1.8

Group 2: Natural history and iceberg analysis

Map the complete natural history of diarrhoeal disease + malnutrition from prepathogenesis to outcome
Apply the iceberg model to the Sundarpura data: quantify what is seen vs unseen, and explain the implications for PHC surveillance strategy
Identify which phase of natural history the 6 recurrent-diarrhoea children and the 2 visibly wasted children represent

Competencies: CM1.4, CM1.5

Group 3: Prevention planning across all four levels

Design one feasible intervention per prevention level (primordial/primary/secondary/tertiary) using only PHC and ASHA resources
Justify each intervention's placement in the natural history timeline
Identify which national health programme addresses the secondary prevention gap (growth monitoring) and name the specific programme component

Competencies: CM1.5, CM1.7

Group 4: Health communication and BCC

Apply the KAP model to analyse why families in Sundarpura delay care-seeking for malnourished children
Design Savitribai's 2-minute interpersonal counselling script including a teach-back closure
Select and justify two IEC channels appropriate for a low-literacy, semi-rural community — explain how each fits the Ottawa Charter community action area

Competencies: CM1.6, CM1.9

Group 5: Health indicators, data systems, and demographic context

Interpret the full district indicator profile (IMR, CBR, TFR) and compare against national benchmarks using NFHS-5 and SRS reference values
Identify the data system gap that allowed the subclinical malnutrition burden to go undetected
Explain how India's demographic profile (high TFR, young age structure) affects CDR interpretation in a district like Sundarpura

Competencies: CM1.7, CM1.8

Learning Issues

Research these questions and bring your findings to the discussion.

[CM1.3] Describe the epidemiological triad framework, differentiating agent, host, and environmental factors for a waterborne disease in an Indian rural setting. Explain how the web of causation model extends the triad.
[CM1.4] Outline the complete natural history of diarrhoeal disease from prepathogenesis to outcome. Define and explain the iceberg phenomenon and its implications for PHC-level disease surveillance.
[CM1.5] Describe all four levels of prevention (primordial, primary, secondary, tertiary) with one specific example from waterborne disease or child malnutrition for each level. Map each level to the appropriate phase of natural history.
[CM1.7] State the correct formula and denominator for IMR, NMR, MMR, CBR, and TFR. Interpret a district indicator profile and identify priority health problems. Explain why CDR must be interpreted alongside age-structure data.
[CM1.8] Describe India's current demographic profile — population size, CBR, CDR, TFR, life expectancy (NFHS-5/SRS data). Explain the health implications of high TFR and young age structure for a PHC catchment area.
[CM1.9] Describe the teach-back method (definition, steps, purpose). Explain how it differs from patient health education delivery. Draft a one-paragraph example of a teach-back exchange between an ASHA and a mother about oral rehydration therapy.