Psychosocial Foundation of Nursing I Clement
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SECTION 1
General Concepts

Health and Illness1

 
DEFINITIONS
  1. Acute illness: Illness characterized by symptoms that are of relatively short duration, are usually severe and affect the functioning of the clients in all dimensions.
  2. Adaptation: Process by which changes occur in any of a person's dimensions in response to stress.
  3. Etiology: Identification of the cause of a problem. The cause may be direct or a contributing factor in the development of client problem or need.
  4. Health: Dynamic state in which an individual adapts to internal and external environments so that there is a state of physical, emotional, intellectual, social and spiritual well-being.
  5. Health behavior: Activities through which a person maintain, attains or regains behavior as an expression of personal health beliefs.
  6. Health- belief model: Conceptual framework that predicts a person's health behavior as an expression of personal beliefs.
  7. Health- illness continuum: Scale by means of which a personnel's level of health can be described, ranging from high level wellness to severe illness. The scales take in to account the presence of risk factors.
  8. Health promotion: Activities directed toward maintain or enhancing the health and well-being of clients.
  9. Health promoting behavior: Considered a third subcategory of health behavior and through assessment, reveal needs for vehicular safety, home safety, domestic violence recognition, recreational safety, occupational safety and health.
  10. Holistic health: A system of compressive or total care that considers the physical, emotional, social, economical and spiritual needs of the person the response to the illness, and the effect of the illness on the person's ability to meet self care needs.
  11. Models: Models are graphic or symbolic representations of phenomena that objectify and present certain perspectives or points of view about nature or function or both.
  12. Concept: Concepts are the elements or components of a phenomenon necessary to understand the phenomenon and derived from impressions the human mind receives about phenomena through sensing the human environment.
  13. Philosophy: A philosophy is statement of belief and values about human being and their world.
  14. Theory: Theory refers to a set of logically inter-related concepts, statement, proposition and definitions which have been derived from philosophical beliefs of scientific data and from which questions or hypothesis an be deduced, tested and verified.
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  15. Health: A state of physical, mental and social well-being and the absence of disease or other disorders. It involves constant change and adaptation to stress.
  16. Community: Community as a group of inhabitants living together in a somewhat localized area under the same general regulations and having common interests, functions, needs and organizations.
  17. Nursing: Nursing is an art, science and profession by which we render, serve to human being to help him to regain or to keep a normal state of body and mind and when it cannot accomplish this, it help him for the relief from physical pain, mental anxiety or spiritual discomfort.
  18. Community health: Community (public) health is a science and art of preventing disease, prolonging life and promoting health and efficiency through organized effort.
  19. Community health nursing: Community health nursing is a synthesis of nursing and public health practice applied of promoting and preserving the health of people. The practice is general and compressive. It is not limited to a particular age group or diagnosis, and continuing, not episodic.
  20. Profession: A profession is an occupation with moral principles that are devoted to the human and social welfare. The service is based on specialized knowledge and skill developed in a scientific and learned manner.
  21. Quality care: The degree of which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
  22. Health care team: Health care team refers to all of the personal in all of the departments of a health care facility, who provides health care services. They are doctors, nurses, technicians and paramedical staffs.
  23. Primary nursing: In primary nursing, a professional nurse has total responsibility for a particular patient or group of patients. The model's purpose is to provide continuity and coordination of care.
  24. Primary health care: It is a essential health care based on practical, scientifically sound and socially accepted methods and technology, made universally acceptable to individuals and families in the community involving their full participation and at a cost that the community and country can afford to maintain at every stage of their development.
  25. Health center: It is defined as an institution for the promotion of health and welfare of the people in a given area, which seeks to achieve health work through coordination with welfare and relive organization.
  26. Comprehensive health care: Comprehensive health care is the combined (integrated) curative, preventive, promotive and restorative care made available to the people without distinctions of caste, creed or economic status from birth to death (from womb to tomb).
  27. Primary health center: Primary health center is an institution for providing comprehensives health care, e.g. preventive, promotive and curative services, to the people living in a defined geographical area. It seeks to achieve its purpose by grouping under one roof or coordinate all the health work of that area.
  28. Health for all: Health for all has been defined as attainment of a level of health that will enable every individual to lead a socially and economically productive life.
  29. Community development block: Community development is a process which is designed to promote better living of the whole community, with the active participation by the community itself along with governmental efforts.
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  30. Community health nurse: Community health nurse is person plays important role in helping people learn to care themselves and to work with other community residents to develop the capacity or infrastructure needed to ensure essential health care for every one.
  31. Disease: Any deviation from or interruption of the normal structure or function of any part, organ or system of the body, manifesting with a characteristic set of sign and symptoms.
 
CONCEPT OF HEALTH
Health is considered by many as the opposite of illness or disease. For some, it means a well developed or adequately nourished body, capable of various activities and able to withstand physical stress. All communities have their concepts of health integrated as a part of their culture. Widely differing culture groups share the concept of health as a state of balance and harmony.
The WHO has defined health as a State of complete physical, mental, social, spiritual well-being, and not merely absence of disease or infirmity. The concept of positive wholeness or completeness is emphasized and health is seen as more than a physical state. An individual's health is never static and is always in a dynamic equilibrium with his environment.
Physical well-being is measurable although it is of varying ranges and validity. As regards mental well-being, measurable standards vary from culture to culture and hence the criteria for mental well-being may differ from one country to another or from place to place within the same country. There is also difference of opinion as to what is precisely meant by social well-being. Social well-being may be regarded as a state of predisposing condition of health.
Traditionally health has been defined in terms of the presence or absence of disease. Nightingale defined health as a state of being well and using every power the individual possess to the fullest extent. It reflects concern for the individual as a total person functioning physically, psychologically and socially. Mental processes determine people's relationship with their physical and social surrounding their attitudes about life and their interaction with others.
 
MULTIPLE FACTS OF HEALTH—WHO
  1. Health a three-dimensional state: “Health is a state of complete physical, mental and social well being and not merely the absence of disease or infirmity.”
  2. Health a fundamental right: “The enjoy­ment of the highest attainable standards of health is one of the fundamental rights of every human being, without distinction of race, religion, and political belief, economic and social condition.”
  3. Health for peace and security: “The health for all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest cooperation of individuals.”
  4. Health a government responsibility: “Government have a responsibility for the health of their peoples, which can be fulfilled only by the provision of adequate health and social measures.”
  5. Health and health information: “The extension to all people of the benefits of medical, psychological, and related know­ledge is essential to be fullest attainment of health.“
  6. Health and people cooperation: “Informed opinion and active cooperation on the part of the public, are of the utmost importance in the improvement of health of the people.”
  7. Health and health care: “Unequal develop­ment in different countries in the promotion of health and control of disease, especially communicable disease is a common danger.”
  8. Health and child development: “Healthy development of the child is of basic importance. The ability to live harmonically in changing total environment is essential to such development.”
  9. Health “gain for all“: The achievement of any state in the promotion and protection of health is of value to all.
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CONCEPTIONS OF HEALTH MODELS
Smith (1983) describes the various conceptions of health in four models. These are the clinical, role—performance, adaptive and eudemonistic models. Each of these models can be defined by the characterization of the extremes of health-illness continuum.
  1. Clinical model:
    Health extreme: Absence of signs or symptoms of disease or disability as identified by Medical science.
    Illness extreme: Conspicuous presence of these signs and symptoms.
  2. Role performance model:
    Health extreme: Performance of social roles with maximal expected output.
    Illness extreme: Failure in performance role.
  3. Adoptive model:
    Health extreme: Flexible adaptation of the person to the environment and interaction with it to the maximal advantage.
    Illness extreme: Alienation of the person from the environment and failure of self-corrective responses.
  4. Eudemonistic model:
    Health extreme: Exuberant well-being.
    Illness extreme: Enervation, languishing debility.
 
CONCEPT OF DISEASE
Disease can be considered as something more than mere deviation from health, each disease being a distinct entity, with distinguishing qualities in its pathologic process, its typical clinical appearance and often its characteristic epidemiologic pattern of distribution in terms of time, place and person. The concept of disease also may vary from one society to another society. There will be no difficulty in distinguishing an illness which is severe enough to necessitate bed rest and treatment.
But milder condition of disease and in apparent or subcilinical conditions which do not make these individual take to bed are likely to be missed or ignored. Just like the border-line health conditions, diseases of mild nature and in apparent or subclinical conditions are supposed to lie in the middle of a spectrum.
At one end of this spectrum is “optimal health” and at the other end “serious disease” and in between those two ends, various grades of health and disease are located. The milder the disease or the more border-line the health, the more difficult it is to differentiate between health and disease.
 
FACTORS INFLUENCING HEALTH
Health influenced by various factors which interact with each other and determine the health status of many individual, family and community at large at any given point of time. These factors known as determinants of health. According to WHO expert committee on community health nursing – Technical report series 558 (1974) and Blum, theses factors are categorized as human biology, environment, lifestyle, health and health allied resources.
 
Human Biology
  1. Genetic inheritance: Hereditary or genetic predisposition to specific illness is a major physical risk factor. For example, a person with a family history of diabetes mellitus is at risk for developing the disease later in life. Other documented genetic risk factors include family his histories of cancer, coronary disease and renal disease.
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  2. Age: Age increases susceptibility to certain illness. For example, the risk of cardiovascular disease increases with age for both sexes. The risk of birth defects and complications of pregnancy increase in women-bearing children after age 35. Age risk factors are often closely associated with other risk factors such as family history and personal habits.
  3. Race: Race increases susceptibility to certain illness. For example, the risk of sickle cell anemia is more common in Africans and Mediterranean people.
  4. Self concept: Self concept implies individual's perception of his or physical, intellectual and social abilities.
 
Environment
  1. The physical environment: The physical environment includes atmospheric pressures, gravity, light and sound waves, temperature, humidity, wind velocity, solar radiation, electromagnetic fields and seasonal variations, etc. The variety of pollutants are found to pollute air, water, food and soil and are the cause of various acute and chronic diseases, e.g. gastrointestinal, respiratory, skin cancer, cardiovascular diseases, etc.
  2. The biological environment: Most of the plants and animals are useful to human being to promote health but are the same time, they human being to promote health but are the same time, the produce diseases like malaria, insect bits and allergic reactions.
  3. The social environment: The social environments include other people and social institutions, sociocultural events, religious beliefs, moral and ethical values and social rules and regulations, pertaining to living society, socioeconomic support system.
 
Life Style
Many activities, habits and practices involve risk factors, the stresses of life crises and frequent life changes also risk factors. Health practices and behaviors can have positive or negative effects in health. Practices with potential negative effects are risk factor these include overeating or poor nutrition, insufficient rest and sleep and poor personal hygiene.
Other habits that put a person at risk for illness include smoking alcohol or drug abuse, and activities involving a threat of injury such as skydiving or mountain climbing. Some habits are risk factors for specific diseases. For example, excessive sunbathing increases the risk of skin cancer, and being overweight increases the risk of cardiovascular disease.
Prolonged emotional stress may increase the chance of illness. Emotional stress may occur with events such as divorce, pregnancy and arguments. Job-related stresses, for example, many overtax a person's cognitive skills and decision making ability leading to mental overload or burnout.
 
Health and Health Allied Resources
  1. Health services: Health services are directly concerned with improvement of health status of people. Health services can also contribute on socioeconomic development of people because sound health can improve and increase the physical, intellectual and emotional capacity of people to get educated, work and earn for their livelihood improve their life style which will further reinforce their health.
  2. Socioeconomic conditions: Socioeconomic conditions have significant influence on community health. In developed countries like America, UK and Canada, there has been significant reduction in the morbidity and mortality rates and increases in longevity at birth because of socioeconomic, developments. Socioeconomic conditions include economic status, education, occupation and living standards.
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  3. Political system: The political system has a very strong role in health promotion of people in the country. The health care delivery system is determined by the political system though there is constitutional control. Decisions pertaining to health policy, allocation of funds, programs, manpower development, infrastructure, health technology and delivery of health services are made by the ruling party within the parliament system.
  4. Health related services: The health related services include education governmental policies; social welfare developmental programs food and agriculture, industry, communication and broadcasting rural and urban development and transportation facilities. The health related services needs to have balanced approach between National Health Policy and Voluntary Health Promotes Active Participation.
 
CULTURAL FACTORS IN HEALTH AND DISEASE
The member of a particular society quite unconsciously agrees upon a common pattern of living. It includes basic rules for living together. These rules could be understood as the culture of the society. The behavior pattern of a particular culture are not biologically inherited but socially acquired through learning.
Concept of etiology and cure: Supernatural causes like wrath of god and goodness, breach of taboo, past sins, evil eye and spirit or ghost intrusion. Physical causes include the effects of weather, water and impure blood.
  1. Environmental sanitation: Sanitation is the science of safeguarding health. It is the quality of living that is exposed in the clean home, the clean farm, the clean business, the clean neighborhood and the clean community. Environmental sanitation is nothing but the introduction of such methods which bring about control of all the factors in the physical environment.
  2. Food habits: Food habits have deep psychological roots and are associated with love, affection, warmth, self-image and social prestige. The diet of the people is influenced by local conditions, religious customs and beliefs. Vegetarianism and hindus beliefs—these food habits have a religious sanction from early days.
  3. Mother and child health: Mother and child health is surrounded by a wide range of customs and beliefs all over the world. MCH care and good customs such as prolonged breastfeeding, oil bath, massage and exposure to sun. MCH care and bad customs are the child is not put to breast during the first 3 days of birth because of the belief that colostrums might be harmful.
  4. Personal hygiene: Hygiene is the science of health and includes all factors which contribute to healthful living. Personal hygiene includes all those personal factors which influence the health and well being of an individual. The practice of an oil bath is a good Indian custom. Circumcision is a prevalent custom among muslims which has a religious sanction.
  5. Sex and marriage: Sexual customs vary among different social, religious and ethnic groups. Orthodox Jews are forbidden to have intercourse for seven days after the menstruation ceases, these custom have an important bearing in family planning. Marriage is sacred. It is the usual social custom in India to perform marriages early at about the age of puberty. Child marriages are fortunately disappearing. The high rate of venereal diseases in Himachal Pradesh is attributed to the local marriage customs.
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CONCEPT OF NURSING
Nurses provide care for three types of clients: Individuals, families and communities. Nursing practice involves four areas: Promoting health and wellness, preventing illness, restoring health and care of dying.
  1. Promoting health and wellness: Wellness is a state of well-being. It means engaging in attitudes and behavior that enhance the quality of life and maximize personal potential. Nurses promote wellness in clients who are both healthy and ill. This may involve individual and community activities to enhance healthy lifestyles such as improving nutrition and physical fitness, preventing drug and alcohol misuse, restricting smoking and preventing accidents and injury in home and work place.
  2. Preventing illness: The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care and prevention of sexually transmitted disease.
  3. Restoring health: Restoring health focuses on the ill client and it extends from early detection of disease through helping the client during the recovery period. Nursing activities such as providing direct care to the ill person, performing diagnostic and assessment procedures, teaching clients about recovery activities and rehabilitating client to their optimal functional level following physical or mental injury.
  4. Care of dying: This area of nursing practice involves comforting and caring for people of all ages who are dying. It includes helping clients live as comfortably as possible until death and helping support persons cope with death. Nurses carry out these activities work in homes, hospitals and extended care facilities.
 
DEFINITIONS OF HEALTH AND NURSING
 
Health
Health is recognized as a “fundamental right of every human being. The widely accepted definition of health is that given by the World Health Organization (WHO) which states:
“Health is a state of complete physical, mental, social, spiritual well-being, and not merely an absence of disease or infirmity”—WHO.
“Health is a quality of life resulting from total functioning of the individual that empower him to achieve personally satisfying and socially useful life”—Webster.
“Health is quality of life that enables individuals to live, and serve best”—William.
“Health is defined as dynamic state of wellness which exists on a continuum and ranges from a high level of wellness to high level of illness”—Dunn.
 
Nursing
Nursing is a service which includes ministration to the sick, care of the whole patient (his mind as well as body), the care of the patient's environment (physical as well as social), health education and health services to the individual family and society for the prevention of disease and promotion of health.
Nursing is the unique function of the nurse that is to assist the individual (sick or well) in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge (Virginia Henderson).8
Nursing practice is a direct service, goal directed and adaptable to the needs of the individual, the family and community during their health and illness”—American Nurses Association.
 
INTRODUCTION TO HEALTH AND ILLNESS
  1. Health in its broadest sense is a dynamic state in which the individual adapts to changes in internal and external environments to maintain a state of wellbeing. The internal environment includes many factors that influence health, including genetic and psychological variables, intellectual and spiritual dimensions and disease processes.
  2. The external environment includes factors outside the person that may influence health, including factors outside the person that may influence health, including the physical environment, social relationships, and economic variables because both environments continuously change, the person must maintain a state of well being.
  3. Health and illness therefore must be defined in terms of individual. Health can include conditions that the client or nurse may have previously considered to be illness. Health is also closely related to an individual's work place and home life and stressors can be the result of those environments.
 
CONCEPTS OF HEALTH, ILLNESS AND SICK BEHAVIORS
  1. It is useful for the nurse to be aware of the behavioral components of health, illness and sick role behavior.
  2. Every person develops a system of health beliefs and attitudes, and these tend to fall within the framework provided by society or cultural heritage.
  3. Health behavior activities a person engages in, when feeling well, to take measures to prevent disease and illness or to detect them before symptom occur.
  4. Illness behavior activities a person engages in, when feeling ill, that will lead to the defining of the state of health and that will gain help.
  5. Sick-role behavior, activities a person engages in believing himself ill. For any individual the level of health behavior is determined by the significance of symptoms—danger value, visibility, ambiguity, fear of unknown, the expectations of those from whom help is sought, feeling about dependence and fear of loss of control, the expectations of the illness position, including past experiences with illness.
 
ILLNESS -ILLNESS BEHAVIOR
  1. Illness is not merely the presence of disease process. Illness is a state in which a person's physical, emotional, intellectual, social, developmental or spiritual functioning is diminished or impaired compared with that person's previous experiences.
  2. Illness behavior involves the ways persons monitor their bodies, definite and interpret their symptoms, take remedial actions, and use their health care system.
  3. The important internal values influencing the way clients behave when they are ill are their perceptions of symptoms and the nature of the illness. A client's illness behavior can also be affected by the nature of the illness.
  4. Acute illness involves symptoms of relatively short duration that are usually severe and may affect functioning in any dimension.
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  5. Chronic illnesses persist, usually longer than 6 months, and can affect functioning in any dimension.
  6. External variables influencing a client's illness behavior include the visibility of symptoms, social groups, cultural background, economic variables, accessibility of the health care system and social support.
 
STAGES OF ILLNESS BEHAVIOR
 
Symptom Experience
  1. During the initial stage, a person is aware that some thing is wrong. A person usually recognizes a physical sensation or a limitation in functioning but does not suspect a specific diagnosis.
  2. The person's perception of symptoms includes awareness of a physical change such as pain, a rash, or a lump.
 
Assumption of the Sick Role
  1. The assumption of the sick role results in emotional changes, such as withdrawal or depression, and physical changes.
  2. Emotional changes may be simple or complex, depending on the severity of the illness, the degree of disability and anticipated length of the illness.
 
Medical Care Contact
  1. If symptoms persist despite home remedies, become severe or require emergency care, the person is motivated to seek professional health services.
  2. In this stage the client seeks/expect acknowledgement of the illness, as well as treatment. In addition, the client seeks an explanation of the symptoms, the cause of the symptoms, the course of the illness for future health.
  3. Client's illness can be validated at any point on the health illness continuum. A health professional may determine that they do not have an illness or that illnesses are present and may be life threatening.
 
Dependent Client Role
  1. After accepting the illness and seeking treatment, the client enters the fourth stage of illness behavior.
  2. In this stage, the client depends on health care professionals for relief of symptoms. The client accepts care, sympathy and protection from the demands and stresses of life.
  3. It is socially permissible for clients in the dependent role to be relieved of normal obligations and tasks.
 
Recovery Stage
  1. The final stage of illness behavior—recovery and rehabilitation—can arrive suddenly, such as when a fever subsides.
  2. The recovery is not prompt; long-term care may be required before the client is able to resume an optimal level of functioning.
  3. In the case of chronic illness, the final stage may involve an adjustment to a prolonged reduction in health and functioning.
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IMPACT OF ILLNESS ON FAMILY
 
Behavioral and Emotional Changes
  1. People react differently to illness. Individual behavioral and emotional reactions depend on the nature of the illness, the client's attitude toward it, the reaction of others to it, and the variables of illness behavior.
  2. Severe illness, particularly one that is life threatening, can lead to more extensive emotional and behavioral change, such as anxiety, shock, dental, anger and withdrawal.
 
Impact of Family Roles
  1. When an illness occurs, the roles of client and family may change. Such a change may be subtle and short term or drastic and long term.
  2. An individual and family generally adjust more easily to subtle, short-term changes. In most cases they know that the role change is only temporary.
  3. Long term changes, however, require an adjustment process similar to the grief process. The client and family often require specific counseling and guidance to assist them in coping with role changes.
 
Impact on Body Changes
  1. Some illnesses result in changes in physical appearance, and clients and families react differently to these changes.
  2. When changes in body image occur, such as results from a leg amputation, the client generally adjusts in the following phases: shock, withdrawal, acknowledgment, acceptance and rehabilitation.
  3. Withdrawal is an adaptive coping mechanism that can assist the client in making the adjustments.
 
Impact of Self-concepts
  1. Self-concept is individual's mental image of themselves, including how they view their strengths and weaknesses in all aspects of their personalities.
  2. Self-concepts depend in part of body image and roles but also include other aspects of the psychological and spiritual self.
  3. Self-concept changes because of illness may no longer meet the expectations of the family, leading to tension or conflict.
 
Impact of Family Dynamics
  1. Family dynamics is the process by which the family functions, makes decisions, give support to individual members, and copes with everyday changes and challenges.
  2. If a parent in a family becomes ill, family activities and decision making often come to a habit as the other family members wait for the illness to pass, or they delay action because they are reluctant to assume the ill person's roles or responsibilities.
 
HEALTH-ILLNESS CONTINUUM (FIG. 1.1)
  1. According to Neuman (1990), health on a continuum is the degree of client wellness that exist at any point in time ranging from an optimal wellness condition, with available energy at its maximum, to death, which represents total energy depletion.
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    zoom view
    Fig. 1.1: Health maintainee-strategies
  2. According to health-illness continuum model, health is a dynamic state that continuously alters as a person adapts to changes in the internal and external environments to maintain a state of physical, emotional, intellectual, social, developmental and spiritual well-being.
  3. The continuum is thought of a complex, dynamic process that includes physical, psychological and social components. There are adoptive or maladaptive behavioral responses to internal and external stimuli.
  4. Health and illness tend to merge but may represent patterns of adoptive change along the continuum. The direction of change may be reversible, depending on the quality of the individual's adoptive efforts.
  5. The individual at the illness end of the continuum is characterized by feeling of uncertainty, helplessness, loss of control, loss of identity and incapacity for problem solving.
  6. As the patient is in the sick role, there is incapacity to meet other social roles, the person has sought diagnosis and get treatment.
  7. Less far along the illness end of the continuum, as illness behavior are brought in to play, the person may be tired, rundown and irritable with complaints of loss of sleep, appetite, dependence, self-absorption, minor illnesses such as colds, infections, headaches and backaches.
  8. Between illness and wellness there is the ambiguous area where no symptoms are present and the person is neither especially well nor especially ill.
  9. At the health end of the continuum, as health behaviors are utilized, the person is not only unaware of disease and with out pain, fatigue or somatic complications but also tends to be resistant to infections, industrious, vigorous and physically agile, with a strong sense of identity and autonomy, carring out usual social roles and needing no health care.
  10. The goal in preventive health care is to maintain equilibrium between health and illness, with balance in favor of maximum wellness for the individual.
 
MODELS OF HEALTH AND ILLNESS (FIG. 1.2)
 
Health-wellness Model
  1. It was developed by Dunn (1997), the high level wellness model is oriented toward maximizing the health potential of an individual.
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    zoom view
    Fig. 1.2: Health and illness continuation model
  2. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment.
  3. It involves progress toward a higher level of functioning open-ended and expanding challenges to live at the fullest potential.
 
Agent-host-environmental Model
  1. The agent-host-environmental model of health and illness originated in the community health work of Level et al.
  2. According to this approach the health or illness of an individual or group depends on the dynamic relationship of the agent, host and environment.
  3. The agent is any internal or external factors that its presence or absence can lead to disease or illness.
  4. The host is the person or persons who may be susceptible to a particular illness or diseases.
  5. The environment consists of all factors outside of the host. It includes physical environment, social environment and biological environment.
 
Health Belief Model
  1. Rosenstoch's (1794) and Bakerand Maiman's (1975) health belief model addresses the relationship between a person's belief and behavior.
  2. It provides a way of understanding and predicating how clients will behave in relations to their health and how they will comply with health care therapies.
  3. The first component in this model involves the individual's perception of susceptibility to an illness.
  4. The second component is the individual's perception of the seriousness of the illness. This perception is influenced and modified by demographic and sociopsychological variables, perceived threats of the illnesses, and focus to action.
  5. The third component—the likelihood that a person will take preventive action—is the person's perception of the benefits of taking action.
 
Health Promotion Model
  1. The health promotion model proposed by Pender (1996). It was designed to be a complementary counterpart to models of health protection.
  2. Health promotion is directed at increasing a client's level of well-being. The model focuses on three functions.
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  3. The model also organizes cues into a pattern to explain the likelihood of a client's participation in health-promotion behavior.
  4. The focus of this model is to explain the reasons that individuals engage in health activities. It is not designed for use with families or communities.
 
BIOPSYCHOSOCIAL ASPECT OF HEALTH AND ILLNESS
 
Introduction
Physical, social, cultural and psychological factors interact dynamically and have an important influence on patient care needs. There are needs common to everyone, no matter their sociocultural background, so-called human needs. These needs when they are not met create tensions and these tensions may give rise to anxiety that can hamper recovery if not relieved (Figs 1.3A and B).
 
Developmental Needs
  1. Prenatal: This stage determines many characteristics of the person and to some extend the requirements for use of adaptive resources throughout life.
  2. Neonatal: Developmental tasks are mostly physical, foundations are begun at this time for later personality responses.
  3. Infancy: This is a time of much physical, but foundations are begun at this time for later personality responses.
  4. Childhood: Marked physical growth continues during this time. There is the beginning of role identification and moving out from the family to the peer group and community.
  5. Adolescence: Many physical and emotional changes occur as growth and maturation continues, changing hormonal activity and search for identity are major stresses for the adolescent.
  6. Young adulthood: Physical maturation is completed. There are many psychosocial stresses related to family and community roles during this stage.
  7. Middle adulthood: Developmental tasks are mostly psychosocial, relating to reassessment of goals, physical stamina and hormone output beginning to decline.
  8. Older years: Physical conditioning is generally declining, and decreased sensory acuity may be noticeable. Developmental tasks are related to sharing accumulated experiences and evaluating achievements.
zoom view
Figs 1.3A and B: (A) Biopsychosocial model, (B) Maslow's hierarchy of needs
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Cultural Influences
  1. Culture may be thought of as the total way of life of a people, the social legacy the individuals acquire from his or her groups.
  2. The culture concept is cardial to an understanding of ourselves and our world.
  3. Custom and group habits are referred to as folkways and mores. Folkways are the accustomed and time-honored ways of doing things, the social habits that become routine and that are often performed without thinking.
  4. The patient's cultural background helps to determine the way the relationship with the physician or nurse is perceived and facilitates or impedes interaction or communication.
 
Religious Aspects
  1. Religion traditionally has focused on a god beyond the individual and has concentrated it self with relating the individual and has concerned itself with relating the individual to that god.
  2. Religious beliefs are seldom held to oneself but are part of group processes, so that there is immediate family or group support for the patient.
  3. It helps the patent's own attitude or belief that recovery is possible and that there are forces available to facilitate the healing process.
  4. It is important if the nurse is to be of help, to understand not only the spiritual needs of the patient but also the means and methods that organized religion has for meeting those needs.
 
HEALTH FOR ALL
  1. The world health assembly in its 30th meeting in 1977 decided the goal of health for all (HFA) and defined that “Main Social Targets of Governments and WHO” in the coming decades should be the attainment of all citizens of the world by the year 2000 of a level of health that will permit them to lead socially and economically productive life.
  2. Attainment of a level of health that will enable every individual to lead a socially and economically productive life.
 
Health for All Goals
  1. Realization of highest possible of health which includes physical, mental and social well-being.
  2. Attainment of minimum level of health that would enable to the economically productive and participate actively in social life of community in which they live.
  3. Removal of obstacles to health such as unemployment, ignorance, poor living conditions, standards and malnutrition, etc.
  4. Health care services are within the reach of all in the country.
 
Strategies for Health for All
The alma ata declaration called for global strategy to provide guidelines for member countries to refer. In 1981, the WHO after consultations with member countries developed a global strategy for health for all. The global strategy provides common broad framework which can be modified and adopted by countries according to their needs. The global strategy for HFA is based on the following principles.
  1. Health is a fundamental human right and a world wide social goal and an integral part of social and economic development of the communities.
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  2. People have right and the duty of participate individually and collectively in the planning and implementation of their health care.
  3. The existing gross inequality in the health strategies is of common concern of all countries and must be drastically reduced.
  4. Government has responsibility for the health of their people.
  5. Countries and people must become self reliant in health matters.
  6. Governments and health professionals have the responsibility of providing health information to people.
  7. There should be equitable distribution of resources within and among the countries but should be allocated most to those who need most.
  8. Primary health care would be the key to the success of HPA and it has to be the integral part of the country's health system.
  9. Development and application of appropriate technology according to health care system of the nation.
  10. Research in the field of biomedical and health services must be conducted and findings should be applied soon.
The National Health Policy echoes the WHO a call for HFA and the alma ata declaration. It had laid down specific goals in respect of various health indicators by different dates such as 1990 and 2000 AD.
  1. Reduction of infant mortality from the level of 125 (1978) to below 60.
  2. To raise the expectation of life at birth from the level of 523 years to 64.
  3. To reduce the crude death rate from the level of 14 per 1000 population to 21.
  4. To reduce the crude birth rate from the level of 33 per 1000 population to 21.
  5. To achieve a net reproduction rate of one rural population.
 
PRIMARY HEALTH CARE
 
Definition
Primary health care is essential health care made universally accessible to 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. It forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community (alma ata, 1978).
 
Highlights of this Definition
This definition highlights several attributes of primary health care. It stresses on:
  1. Its essentiality by observing that primary health is essential health care.
  2. Its accessibility by observing “made universally accessible to individuals and families in the community.
  3. Its acceptability by observing by means acceptable to them.
  4. Its patricianly by observing “acts a cost that the community and country can afford”.
  5. Its affordability by observing “it forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community”.
  6. Its integrality by observing “it forms an integral part both of the country's health system of which it is the nucleus and the overall social and economic development of the community.
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Attributes of Primary Health Care
  1. Accessibility: Primary health care permeates uniformly to reach equitably to all segments of population.
  2. Acceptability: Primary health care achieves acceptability through cultural assimilation of its policies and programs.
  3. Adaptability: Primary health care system is highly flexible and adaptable. It believes in “adaptation” rather than “adaptation”.
  4. Affordability: Primary health care is affordable to consumer as well as providers.
  5. Availability: Primary health care is always ready to respond to any demand at any time.
  6. Appropriateness: Primary health care system evolves from the socioeconomic conditions, social values and health situation of a community, it is quite appropriate from all angles.
  7. Closeness: Primary health center is close at hand to people at their door steps.
  8. Continuity: Primary health service is a continuous service which extends from “womb to tomb” and addresses the changing needs of an individual in all situations of health and disease.
  9. Comprehensiveness: Primary health care is comprehensive and the curative needs of the community.
  10. Coordinativeness: Primary health care is dependent on innersectoral coordination and community participation.
 
Elements of Primary Health Care
As per Alma Ata declaration primary health care includes:
  1. Educration concerning prevailing health problems and methods of identifying, preventing and controlling them.
  2. Promotion of food supply and proper nutrition.
  3. An adequate supply of water and basic sanitation.
  4. Maternal and child health care including family planning.
  5. Immunization against the major infectious disease.
  6. Prevention and control of locally endemic diseases.
  7. Appropriate treatment of common diseases and injuries.
  8. Promotion of mental health.
  9. Provision of essential drugs.
 
Principles of Primary Health Care
  1. Equitable distribution: Primary health care services must be shared equally by all people irrespective of their ability to pay (rich, poor, urban or rural).
  2. Community participation: Primary health care must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services.
  3. Coverage and accessibility: Primary health care implies providing health care services to all which are required by them. The care has to be appropriate and adequate in content and in amount to satisfy the essential health needs of the people and has to be provided by methods acceptable to them.
  4. Inter sectoral coordination: Primary health care requires joint efforts of other health related sectors such as agriculture, animal husbandry, food, industry, housing, social welfare, public works, communication and other sectors.
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  5. Appropriate health technology: The technology that is scientific, adaptable to local need and socially acceptable instead of costly methods, equipment and technology.
  6. Human resource: Health resource is very essential to make full use of all the available resources including the human potential of the entire community.
  7. Referral system: Referral system would be desirable to develop referring from one level to another with laid down procedures and policies.
  8. Logistics of supply: The logistic of supply include planning and budgeting for the supplies required procurement or manufacture, storage distribution and control.
  9. The physical facilities: The physical facilities for primary health care need to be simple and clean. It should have a specious waiting area with toilet facility.
  10. Control and evaluation: A process of evaluation has to be built into assess the relevance, progress, efficiency, effectiveness and impact of the services.
 
Role of Nurse in Primary Health Care
An extent committee on community health nursing was concerned by WHO Executive Board in July 1974 to recommend way in which nursing could have critical impact on the urgent health problems throughout the world. The committee made specific recommendations.
  1. The development of community health nursing services, responsive to community health needs that would assure primary health care coverage for all.
  2. The reformulation of basic and postbasic nursing education as to prepare all nurses for community health nursing.
  3. The inclusion of nursing in national development plans in a way that would ensure the rational distribution and the appropriate utilization and support of nursing personnel.
 
Role of Nurse in Primary Health Care
  1. Community health nurse work with population, community, family, individual. The focus is multiple or promoting health maintaining a degree of balance toward health.
  2. Community health nurse focus on assessment of the impact of the socioeconomical and cultural factors affecting health measures the must constantly be dealt with and take priority in order to make family assume health measures.
  3. The community health nurse works with entire spectrum of health and illness conditions from optimal health to minor or severe conditions from acute to chronic illness.
  4. The community health nurse works in all kinds of setting such as home, school, clinic, industry, etc.
  5. The community health nurse works in school where primary goal is health education and disease prevention.
  6. The community health nurse works in industry is to improve the production and employees safety.
  7. The community health nurse is responsible for assisting patients and families to coordinate health care, which necessitates contact with personnel from health, welfare and other significant community agencies.
  8. Community health nurse has responsibilities in education an training of individuals, auxiliaries and others.
  9. The community health nurse involves in provision of direct services to patients both preventive and curative at the out-patient, in-patient clinics and community.
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Major Role of Child Health Nursing in Primary Health Care
  1. Facilitative role
  2. Developmental role
  3. Supportive role
    1. Training
    2. Management
    3. Supervision
    4. Program implementation
    5. Program evaluation
    6. Policy making
    7. Program planning
  4. Clinical role.
 
LEVELS OF DISEASE PREVENTION
The disease process, in many instances is susceptible to interruption in order to limit its further progress or the speed of its progression. As disease involves interaction of host, agent and environment prevention can be achieved by altering one or more of these three elements so that interaction does not take place or is interrupted in favor of the host. Effective preventive measure requires that the disease process be interrupted as early in its course as possible.
The interaction between the agent and the host can be avoided either by the elimination of the agent in the environment or by converting the human host susceptible or immune to the attack of the agent. Those attempts to bring about changes in the three elements before the disease stimulus is produced are grouped under one type of prevention namely primary prevention. When the disease stimulus has already been practiced and the disease process has crossed over to the period of pathogenesis, two types of prevention—secondary and tertiary prevention.
 
Primary Prevention
Primary prevention can be defined as “action taken prior to the onset of disease which removes the possibility that a disease will ever occur”. It signifies intervention in the prepathogenesis phase of a disease or health problem or other departure from health.
Primary prevention is applied at the prepathogenic period; it includes health promotion and specific protection
  1. Health promotion: The first level of prevention is by promoting and maintaining the health of the host by nutrition, health education, good heredity and other health promotion activities.
  2. Specific protection: It may be directed towards the agent like disinfection of contaminated particles, materials, water, food, and other particles on the assumption that the agent has escaped into these vehicles or environment. Specific protection can also be achieved by immunizations to increase the resistance of the host so that the host will be able to withstand the onslaught of the agent. This is done by the active and passive immunizations.
 
Secondary Prevention
Secondary prevention can be defined as “action” which halts the progress of a disease at its incipient stage and prevents complications. The specific interventions are early diagnosis, e.g. screening tests, case finding programs) and adequate treatment. The secondary prevention done by early diagnosis and treatment.
Early diagnosis and prompt treatment comes under secondary prevention. If primary prevention fails or when suitable measures are not available (as in cancer) the disease stimulus is bound to 19be produced. Early detection of the disease is possible by periodic examinations of population groups who are at special risks like antenatal mothers, growing children, industrial worker, etc.
Monitoring of persons middle age and above is one of the modern methods of early detection of cancer. In many instances, this detection of the diseases condition is possible only after the onset of the signs and symptoms. Early detection of the disease ensures prompt treatment so that the disease will not progress further.
 
Tertiary Prevention
When the disease process has advance beyond its early stages, it is still possible to accomplish prevention by what might be called “Tertiary prevention”. It signifies intervention in the late pathogenesis phase. Tertiary prevention can be defined as “all measures available to reduce or limit impairment and disabilities, minimize suffering caused by existing departures and disabilities, minimize suffering caused by existing departures from good health and to promote the patient's adjustments to irremediable conditions”. Tertiary prevention includes disability limitation and rehabilitation.
  1. Disability limitation: It is necessary that the disability that is caused by limited by active medical or surgical treatment so that there is no further deterioration of the disease process.
  2. Rehabilitation: Those with permanent disability as in the case of leprosy, tuberculosis, polio, mental retardation, etc. will not be able to lead an independent life unless they are rehabilitated. This level will be needed only when have failed in the application of previous levels of prevention.
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