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CM2.1-5 | Social and Behavioural Determinants of Health — PBL Case

CLINICAL SETTING

Savitri Kadam, a 32-year-old woman from a small village in Vidarbha, Maharashtra, finally arrives at the Primary Health Centre on a Tuesday morning. She has been unwell for over three months — progressively worsening breathlessness, low-grade fever, and evening sweats. She walked two kilometres to the bus stop and waited 90 minutes before a bus arrived; the journey took another hour. Her husband, Vijay (a seasonal cotton farmer, Class 4 educated), could not accompany her — he is working at a distant field during the busy harvest season. Savitri has three children under ten. The family's land holding is 1.5 acres and they have no other regular income. The family does not have a PM-JAY card. Savitri tells you quietly: 'My mother-in-law said hospitals are only for very serious cases. And we thought the cough would go away with the kaadha (herbal decoction) we make at home.'

Trigger 1: First Encounter at the PHC

Savitri has no prior PHC visits for this illness. On examination: temperature 37.8°C, weight 42 kg (BMI 16.5), respiratory rate 22/min. She coughs during the consultation. Chest auscultation reveals coarse crepitations in the right upper zone. You note she has walked six kilometres total today. She says she has no money for investigations and asks if she can come back 'some other time when my husband is free.'

DISCUSSION POINTS

  • What is your differential diagnosis based on the clinical and social presentation? Rank your differentials with supporting reasoning.
  • What socio-cultural factors are already evident from this encounter? Map them using the family assessment framework.
  • What information about Vijay's occupation, land holding, and income do you need to calculate this family's SES using the Pareek scale? What would you estimate their class to be?
  • What should you do RIGHT NOW — before Savitri leaves — given that she says she may not return?
Click to reveal Trigger 2: The ASHA Worker's Report (discuss previous trigger first!)

Trigger 2: The ASHA Worker's Report

Savitri agrees to a sputum smear — result: 3+ AFB positive. You ask the local ASHA worker, Meenakshi, to conduct a household visit. Meenakshi's report (three days later): The Kadam home is a two-room mud house with poor ventilation and a shared courtyard with two other families. The household per-capita income is approximately Rs 2,200/month (below the current BPL threshold). Vijay's mother (the mother-in-law) is the dominant decision-maker in the household. She believes that Savitri's illness is punishment for 'not managing the home properly.' The three children sleep in the same room as Savitri. There is no PM-JAY enrolment; the family was not included in the last BPL survey. The village has no sub-centre within 5 km. Meenakshi estimates that Savitri's transport, investigation, and medication costs over the past week equal Rs 1,100 — approximately 50% of that week's household food expenditure.

DISCUSSION POINTS

  • Classify this family's SES using the Pareek scale. What domains does the Pareek scale use that the Kuppuswamy scale does not?
  • Is this household experiencing catastrophic health expenditure? Apply the WHO threshold. What are the implications for treatment adherence?
  • Systematically map all barriers to health-seeking behaviour in this case using the Andersen Behavioural Model — identify at least two predisposing, two enabling, and one need factor.
  • The mother-in-law's belief that the illness is self-caused: what type of social norm or community psychology concept explains her attitude? How would you address it in a family meeting?
Click to reveal Trigger 3: Six Weeks Later — A Community-Level Decision (discuss previous trigger first!)

Trigger 3: Six Weeks Later — A Community-Level Decision

Savitri has started DOTS (Directly Observed Treatment, Short-course). The ASHA worker accompanies her twice weekly. However, at week four, Savitri missed two doses — Vijay was ill and the ASHA was busy with a maternal case. At a Village Health, Sanitation and Nutrition Committee (VHSNC) meeting, Meenakshi raises the Kadam case. The sarpanch notes that two other families in the same colony are in similar situations — no PM-JAY cards, living below poverty, with sick members who cannot access the PHC easily. The VHSNC decides to hold a camp and conduct community-level action.

DISCUSSION POINTS

  • What is the VHSNC's role in addressing these barriers? What specific actions can it take for the Kadam family and the two other families?
  • Which social security measures should be initiated immediately? Consider PM-JAY enrolment, MGNREGA, and any other relevant schemes. Identify the eligibility criteria for each.
  • How does social capital — in this case, the ASHA-VHSNC-community network — function as a protective factor against the poverty-disease spiral?
  • Design a community-level action plan (3–5 steps) that addresses structural determinants of health for the 'Savitri colony.' Include both short-term (treatment completion) and medium-term (SES improvement) goals.

Group Task Assignments

Group 1: SES Assessment and Tool Application

  • Apply the Pareek scale domains to the Kadam family using data from Trigger 2.
  • Compare Pareek and Kuppuswamy scales — when is each used and why?
  • Present the SES class and its implications for the patient's health risk to the full group.

Competencies: CM2.2

Group 2: Andersen Model Barrier Analysis

  • Create a structured barrier map (predisposing / enabling / need) for Savitri's case.
  • Rank the barriers by impact on treatment adherence.
  • Propose one intervention for the most dominant barrier category.

Competencies: CM2.3

Group 3: Community Psychology and Social Norms

  • Identify all social norms operating in this case (descriptive, injunctive) and their source (mother-in-law, community, ASHA).
  • Explain how the mother-in-law's illness attribution fits into social psychology concepts (attribution theory).
  • Propose a family meeting plan to reframe illness attribution without confronting the mother-in-law directly.

Competencies: CM2.4

Group 4: Poverty, Catastrophic Expenditure, and Social Security

  • Calculate whether the Kadam family experienced catastrophic health expenditure using the WHO 10% threshold.
  • Identify all social security schemes for which they are eligible and the steps for enrolment.
  • Explain the poverty-disease spiral mechanism in this case.

Competencies: CM2.5

Group 5: Community Action and VHSNC Planning

  • Draft a VHSNC meeting agenda to address the 'Savitri colony' situation.
  • Identify the roles of the sarpanch, ASHA, ANM, and PHC medical officer in the action plan.
  • Design a follow-up mechanism to ensure PM-JAY enrolment and DOTS adherence for all three affected families.

Competencies: CM2.1, CM2.3

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [CM2.1] What are the five steps of a structured clinico-socio-cultural and demographic assessment? How does this assessment differ from a standard clinical history?
  2. [CM2.2] How do the Modified Kuppuswamy and Pareek SES scales differ in their domains, scoring, and appropriate settings? When should each be used?
  3. [CM2.3] What are the predisposing, enabling, and need factors in the Andersen Behavioural Model? Identify one real intervention that targets each category.
  4. [CM2.4] How do descriptive and injunctive social norms and attribution theory explain health-seeking delays in Indian rural communities? Cite one documented example.
  5. [CM2.5] What is catastrophic health expenditure, and how does the poverty-disease spiral operate? What social security measures in India's current policy landscape address this?