Chapter II

CONCEPTUAL FRAMEWORK AND REVIEW OF RELATED LITERATURE

This chapter presents the conceptual framework, review of related literature, articles, and other related concepts within the study. This helped establish the guidelines and the significance of the study conducted. The student nurses delved into numerous topics regarding community health nursing and the application of Community Organizing Participatory Action Research (COPAR) that paved its way to the realization of this community diagnosis. Conceptual Framework The community-as-client model, based on Neumans model of a total-person approach in viewing patients problems, was developed by the authors to illustrate the definition of public health nursing as the synthesis of public health and nursing. The model has been renamed the community-as-partner model to emphasize the underlying philosophy of primary health care. There are two central factors in this model (Figure 1): A focus on the community as partner (represented by the assessment wheel at the top, which incorporates the communitys people as the core) and the use of the nursing process.

The core of the assessment wheel represents the people that make up the community. Included in the core are the population as well as their

Assessment

Stressor s

Analysis

Lines of Resistanc e

Community Nursing Diagnosis

Plan

Interventions

Evaluation

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Figure 1.Conceptual Framework

values, beliefs, and history. As residents of the community, the people are affected by and, in turn, influence the eight (8) subsystems of the community. These subsystems are physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation. The solid line surrounding the community represents its normal line of defense, or the level of health. The normal line of defense may include characteristics such as a high rate of immunity, low infant mortality, or middle class income level. The normal line of defense also includes usual patterns of coping, along with problem-solving capabilities; it represents the health of the community. The flexible line of defense, depicted as a broken line around a community and its normal line of defense, is a buffer zone representing a dynamic level of health resulting from a temporary response to stressors. This temporary response may be neighborhood mobilization against an environmental stressor such as flooding or a social stressor such as an unwanted adult bookstore. The eight subsystems are divided by broken lines to remind us that they are not discrete and separate but influence (and are influenced by) one another. The eight divisions both define the

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major subsystems of a community and provide the community health nurse with a frame work for assessment. Within the community are lines of resistance, internal mechanisms that act to defend against stressors. Lines of resistance exist throughout each of the subsystems and represent the communitys strengths. Stressors are tension-producing stimuli that have the potential of causing disequilibrium in the system. They may originate inside the community or inside the community. Stressors penetrate the flexible and normal lines of defense, resulting in disruption of the community. Inadequate, inaccessible or unaffordable services are stressors on the health of the community. The degree of reaction is the amount of disequilibrium or disruption that results from stressors impinging on the communitys lines of defense. The degree of reaction may be reflected in mortality and morbidity rates, unemployment, or crime statistics are some of the examples. Stressors and and degree of reaction become part of the community nursing diagnosis. Review of Related Literature This part discusses the review of related literature needed to justify facts regarding data gathered from the community. Community

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A community is an essential and permanent feature of human experience. According to the World Health Organization (1974), a community is a social group determined by geographic boundaries and/or common values and interests. Its members know and interact with one another. It functions within a particular social structure and exhibits and create norms, values and social institutions. As aforementioned, a community is defined by its geographic boundaries and thus called geographic community. It is consists of a collecting of people located in a specific place and is made up of institutions organized into a social system. Frequently, a single part of a city can be treated as a community. Cities are often broken down into census tracts, or neighborhoods. In community health, it is useful to identify the geographic area as a community. A community demarcated by geographic boundaries, such as a city becomes a clear target for the analysis of health needs. A geographic community is easily mobilized for action. Groups can be formed to carry out intervention and prevention efforts that address needs specific to that community. Furthermore, health actions can be enhanced through the support of politically powerful individuals and resources present in a geographic community. On a larger scale, the world can be considered as global community. Indeed, it is very important to view the world this way since the world is one large community that needs to work together to ensure a healthy today and a healthier and safer tomorrow (Allender et. al., 2010).
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A community can also be identified by a common interest or goal. A collection of people, even if they were widely scattered geographically, can have an interest that binds the members together. Sometimes, within a certain geographic area, a group of people develop a sense of community by promoting their common interest. The kinds of shared interests that lead to the formation of communities vary widely. On the other hand, community can also be defined by a pooling of efforts by people and agencies toward solving a health-related problem. The shape of this community varies with the nature of the problem, the size of the geographic area affected, and the number resources needed to address the problem (Stancope et. al., 2010). In the Philippines, a community can be classified as rural, urban, and suburban. Rural or the open lands usually places in the provincial areas where people make earn their living by agriculture and things of sort. Mostly it is less dense and more spacious. Urban or the city is a nonagricultural type of community. The community is dense and mostly populating the whole community the major source of income are the industrial products and technology. While suburban is usually the capital of provinces where there is a mix of agriculture and industry, although technology is not in its highest peak but it is utilized to increase the productivity of both the industrial and agricultural side (Untalan, 2005). According to Healthy People 2010 (2001), a healthy community is characterized by a safe and healthy environment, offers access to health
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care services, focusing on both treatment and prevention for all members of the community, and has roads, playgrounds, scholls and other services to meet the needs of the population. While In 1980s, the WHO initiated the Healthy Cities movement to improve the health status of urban populations. Who defined a healthy city as one that is continually creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all functions of life and in developing their maximum potential (WHO, 2004). Community Size One of the first things community health nurses need to know about a community is its size. The size of a community also influences the presence of inadequate housing, the heterogeneity of the population, and almost every conceivable aspect of health needs and services. Knowing the communitys size provides community health nurses with important information of planning (Allender, 2010). The traditional notion of neighborhood was of an area that housed a population for which one elementary school should serve its children. As the birth rate or death rate declines, more people live alone, and more elderly people live without children, the elementary school as a criterion of neighborhood becomes less relevant. As more people relate to friends and co-workers other than neighbours, the concept of neighborhood itself

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becomes less compelling as an organizational building block of the community (Green et. al, 2005). Community size is often found to be negatively correlated with prosocial behaviors such as formal volunteering, working on public projects and informal help to friends and strangers. This may be because people who reside in large communities simply spend less time socializing with each other. As a result, people living in large cities have on average fewer friends, and hence their social networks support less cooperation (Allcott et. al, 2007). Population Group Considering the community as a client, one should examine the population of the total community. The health of any community is greatly influenced by the attributes of its population. A healthy community has leaders who are aware of the populations characteristics, know its various needs and respond to its needs. Population or aggregate is collection of people who share one or more personal or environmental characteristics. Members of a community can be defined either in terms of geography or a special interest and these members comprise a population (Stanhope et. al., 2010). From the perspective of the community, the population consists not of a specialized aggregate, but of all the diverse people who live within the boundaries of the community. Population group refers to the population group or groups, to which the person belongs depending on their shared interest or goals. These
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groups may be within a community or cut across many communities (Anderson et. al., 2004). Some of these groups include: children, elderly, men and women. Children Children are usually the first to suffer from socioeconomic difficulties and political problems of the country. Care of the children presents community health nurses with significant opportunities to influence the future health of the general population. One of the most effective ways to improve the health status of a community is to maintain and enhance the health of its children. Health promotion and prevention for this age group can make a tremendous impact on the overall future health of a population. Children, who receive effective health care services, particularly health promotion and illness prevention services, are far less likely to develop a variety of acute and chronic health problems. If children are taught to engage in healthy behaviors, their lifetime health status will be positively influenced (Stanhope et. al., 2010). When assessing the infant and toddler, the nurse should begin by interviewing the primary caregiver. Typically the areas covered include nutrition, growth and development, and vision and hearing. Monitoring growth and development is easily done by weighing the infant and measuring length and head circumference, and plotting the results on a growth grid (Allender, 2010).

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Basic health services for the prevention of disease and the early identification of illness or disability should be available to all children. Wellchild clinics providing assessment of growth and development, nutrition information, nurturing and anticipatory guidance, and immunization for children should be available. Well-child care should be at regular intervals and may be performed by allied health personnel other than physicians. Parent- infant bonding and anticipatory counseling to prevent problems will enable the child to grow up in a healthful and well-structured atmosphere (Green et. al., 2005). Children are healthier than ever before, certainly as measured by the usual morbidity and mortality indicators. However, there are different threats to the health of children and youth, often characterized as the new morbidity, for which environmental (social, physical, familial, and economic) and behavioral factors have been identified as causative and contributive (Maurer et. al, 2009). Elderly The elderly may constitute a large and growing population of group in a country. They make up a group whose health needs we do not fully understand, and we have yet to offer the full complement of services they require and deserve (Stancope et. al., 2010). For community health nursing, this population group poses a special challenge. The increasing number of elderly people in the community multiplies the need for health-promoting and preventive
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services to maximize their ability to remain independent and contributing citizens. This groups greater longevity, replete with all the problems brought on by diminishing functional capacity and increasing chronic disease and disability, brings another dimension of concern. Significant economic, environmental, and social changes create a demand for greater productive and preventive services for older adults in addition to requiring adjustments in health care provision patterns (Maurer et. al., 2009). No one knows conclusively all the variables that influence healthy aging, but it is known that a lifetime of healthy habits and circumstances, a strong social support system, and a positive emotional outlook all significantly influence the resources people my bring to their later years. Wellness among the older population varies considerably. It is influenced by many factors, including personality traits, life experiences, current physical health and societal supports and personal health behaviours including smoking, obesity and excessive alcohol use (Allender, 2010). Effective nursing among any population requires familiarity with that groups health problems and needs. Aging, in and of itself, is not a health problem. Rather, aging is a normal, irreversible physiologic process. However, its pace can sometimes be slowed, as researchers are discovering, and many of the problems associated with aging can be prevented. The elderly, like any other age group, have certain basic needs that need to be given attention in order to maintain health (Allender, 2010). Legal Bases
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Public Health Nurses need to know the laws affecting health and nursing practice in the Philippines. As practicing nurse in the community setting, the public health nurse must be familiar with the existing laws and standards that govern safe nursing practice. Public Health Nursing in the Philippines evolved alongside the institutional development of the Department of Health, the government agency mandated to protect and promote peoples health and the biggest employer of health workers including public health nurses. Historical

accounts show that as far back as the 1900s, nurses working in the communities were already given the title Public Health Nurses (Public Health Nursing, 2007). In the light of the changing national and global health situation and the acknowledgment that nursing is a significant contributor to health, the Public Health Nurse is strategically positioned to make a difference in the health outcomes of individuals, families and communities cared for (Public Health Nursing in the Philippines, 2007). Community Health Nursing It is a nursing practice in the community, with the primary focus on the health care of the individuals, families, and groups in a community. The goal is to preserve, protect, promote, or maintain health. The World Health Organization Expert Committee of Nursing defines public health nursing as a special field of nursing that combines the skills of nursing that combines the skills of nursing, public health and
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some phases of social assistance and functions as part of the total public health program for the promotion of health, the improvement of the conditions in the social and physical environment, rehabilitation of illness and disability. Jacobson(2004) states that community health nursing is a learned practice discipline with the ultimate goal of contributing, as individuals and in collaboration with others, to the promotion of the clients optimum level of functioning through teaching and delivery of care. Community Health Nursing is a unique blend of nursing and public health practice woven into a human service that properly developed and applied has a tremendous impact on human well being. Its responsibilities extend to the care and supervision of individuals and families in their homes, in places of work, in schools and clinics. It is one of the basic services of health departments. The community health nurses, as members of the health team, are expected to integrate within the context of family health care, the priority programs of the Department of Health (Untalan, 2005). Community Health Nursing is a service rendered by a professional nurse with the community, groups, families and individuals at home, in health centers, in clinics, in school, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation. (Freeman, 2002).

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Concepts basic to nursing are used in working with the clients: individuals, families, group and communities. Some concepts of community health nursing are: The primary focus of community health nursing practice is on health promotion. The community health nurse, by the nature of his/her work, has the opportunity and responsibility for evaluating the health status of people and groups and relating them to practice; Community health nursing practice is extended to benefit not only the individual but the whole family and community; Community health nurses are generalists in terms of their practice through lifes continuumits full range of health problems and needs; Contact with the client and the family may continue over a long period of time which include all ages and all types of health care; The nature of community health nursing practice requires that current knowledge derived from the biological and social sciences, ecology, clinical nursing and community health organizations be utilized; The dynamic process of assessing, planning, implementing, and intervening, provide periodic measurements of progress, evaluation and continuum of the cycle until the termination of nursing is implicit in the practice of community health nursing (Green, 2005). The ultimate goal of community health services is to raise the level of health of the citizenry. To this end, the goal of community health nursing is to help communities and families to cope with the discontinuities in health and threats in such a way as to maximize their potential for high level of wellness, as well as to promote reciprocally supportive relationship
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between people and their physical and social environment (Allender et. al, 2010). Community Health Nurse Community health nurses work with these clients while looking at the effect of their health status on the health of the community as a whole. Most community health nurses and many staff public health nurses- both historically and at present- focus on providing direct care services, including health education, to persons or families outside of institutional settings, either in the home or clinic. Historically, the term community health nurse applied to all nurses who practiced in the community, regardless of whether they had preparation in public health nursing. Specifically, the community health nurse operates from a health care focus that is based on an understanding of broader community needs. The nurse is continually evaluating the community to see if changes are occurring that will influence the health of the people who live here (Allender et. al, 2010). Evidence that community health nurses are practicing effectively in the community would include the provision of the following: Provides quality services that can control costs; Focuses on disease prevention and health promotion; Organizes services where people live, work, play, and learn; Works in partnerships and with coalitions; Works across the life span and with culturally diverse populations; Works with at- risk populations to promote access to services; Develops the communitys
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capacity for health; Works with policy makers for policy change; Works to make the environment healthier (Flynn, 1998). The community health nurse promote health through education about prevailing health problems, proper nutrition, beneficial forms of exercise, and environmental factors such as safe food, water, air, and buildings. The community health nurse is likely to be involved in immunizing individuals as well as organizing the immunization programs for vaccinating the community for influenza, for example, and educating the community about the value of this service. Other individual and family services include maternal and child health care, treatment of common communicable and infectious diseases and injuries, and providing basic screening programs for such problems as lice, vision, hearing, and scoliosis (Zotti et. al., 1996). Community health nurses have always been involved in providing family-centered care to individuals, families and groups across the life span; they also work to identify high-risk groups in the community. Once such groups are identified, the community health nurse can work with others to develop appropriate policies and interventions to reduce risk and provide beneficial services. Both community health nurses and

community- based nurses must be aware of the cultural diversity and provide care that is appropriate to the needs of the recipient. Likewise, both groups of nurses provide care in homes (Green, 2005). Community Nurses Involvement in Community Activities
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Nursing care provision is an inherent function of the nurse. Her practice as a nurse is based on the science and art of caring, in whatever setting she may be or role she may have, providing nursing care is at the heart of it. Public health nursing is caring for individuals, families and communities toward health promotion and disease prevention; as such Public Health Nurses are expected to provide nursing care (Zotti et. al., 1996). This function of the Public Health Nurse brings activities or group of activities systematically into proper relation or harmony with each other. Public Health Nurses are the care coordinators for communities and their members. They are actively involved both socially and politically to empower individuals, families and communities as an entity to initiate and maintain health promoting environments (Allcott et. al, 2007). The Public Health Nurse understands that in the performance of her function in health promotion and education her activities go beyond health teachings and health information campaigns. She understands that health is determined by various factors such as physical and political environment, socio-economic status, personal coping skills and many other circumstances, and it is inappropriate to blame or credit a persons health to himself alone because he is unlikely to control many of these factors. Understanding the multidimensional nature of heath will enable her to plan and implement health promoting interventions for individuals and communities (Maurer et. al, 2009).
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As an educator, the nurse provides clients with information that allows them to make healthier choices and practices. Giving health

education is a very important function of the public health nurse. It is a basic health service. A health education activity is a major component of any public health program. In order to improve individual, family and

community health, correct knowledge, attitude and skill should be taught and subsequently practiced (Public Health Nursing in the Philippines, 2007). Primary Health Care According to the WHO (1978), PHC is more broadly defined than primary care. Primary care refers to personal health care that provides for first contact and continuous, comprehensive, and coordinated care. It addresses the most common needs of patients within a community by providing preventive, curative, and rehabilitative services to maximize their health and well-being. While PHC includes a comprehensive range of services including public health, preventive, diagnostic, therapeutic, and rehabilitative services. It is an essential health care made universally accessible to those individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country can afford every stage of development. Full community participation means that individuals within the community participate in defining health problems and developing approaches to

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address the problems. Any community in any country can be a setting for health care. The concept of primary health care is characterized by partnership and empowerment of the people that shall permeate as the core strategy in the effective provision of essential health services that are community based, accessible, acceptable and sustainable at a cost which the community and the government can afford. It is a strategy, which focuses responsibility for health on the individual, his family and the community. It includes the full participation and active involvement of the community towards the development of self-reliant people, capable of achieving an acceptable level of health and well being. It also recognizes the interrelationship between health and the overall political, socio-cultural and economic development of society (Public Health Nursing, 2007). Public Health Public health is a scientific discipline that includes the

epidemiology, statistics and assessment-including attention to behavioral, cultural, and economic factors-as well as program planning and policy development. In the recent years, efforts in the United states to change the way in which health care is delivered have focused heavily on looking at ways to change the delivery of medical care and health insurance. Limited attention has been focused on looking at the health of the population. Although people are excited when a new drug is discovered that cures a disease or when a new way to transplant organs is perfected,
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it is important to know about the significant gains in the health of populations that have come largely from public health accomplishments (Public Health Nursing, 2007). Another way of looking at the benefits of public health practice is to look at how early deaths can be prevented. The U.S. Public Health Service estimates that the medical treatment can prevent only about 10% of all early deaths in the U.S., whereas population-focused public helth approaches could health prevent about 70% of early deaths in America through measures that influence the way people eat, drink, drive, engage in exercise, and treat the environment(U.S. Department of Health and Human Services, 2000). Public health practice provides many benefits, especially considering the small portion of te health care in the United States that is used for this prevention and population-focused specialty (Public Health Nursing, 2007). Public health is best described as what society collective does to ensure that conditions exist in which people can be. Public health is a community-oriented, population-focused specialty area. The overall mission of the public health is to organize community efforts that will use scientific and technical knowledge to prevent disease and promote health (Institute of Medicine, 2003). Hanlon(2006) stresses that public health is dedicated to the common attainment of the highest level of physical, mental and social well-being and longevity consistent with available knowledge and
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resources at a given time and place. It holds this goal as its contribution to the most effective total development and life of the individual and his society. Factors Affecting Health Social and economic factors predispose people to vulnerability Poverty, a limited social support, and examples of limitations in physical and environmental resources. People with preexisting illnesses, such those with communicable or diseases or those with chronic illnesses such as cancer, heart disease or chronic airway disease, have less physical ability to cope with stress than those without such physical problems. Human capital refers to all the strengths, knowledge and skills that enable a person to live a productive, happy life. People with little education have less human capital because their choices are more limited than are those of people with higher levels of education. Some groups such as poor, the homeless and migrant workers are invisible to society as a whole and tend to be forgotten in health and social planning. Health disparities refer to the wide variations in health services and and health status among certain population groups (U.S. Department of Health and Human Services, 2001). The World Health Organization defines health as a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The modern concept of health refers to optimum level of individuals, families and communities (Kozier, 2007).
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Demography Demography is the science which deals with the study of the human populations size, composition and distribution in space e. Population size simply refers to the number of people or area at a given time. When the population is characterized in relation to certain variables such as age, sex, occupation or educational level, then the population composition is being described. The nurse also describes how people are distributed in a specific geographic location (Maglaya, 2004). Demography reflects population diversity and trends by studying population composition, growth, and movement. Birth, death, and migration data from demography combine with the study of disease transmission and distribution in population constitute epidemiology. We introduced human ecology, the study of population interactions with physical and biological environments, in the last chapter. We intended this to social ecology in examining how these interactions develop as a function of social processes. Demography takes up the study of population trends as measured over time by three sets of data. One consists of vital indexes such as birthdates and death rates. A second consists of measures of population diversity such as ethnic composition, density, rural-urban-suburban residential patterns, and migration. The third consists of socioeconomic indicators such as income, occupation, and educational attainment (Stanhope et. al, 2010).

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Seasonal variations in population movement and vital rates result partly from climate and partly from cultural and social conditions affecting employment and traditions associated with seasons and holidays. In North America, for example, the highest death rates tend to occur in the winter months. The holiday season of Christmas and New Years and contribute a large share of the increase through automobile crashes, suicides, and heart attacks. the relatively higher incidence of respiratory conditions and associated deaths in the winter attest to some climate effect, but not just because of exposure to cold temperatures. Some of it is attributable to being more exposed to tge transmission of communicable diseases among people confined indoors. The latter explanation suggests that social norms of adaption to climate conditions are important in providing protection and in exposing the individual to additional risk (Green et. al., 2005). Sources of Demographic Data Population demographics have also affected the demand for health care services. A community can be assessed by analyzing the characteristics of the people in that community. These characteristics are defined through the demographics of the community, which include the number, composition by age, rate of growth and decline, social class, and mobility of the people in the community. Other vital statistics include the birth rate, overall death rate (mortality), mortality by cause and by age, and infant mortality rate. Of these, the infant mortality rate is considered to
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be the most important statistical indicator regarding the level of maternalinfant health in a community. Vital statistics also include morbidity or rate of a particular disease within a community. These vital statistics are the vital signs of the community. They tell a very important story about the health of a community or population (Hunt, 2009).

General Household Data and Economic Data In 2001, the average life expectancy at birth was 69.25 years- 71.9 for females and 66.6 for males- up from 68.6 years in 1999. The countrys population is very young; thirty-nine percent (39%) of the total population in 1994 was estimated to be in the 0-14 age group. Only 5% were 60 years old and above. Given these percentages, the dependency ratio was computed to be 79, that is, there are 79 people who depend on 100 people in the productive age group (15-59) (www.doh.gov.ph, 2005). According to the National Statistics Office, the simple literacy rate of the Philippines as of year 2000 is 92.3 % in the year 1997. The average annual income of a family is 147,888 as of 2003 from the year 1997 of 127,168 and expenditure 99,537 in year 1997. The poverty incidence is 31.88 % of total families in the year 1997 (poverty threshold 2000 in rural areas of SOCSKARGEN region is 11,238 and 14,396 in urban areas). The Philippines has an 8.2% as of April 2006 from 16.9% as of January 2001 as our unemployment rate and 25.4 % April 2006 unemployment rate from the 1997: 11.4 % unemployment rate.
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The underemployment rate of the Philippines is continuously increasing and the unemployment rate of the Philippines is continuously decreasing. Also the literacy rate of the Filipinos is decreasing. There are 35,224 Filipinos who are in the labor force and 1,591 of them are from Region 12. There are only 32,384 people employed in our country today and 1,497 of them are from Region 12. (www.census.gov.ph, 2006). Social and Cultural Factors Every community, every social or ethnic group has its own culture. Furthermore, all the individual members behave in the context of that specific culture. Each of us belongs to a group or set of overlapping groups that influences our thoughts and actions. Even very small elements of everyday living are influenced by our culture. For instance, culture determines the distance we stand from another person while talking. Consider how culture influences our perception of time. When we make an appointment to see someone, we expect the other person to be on time or not more than a few minutes late (Hunt, 2009). Culture profoundly influences thinking and behavior, is an essential dimension of health care. Just as physical and psychological factors determine clients needs and attitudes toward health and illness, so too does culture. Kark emphasizes that culture is perhaps the most relevant social determinant of community health. Culture influences diet ad eating practices. Culture determines how people rear their children, react to pain, cope with stress, deal with death, respond to health practitioners, and
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value the past, present, and future, yet the concept of culture is not always clearly understood or incorporated into health care. Culture includes more than race and ethnicity and may include a persons gender, religion, socioeconomic status, sexual orientation, age, environment, family background, and life experiences. Barriers to providing culturally

competent care are stereotyping, prejudice and racism, ethnocentrism, cultural imposition, cultural conflict, and cultural shock (Stanhope et. al, 2010). Although all cultures are not the same, all cultures have the same basic organizing factors. These factors should be explored in a cultural assessment because of the potential for differences among groups. Variations among cultures are reflected in verbal styles and in nonverbal styles. Basic to successful interactions between clients and providers is the understanding that we are all different from one another, with different ethnic and cultural backgrounds, and therefore, different health and illness beliefs and practices. But despite our differences, we come together at a mutually agreed on place to achieve a common goal: to maintain or regain health. The dilemma presented here is that health means different things to each of us; we recognize it and measure changes in it differently, act in diverse ways when faced with these changes, and seek different methods for achieving healing outcomes (Anderson et. al., 2008). Socioeconomic Status
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Socioeconomic

factors

contribute

greatly

to

understanding

perceptions of health and illness among minority. These groups may not have opportunities for education, occupation, income earning, and property ownership similar to those of the dominant group. Socioeconomic status is a critical factor in determining access to health care and the development of some chronic health problems. The proportion of poor families in a minority group is greater. Consequently, minority group is greater. Minority families are disproportionately represented on the lower tiers of the socioeconomic ladder. Poor economic achievement is also common characteristic found among populations at risk, such as those in poverty, the homeless, migrant workers, and refugees. Data suggest that when nurses and clients come from the same social class, it is more likely that they operate from the same health belief model and consequently there is opportunity for misinterpretation and health problems in communication (Stanhope et. al, 2010). There is also danger in believing that certain cultural behaviors, such as folk practices, are restricted to lower socioeconomic classes. Nurses must conduct a cultural assessment for all individuals when they first come in contact with them. Nurses should have guidance in integrating cultural concepts with other aspects of client care to meet their clients total health care needs. Nurses should be able to distinguish between issues of culture and socioeconomic class and not misinterpret

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behavior as having a cultural origin, when in fact it should be attributed to socioeconomic (Stanhope et. al, 2010). Geography, Topography and Climate Geography refers to the surface of the earth. Topography indicates the detailed mapping or charting of the features of a relatively small area, district, or locality. With climate, the composite or generally prevailing weather conditions of a region, as temperature, air pressure, humidity, precipitation, sunshine, cloudiness, and winds, throughout the year, averaged over a series of years (Zotti et. al., 1996). Environmental Health Environment is the accumulation of physical, social, cultural, economic and political conditions that influence the lives of communities. The communitys health depends on the integrity of the physical environment, the humaneness of the social relations in the environment, the availability of the resources necessary to sustain life and manage illness, the equitable distribution of health risks, attainable employment and education, cultural preservation and tolerance of diversity among subgroups, access to historical heritage, and a sense of empowerment and hope (Hall et. al., 2007). Environmental health is of ever-increasing importance to

community health nursing practice. Accumulated evidence shows that the environmental changes of the past few decades have profoundly
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influenced the status of public health. The safety, beauty, and lifesustaining capacity of the physical environment are unquestionably of global consequence (Hunt, 2009). The ultimate goal of the critical practice of community health nursing is liberating people from health-damaging environmental

conditions (Bent, 2003). From a critical standpoint, helping communities become more aware of the environmental effects on health and helping them make needed changes in their environment are legitimate nursing actions (Hall et. al., 2007). Nutrition American Medicine Association, defined Nutrition as the science of food, the nutrients and the substances therein, there action, interaction, and balance in relation to health and diagnosis, and the focus by the organism ingest, digest, absorbs, transports, utilizes and excretes food substances. This is one key to developing and maintaining a state of optimal health. In addition, it is an essential component of life and therefore an important body of knowledge to consider in discussion of child growth and development. The body requires a wide array of intake products, such as carbohydrates, proteins, fat and micronutrients like vitamins and minerals (Wardlaw et. al., 2007). Promoting good nutrition and dietary habits is one of the most important parts of maintaining child health. The first 6 years are the most important for developing sound lifetime eating habits. The quality of
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nutrition has been widely accepted as an important influence on growth and development. It is now becoming recognized for an important role in disease prevention. Atherosclerosis begins during childhood. Other diseases, such as obesity, diabetes, osteoporosis, and cancer, may have early beginnings also. Low income and minority families are at increased risk for poor nutrition, but all groups show poor dietary habits (Stancope et. al., 2009). Growth Monitoring Growth monitoring involves following changes in a child's physical development, by regular measurement of weight, and sometimes of length. It is an important tool in individual care, for early detection of health and nutrition problems in growing children (Healy et. al., 1988). Immunization The development and widespread use of immunization has been one of the great breakthroughs of modern medicine. It is one of the important elements of health promotion and disease prevention. This provides artificial immunity to a number of dangerous infections, including measles, mumps, rubella, diphtheria, tetanus, pertussis, poliomyelitis and varicella (Pilliteri, 2008). Immunization recommendations rapidly change as new information and products are available. The main goal of the guidelines is to provide flexibility to ensure that the largest number of children will be immunized. All health care providers are urged to access immunization status at every
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encounter with children and to update immunizations whenever possible (Stancope et. al., 2009). Breastfeeding The natural first food of babies is breast milk and its intake should be encouraged for all infants, American Association for pediatrics believes that breastfeeding is the best source of nutrition for babies through the first birthday and should be encouraged by health professionals. It provides excellent nutritional balance, promotes gastrointestinal function, foster immune defenses, psychological benefits and economic advantage (Ladwigs et. al., 2007). Breastfeeding is the preferred method of infant feeding. Breastfed infants have fewer illnesses and allergies. If breastfeeding is not chosen, commercially prepared formulas are an acceptable alternative. Although evaporated milk with added sugar has been used in the past as a low-cost alternative to breast milk, it is now discouraged. Errors in mixing and the lack of vitamins and minerals have been common problems (Stancope et. al., 2009). Family Planning The term family planning is sometimes used interchangeably with the term birth control, although there are some differences between the two terms. While birth control is something anybody can use to prevent pregnancy, family planning is seen as something monogamous couples
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use to temporarily delay pregnancy. In this way, family planning is seen as a method to plan, rather than prevent, children. Family planning is seen as the responsible choice for couples who are not ready to have children in the present but may want to in the future (Sidey et. al., 2005). Family planning includes all methods of birth control, from the pill to condoms, Intrauterine Devices (IUD), injectable hormonal contraceptives, and diaphragms, caps and spermicides. Depending on the area, family planning may also refer to methods used to terminate a pregnancy or possible pregnancy, such as abortion and emergency contraception. Family planning may also refer to surgical sterilization methods, including vasectomies and tubal ligation; and to non-surgical methods of sterilization (Stancope et. al., 2009). It is also the term preferred by religious couples who do not approved of using artificial birth control methods to prevent pregnancy. In this case, family planning, sometimes called natural family planning, refers exclusively to techniques such as temporary abstinence, the withdrawal method, or the rhythm method, in which no outside interference is used. While family planning clinics do not favor any method over others, they are usually able to accommodate most preferences and beliefs (Hunt, 2009).

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