CHAPTER I

THE PROBLEM AND ITS BACKGROUND

Introduction

In a changing world today, people learned to accept the occurrence of different diseases that easily spread and increases. Viral and bacterial infections were transmitted easily due to different factors especially with the current environmental status. Most cases were associated with cough, common colds and fever. Very young age groups were usually the victims of this disease which is commonly called acute respiratory infection due to less immunization of the body. The elderly were also affected due to decreased resistance to infection as their body becomes old and degenerated. Acute respiratory infections (ARI) as described by Hockenberry (2005), was the infection of the upper or the lower respiratory tract. Infections were often spread from one structure to another because of a contagious nature of mucous membrane lining the entire respiratory tract. ARI was caused by variety of infective organisms, most commonly bacteria and viruses. Infants younger than 3 months have a lower infection rate presumably because of proteins function of maternal anti-bodies. The infection rate increased from 3 6 months of age, the time between the appearance of maternal antibodies and the infants own anti-body production. The viral infection rate remained high during toddler and pre-school years (below 5 years of age). According to the World Health Organization (2009), ARIs continued to be the leading cause of acute illness worldwide and remained the most important cause of infant

2 and young children mortality, accounting for about 2 million deaths every year and ranking first among causes of disability-adjusted life-years lost in developing countries. Upper respiratory tract infections were frequent but seldom life-threatening. Lower respiratory tract infections were responsible for more severe illnesses such as influenza, pneumonia, tuberculosis and bronchitis that are the contributors to ARIs morbidity and mortality. In addition to WHOs report, the incidence of ARI in children aged less than 5 years old was estimated to be 0.29 and 0.05 episodes per child year in developing and industrialized countries, respectively which translates into 151 million new episodes each year respectively. While in the Philippines, as stated by the WHO Western Pacific Region, 6 out of 10 leading causes of acute illnesses and mortality in the country were caused by the infections in the respiratory tract. These were the acute lower respiratory infection, pneumonia, bronchitis, bronchiolitis, influenza and tuberculosis. Hence, there were number of ways on how acute respiratory infections among children below five years old may be transmitted. According to the Public Health Nursing in the Philippines (2007), the most common mode of transmission was by an airborne or direct method. It was through inhalation of the droplet or spray from coughing and sneezing of the infected person which contributes to the spread of infection. The indirect method also added to the spread of infection that is through the use of the articles soiled with secretions from the nose and throat of the infected person. Crowding and close association with the patients also facilitated the spread of infection. Furthermore, World Health Organization (2009) added that environment-related health risks have been cited as a significant problem in the incidence of respiratory

3 diseases and infections, with undesired changes in the weather like climate change, air pollution, water pollution, poor sanitation and unhygienic practices contributing to an estimated 22% of reported disease cases and nearly 6% of reported deaths and costing Php 14.3 billion per year in lost income and medical expenses. Family-related health risks also contributed to the incomplete vaccinations and less knowledge about hygiene and food preparations. In the province of Bataan, incidence of acute respiratory infections among children below five years old was very common. In barangay Pto. Rivas, Balanga City, where the study was conducted, the Pto. Rivas Health Center revealed that ARI was the most common case they have and it was said that this incidence increases as the cold and rainy season was approaching. By the year 2007, out of 1260 population of children below five years old, 284 or 22.5% were affected by ARI. By the year 2008, out of 1294 population, 350 or 27% of the population were affected. By the year 2009, out of 1223 population, 418 or 34.2% were affected. And for this year 2010, as of September, out of 1042 population, 410 or 39.3% were already affected by ARI. These increasing rates were quite unmanageable considering the fact that DOH was also facing the increasing rates of other diseases like dengue cases where most of the dying victims are the young aged. Because of this, the researchers investigated and determined the underlying factors that contributed to the occurrence of ARI among children below five years old. This problem cannot be avoided since our country was surrounded by bodies of water and were experiencing climate change. A thorough assessment of the various factors was done in order to help the families affected, the community and the government health

4 officers prevented and managed the said issue.

Statement of the Problem

The general problem of the study was: How do family-related and environmentrelated factors affect the increased rates of Acute Respiratory Infection (ARI) among children below five years old in Brgy. Pto. Rivas during fiscal year 2010? Specifically, the study sought to answer the following questions: 1. How may the family-related factors be described in terms of: 1.1. number of family members; 1.2. parents educational attainment; 1.3. socio economic status and 1.3.1. family income and 1.3.2. type of house? 1.4. family health status 1.4.1. family history of ARI and 1.4.2. preventive measures? 2. How may the environment-related factors be described in terms of: 2.1. home environment and 2.1.1. sanitation practices and 2.1.1.1. food preparation and 2.1.1.2. family members hygiene? 2.2.2. source of water supply 2.2.3. availability of sanitation facilities?

5 2.2. external environment 2.2.1. community sanitation, 2.2.1.1. sewerage system and 2.2.1.2. garbage disposal system? 2.2.2. community economic activities and 2.2.3. neighborhood leisure activities? 3. How may the rates of Acute Respiratory Infection (ARI) be described in terms of its incidence in the past four years? 4. What is the implication of this study to the nursing profession?

Significance of the Study

The study aimed to identify the benefits and importance of the study to the following entities: Community. The study benefited the community because their

community sanitation where sewerage system, garbage disposal and availability of sanitation facilities are included, community economic activities and neighborhood leisure activities were evaluated. They also voiced out what they need with regards to their health needs especially concerning the ARI cases among children below five years old. Health Care Providers. The study helped the health care providers to evaluate the community where they had been assigned. The results served as reference that became useful in determining which area will need further attention and become helpful

6 in identifying the needs of each family or community affected. It served as a guide for them to create proper prevention and control for the incidence of ARI. Parents. Through the results of this study, parents were able to gain more understanding about the importance of proper hygiene like hand washing and waste disposal in order to prevent occurrence or transmission of any infection. They were provided valuable information necessary to educate them and support the health activities and programs of the government to achieve optimum health for their children as possible. Children. Children at young age were susceptible to infections and other diseases. It hoped that through this study, children at their young age were able to learn and apply the basic health practices and its importance in order to prevent infection processes. It also hoped that by their young age, wrong health practices were corrected. Other Family Members. Contributing factors like the family profile, family health history, their practices and home environment were also discussed to determine its relationship in the occurrence of ARI. Other members of the family were educated and were able to help and protect each other from any diseases and infections. Nursing Students. This study served as a guide among nursing students to perform appropriate interventions with regards on dealing with the preventive and control measures of ARI. Learning about the problem helped them spread the awareness and discuss the information necessary to educate other people. Future Researchers. The findings served as reference for the future researchers who will wish to explore and discover the underlying factors affecting the incidence of ARI.

7 Scope and Delimitation of the Study The purpose of this study was to identify the factors that affect the increased rates of ARI among children below five years old in barangay Pto. Rivas, Balanga City during the fiscal year 2010. The study concentrated in the vicinity of barangay Pto. Rivas, Balanga, Bataan. The area was chosen due to high incidence of ARI cases in children below five years old. The study had 30 household respondents chosen by a convenience method. Specifically, the study described the profile of the family in terms of number of family members, parents educational attainment, socio economic status including their family income and type of house and lastly, their health status which includes the family history of ARI and their preventive measures. Hence, the profile of the environment also described in terms of, first, their home environment which includes the sanitation practices, source of water supply and availability of sanitation facilities. Under the sanitation practices, food preparation and family members hygiene were discussed. Second was their external environment which includes community sanitation where the sewerage system and garbage disposal system was described, community economic activities and lastly neighborhood leisure activities. Survey-questionnaires, frequency count and percentage were utilized to describe the profile of the each family and the environment and also the increased rates of ARI among children below five years old. The results of the study were used to determine the significant relationship of the family and the environmental profile to the increased rates of ARI among children below five years old.

8 Notes in Chapter I

Manilyn J. Hockenberry. Wongs Essentials of Pediatric Nursing 7th Edition. Elsevier Mosby Inc, .2005. World Health Organization (WHO). Acute Respiratory Infections. www.who.int/vaccine_research/diseases/ari/en/index.html. Sept. 2009. Retrieved September 2, 2010. World Health Organization Western Pacific Region, Philippines. Health Situation and Trend. www.wpro.who.int/countries/2009/phl/health_situation.htm. Retrieved September 2, 2010 Public Health Nursing in the Philippines 10th Edition. National League of Philippine Government Nurses Incorporated, 2007.

9 CHAPTER II

THEORETICAL FRAMEWORK

This chapter presents the relevant theories, related literature and studies, conceptual framework, hypotheses of the study and definition of terms.

Relevant Theory This study was anchored on the Health Promotion Model by Nola Pender, Environmental Theory by Florence Nightingale and the Adaptation Theory by Sister Callista Roy. First was the Health Promotion Model of Pender (2002) that focused on health promotion and disease prevention. According to her, health promotion and disease prevention should be the primary focus in health care, and when health promotion and prevention fail to prevent problems, and then care in illness became the next priority. As what they said, prevention is better than cure. People can possibly avoid illness or disease to exist if they know how to properly manage certain condition and factors that may affect our health before it may lead to the presence of illness. Health promotion was defined as the behavior motivated by the desire to increase well-being and actualize human health potential. It was an approach to wellness. On the other hand, health protection or illness prevention was described as the behavior motivated by the desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. (Kozier, 2008)

10 Penders Health Promotion Model proposed that moving towards understanding multi-faceted nature of persons correlating with their interpersonal nature and interacting with their interpersonal and physical environments as they trail towards health. This model addressed not only the curative side, but as well as prevention of diseases and promotion of well-being. Also, it had implications for application by emphasizing the importance of individual assessment of the factors believed to influence health behavior changes. By the use of Penders Theory, community program focused on activities that can improve the well-being of the people. Health promotion and disease prevention were easier to carry out in the community, as compared to programs that aim to cure disease conditions. This was because the people in the rural area tend to veer away from modern medical methods. Most of them, due to financial reasons, chose to avail of the services offered by herbolarios and other folk healers. In our local setting, promoting health to our fellow Filipinos was very crucial. Health care providers need to take an action and make a decision to give the community a better healthy life. This theory related to the community, healthcare providers even to parents that can merely influence the health status of themselves as well as their children. Health care providers that play a big role on providing health teaching and awareness that might correct the wrong practices in taking care of their children. By informing them the factors that might affect the health of their children, especially acute respiratory infection was a widely spread disease that can be easily transferred. Families that made up the community became knowledgeable enough to avoid the factors that might cause harm to their health.

11 Second, was the Nightingales (1969) Environmental Theory that stated that the environment was a major component in creating illness. She regarded disease as the reactions of nature against the conditions in which they have placed those. In her theory, she believed that improving the existing environment can greatly influence the health status of a person. The environment was one of the major factors to be considered on the wide spread of acute respiratory infection (ARI). This theory was suitable in our study that can be a help and guide as they push through the research studies. In this theory, Nightingale recognized and emphasized even the smallest and simplest detail that can contribute to a healthy environment such as personal cleanliness, taking food, petty management, ventilation and warmth, etc. An appropriate manipulation of environment prevented diseases; this was accomplished through modern sanitation activities. With this, a healthy and clean environment had a great impact in achiving a healthy living society. Lastly, the Adaptation Theory of Roy (1964) which focused on the concept of adaptation that involved the person, health and environment that are all interrelated in this central concept. According to her, adaptation was the use of conscious awareness and choice to create human and environmental integration rather than a system simply striving to respond to environment stimuli to maintain integrity, every human life was purposeful in a universe that is creative and persons are inseparable from their environment. Since her theory was a combination of philosophical and scientific assumptions, she explained that a health of an individual does not focus only on the environment they inseparably live, however they must also consider it as one of the major factors that it may consist for it to greatly affect our health together with our spiritual

12 belief of ones faith. As an open living system, the person received input or stimuli from both environment and the self. Adaptation occurred when the person responded positively to environmental changes. Therefore, it was possible if all the physiologic needs of an individual, as well as psychological and spiritual integrity will be met in addition on proper guidance and a healthy environment to allow them achieve an adoptive response that promotes the integrity of an individual, which will lead to wellness. This theory possibly helped on disseminating proper health education that will prevent the increasing incidence of acute respiratory infection to children as well as to alleviate their health status to wellness. Since, the study had a great concern to people, environment and improving wellness the theory could be applied in able for the study to understand more and make it easier that can be use as a guide as we go on deeper to this research study.

Related Literature Increased Rates of Acute Respiratory Infections. According to World Health Organization (2007), ARIs were the leading causes of infectious disease morbidity and mortality in the world. Almost four million people die from ARIs each year, with 98% due to lower respiratory tract infection. The mortality rates were particularly high among infants, children and the elderly, predominantly in low and middle-income countries. Likewise, ARIs were among the most frequent causes of consultation or admission to HCFs, particularly in pediatric services. Furthermore, in the WHOs report (2009) , the incidence of ARI in children aged less than 5 years old was estimated to be 0.29 and 0.05 episodes per child year in

13 developing and industrialized countries, respectively which translates into 151 million new episodes each year respectively. While in the Philippines, as stated by the WHO Western Pacific Region, 6 out of 10 leading causes of acute illnesses and mortality in the country are caused by the infections in the respiratory tract. These were the acute lower respiratory infection, pneumonia, bronchitis, bronchiolitis, influenza and tuberculosis. Moreover, Gatan-Magturo (2010), focal person for Climate Change from the National Center for Disease Prevention and Control of the DOH, in a health forum at Oasis Hotel here, talked on the different diseases that could be acquired due to climate change. She said that the increase in ground-level ozone, airborne allergens and other pollutants could trigger respiratory disease exacerbation to include asthma, allergic rhinitis and bronchitis which are most often suffered by the elderly, children and those suffering from respiratory illness. With this report, it was quiet alarming that such cases of ARI continuously increase especially nowadays climate changes that are continuously experiencing. In a third world country like Philippines, these cases were more affected by increasing rates of ARI due to lack of awareness of people that such infection can cause death. Number of Family Members. According to Fischer et. al (2008), although much of the effect of household crowding was confounded by environmental and socioeconomic variables, it is an important independent risk factor for acute lower respiratory illness (especially the number of persons sharing the childrens bedroom). There was an evident need to reduce household crowding in order to reduce both the number and severity of cases of acute respiratory illnesses. The current study thus helped provide a better understanding of the events linked to these diseases at the local level and

14 the basis for establishing specific programs for their control. In addition, Cardoso et. al (2004) stated that even though household crowding places young children at increased risk of acute lower respiratory infection, it may protect them against asthma. Failure to distinguish cases of lower respiratory disease due to infection from those of non-infectious etiology (asthma) resulted in an apparent lack of association between crowding and lower respiratory disease because the two opposing effects cancel each other out. Moreover, Bulkow et. al (2002) added that household crowding was associated with increased risk of ARI hospitalization. The presence of 4 or more children <5 years of age in the household and a crowding index of 2 or more were associated with increased ARI hospitalization risk. Although household crowding was not easily remedied, disease transmission can be decreased through educational programs aimed at increasing the practice of hand washing before caring for infants and lessening exposure of small infants to large groups of people. Therefore, people should be aware that a large number of people or family sharing in a household could be a possible cause of fast transmission of many infections. The more the number of people sharing in a household means a greater risk of disease transmission. Thou, sometimes it would be inevitable proper education to the people and community should be the best action to decrease the possible cases of ARI. Parents Educational Attainment. According to Kubzansky LD et. al (2000), educational attainment was associated with a broad array of psychosocial and biological conditions among the elderly. That an education gradient functions over an array of factors that structure daily life, even in later life in a healthy population. Low levels of

15 education were associated with poorer psychological function (less mastery, efficacy), less optimal health behaviors (increased tobacco consumption and decreased levels of physical activity), poorer biological conditions (decreased pulmonary function, increased body mass index and waist-to-hip ratio), and larger social networks (increased number of contacts, decreased negative support). Several factors (alcohol consumption, high-density lipoprotein cholesterol) were nonlinearly related to educational attainment. In addition, I.R. White et. al (2000) pointed out that educational attainment is associated with self assessed health in adulthood, independently of deprivation-affluence. Long standing illness may be associated with educational attainment. Educational attainment may be a marker for childhood socio-economic circumstances, its association with health may result from occupational characteristics, or education may influence the propensity to follow health education advice. Moreover, Goesling et. al. (2005) explained that education can lead to healthier lives. Its not just access to health insurance that yields better outcomes for better educated people. Education has other important effects on peoples lives: it improved earning power and social status, and it also affected cognitive ability. These factors influenced lifestyle choices, knowledge and understanding of health issues, and the health-related decisions that people make. Better educated people were more able to follow doctors instructions successfully and to navigate medical bureaucracy. Therefore, higher educational attainment of an individual especially the parents leads to higher understanding and quality of health they can give to their family and vice versa. Children were the one at risk for parents that werent aware enough to the needs and protection of their children due to poor education that have reached. Thus, this factor

16 can be one of the possible causes of an increase number of cases of ARI due to poor educational attainment. Socio-economic Status. Infants from families of low socioeconomic status said to suffer higher rates of lower respiratory illness. Economic status of ones family was considered as one of the factors that greatly affect the health of each member. Socioeconomic status was the total measure of a person's work experience and of an individual's or familys economic and social position relative to others based on income, education and occupation. In addition, Cohen (2006) revealed that unemployment was associated with increased susceptibility to infection in adult humans. The association of social status and susceptibility was accounted for primarily by increased risk in the lowest social status groups. Greater risk for infectious illness among people with lower socio-economic status was thought to be attributable to increased exposure to infectious agents and decreased host resistance to infection. Moreover, Huges et. al (2004) pointed out that low socio economic status reflects with a low standard of living such as unfavorable domestic and per domestic environment, overcrowding, that can result with an increased spread of airborne diseases, lack of sufficient sunlight, lack of sufficient air-exchange which is due to ill ventilated room. Because of those factors that were observed, existence acute respiratory tract infections were more common in children belonging to the lower socio-economic status with a large family and poor nutrition. ARI was seen more because of low standard of living, unfavorable domestic and per domestic environment like overcrowding, increased spread of airborne diseases, lack of sufficient sunlight, and lack of sufficient air-exchange

17 which is due to ill ventilated room. Also, this infection was more commonly seen in nonimmunized and partially immunized patients than in fully immunized patients. Therefore, families of low socio economic status were greatly affected of these increasing rates of respiratory illness. Large, unemployed and poor hygiene in a family resulted to a low standard of living in which they could not provide that proper and safety needs of a family. Family Income. Gartenstein (2010) reported from the National Council of State Legislators that about 47 million Americans are uninsured. The rising cost of health insurance made it virtually impossible for many low-income families to afford health insurance. As a result, uninsured individuals and families put off visits to the doctor, causing many treatable conditions to worsen. Many varieties of cancer are nonlethal in their early stages but lethal once they metastasize. Diabetes and risk factors for heart disease, as well, were considerably less dangerous if managed under the care of a physician. Uninsured individuals without adequate access to health care ran the risk developing complications that were prevented through early detection and management. Furthermore, Raphael (2007) noted that in Canada, Canadians living within the poorest 20 per cent of urban neighborhoods died earlier from a wide range of diseases that include respiratory diseases, cardiovascular disease, cancer and diabetes. An inability to afford fresh, nutritious food, coupled with the stress created by poverty and social exclusion, created a lasting impact on physical and mental health. Achieving health equity began long before people are at the point of entering a hospital; it began with ensuring they have an income sufficient to meet their basic needs. Poverty reduction strategies were therefore also be public health strategies. Reducing poverty improved

18 health, reduced incidence of disease and illness, and enabled people to lead more engaging and productive lives. Inequality, and the poor health outcomes that resulted from poverty, were costs that were shared by everyone in society through an increased use of public services, including health care. Therefore, everybody can benefit from poverty reduction. Moreover, Fujii (2009) mentioned that the relationship between family income and child health showed that children from poorer families had worse health than those from wealthier families, and that the negative effect of low income on health accumulated during childhood. In this paper, we disaggregated the accumulated effects of income on child health found in the past studies into the marginal (i.e., contemporaneous) effects and investigated how the contemporaneous effects evolve as children become older. Therefore, not enough family income due to unemployment greatly affected the inability to sustain the needs of each family member. Due to this circumstances, the prioritizing the needs of a family, health was disregarded. Illness that could be cured is left untreated due to financial problems. Type of House. Centre for Epidemiology and Research (2008) explained that housing was identified as a major factor affecting the health of Aboriginal people. Inadequate or poorly maintained housing and the absence of functioning infrastructure posed serious health risks. Overcrowded dwellings and poor quality housing leaded to the spread of infectious diseases. The acute respiratory illnesses in this analysis included acute upper respiratory infections, influenza and pneumonia. Furthermore, Krieger et. al (2002) mentioned that poor housing conditions were associated with a wide range of health conditions, including respiratory infections,

19 asthma, lead poisoning, injuries, and mental health. Addressing housing issues offered public health practitioners an opportunity to address an important social determinant of health. Public health had involved in housing issues. In the 19th century, health officials targeted poor sanitation, crowding, and inadequate ventilation to reduce infectious diseases as well as fire hazards to decrease injuries. Today, public health departments employed multiple strategies to improve housing, such as developing and enforcing housing guidelines and codes, implementing Healthy Homes programs to improve indoor environmental quality, assessing housing conditions, and advocating for healthy, affordable housing. Now was the time for public health to create healthier homes by confronting substandard housing. Moreover, Sharfstein and Sandel (2000) explained that housing was an important determinant of health, and substandard housing was a major public health issue. The public health community grew increasingly aware of the importance of social determinants of health (including housing) in recent years, yet defining the role of public health practitioners in influencing housing conditions became challenging. Responsibility for social determinants of health was seen as lying primarily outside the scope of public health. The quality and accessibility of housing was, however, a particularly appropriate area for public health involvement. An evolving body of scientific evidence demonstrated solid relations between housing and health. The public health community developed, tested, and implemented effective interventions that yield health benefits through improved housing quality. Public health agencies had valuable expertise and resources to contribute to a multi-sect oral approach to housing concerns. Public health had a long (albeit intermittent) history of involvement in the housing arena, and this involvement

20 was generally accepted by other housing stakeholders (e.g., building departments, community housing advocates). Housing related health concerned such as lead exposure and asthma were highly visible. Therefore, quality and safety of a house played an important role that greatly influenced our health. Proper ventilation and sanitation were applied to houses so that a healthy environment promoted a healthy living in every member of the family. Thus, it lowered the possibility spread of respiratory infections. Family History. According to Kilic (2004), diagnosis of ARI depended on taking a detailed history, detecting any abnormal physical sign, and the use of appropriate tests. The differentiation between patients who had infections caused by an immunodeficiency syndrome and those who have recurrent ARIs caused by other predisposing factors, such as structural abnormalities, allergic diseases, or cystic fibrosis, required taking a careful medical history, physical examination and diagnostic studies. It was also important to note that the frequency, duration, severity, and complications of infections and the response to antimicrobial treatment while taking history. A history of persistent or recurrent episodes of pneumonia and chronic sputum production indicated more severe pathology. Persistent cough at night or after getting up in the morning suggested the presence of chronic lung disease and bronchiectasis. A detailed family history in patients in whom immunodeficiency was suspected can add valuable information. Medical history taking included information about any adverse reaction to live viral vaccines. Moreover, Trefny P. (2000) pointed out that the influence of family history of allergy contributes on the clinical course of ARI infection in ambulatory and hospitalized infants. In-patients had a significantly higher rate of atopy in their family history than

21 outpatients, 62% and 29%, respectively. Bronchiolitis was diagnosed more frequently in patients with an atopic burden than those without. In-patients with an atopic family history had a significantly longer hospital stay than those without such a history. He concluded that infants with a family history of atopy were at increased risk for severe ARI infection as indicated by higher rates of hospitalization, longer hospital stay, and more frequent occurrence of bronchiolitis. Furthermore, the COPD Globe (2000) mentioned that severe viral or bacterial respiratory infections that occur in childhood can cause airway abnormalities that may set the stage for COPD in later life. While there was no concrete evidence that these infections cause COPD, they may worsen the condition. There was also evidence, although limited, that some infections contracted before age 2 (for example, pertussis, tuberculosis, or pneumonia) may be a significant factor in the later development of COPD. There was some question, however, whether the previous infection was the cause, or whether they were both related to another factor, such as low birth weight. Therefore, family health history considered important in able to determine and monitor such illness occurred before that might possibly cause also an existing present illness. Thru this factor, an increasing rate of acute respiratory infections were controlled and decreased. Preventive Measures. According to Pillitteri (2007), upper respiratory illnesses occurred universally, making them a concern of parents the world over. Home remedies for such illnesses vary greatly. Hanging garlic around a child's neck was a frequent therapy in Mediterranean countries. "Cupping" or applying pressure to the back to "draw

22 out" an infection (which leaves red circular ecchymotic marks on the child's back) was used in Asian cultures. In addition, Fredrick (2003) stressed out that frequent hand washing remained the most important preventive measure for most acute respiratory infections. Simple measures, such as covering the mouth and nose while sneezing, decreased the risk of transmission of infectious agents. One effective preventive measure for ARI was to consult a doctor promptly if there are respiratory symptoms such as fever, malaise, chills, headache, joint pain, dizziness, rigors, cough, sore throat and runny nose because early treatment was the key. In addition, Taj (2007) stated that although delivery of immunizations was the responsibility of the national Expanded Program of Immunization (EPI), any effective and preventive ARI control program promoted timely childhood immunization as a strategy to control disease morbidity and mortality. Three of the six childhood illnesses targeted by EPI measles, pertussis, and diphtheria were directly or indirectly responsible for 15-25% of all death associated with ARI among children. Therefore, facilitating the delivery of childhood vaccination was paramount to prevent ARI. Preventive measure was one of the factors that greatly influence to decrease the respiratory infections. Proper education and helping people to be aware of the remedies that could be done at home whenever illness occurs were needed. Home Environment. Eure (2005) mentioned that during fall and winter, most people spend a lot more time indoors as the temperatures drop and the days get shorter. Unfortunately the environment in homes may not be as healthy as it should and may in some instances be deadly.

23 In addition, the American Lung Association of Minnesota (2009) stated that the elements within home and workplaces had been increasingly recognized as threats to respiratory health. The most common pollutants were radon, combustion products, biological (molds, pet dander, and pollens), volatile organic compounds, lead dust and asbestos. There were an estimated 42.6 million Americans living with hay fever and/or asthma. Learning how to control a homes environment to reduce allergen levels was important for managing allergies and asthma. Individuals who suffered from asthma, or have other respiratory illness may potentially be at a greater risk for health complications associated with poor air quality in their homes. Asthma was a serious chronic respiratory disease that affects people of all ages. The number of people in Minnesota and nationwide with asthma rose during the past two decades. Furthermore, The Public Health Nursing in the Philippines (2007) added that simple household practices involving solid and liquid waste management (which continue to be carelessly done at the household level), personal hygiene and food and water supply sanitation should be encouraged and promoted. The combined actions of individual households with regard to these practical solutions generated positive effects on the health status of the population. Therefore, implementing a proper and healthy environment reduced the increasing rate of respiratory infections. Fortunately there were several simple things that can be done that will help to prevent illness and injury from an unsafe home environment. Home and Community Sanitation. Sanitation as defined by the WHO (2008) referred to the provision of facilities and services for the safe disposal of human urine and feces. Inadequate sanitation was a major cause of disease world-wide and improving

24 sanitation was known to have a significant beneficial impact on health both in households and across communities. The word 'sanitation' also referred to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal. In addition, The United Nations General Assembly through its Resolution dated December 4, 2006 declared 2008 as the International Year of Sanitation (IYS). The resolution expressed concern on the slow and insufficient progress in providing access to basic sanitation services at the global level and recognized that progress was attained through active commitment and action by all States, as well as United Nations agencies, regional and international organizations, civil society organizations and other relevant stakeholders. Ever since it was establishment, environmental sanitation was recognized as a foundation of a sound public health structure. Article 2(l) of its 1948 Constitution calls for the improvement of sanitation and other aspects of environmental hygiene. Current rates of progress towards the MDG sanitation target were inadequate and in 2008, 1100 million people (17% of the worlds population) with no access to toilets, latrines and other forms of improved sanitation had no other choice than to defecate in the open, resulting in high levels of environmental contamination and exposure to the risks of microbial infections. The vast majority of those without access to basic sanitation (87%) lived in rural areas. Access to improved sanitation was particularly low in the WHO African and South-East Asia regions where more than half of all people remain unsaved. Moreover, the Global Health Observatory revealed that during the period 19902006, over a 1000 million people gained access to improved sanitation facilities. Despite of this, if current trends continued, the world missed the MDG target by a wide margin. In the WHO African Region, coverage of improved sanitation increased from 30% in

25 1990 to 34% in 2008. An annual rate of increase of over 9% needed to reach the MDG target by 2015. In the WHO South-East Asia Region, while coverage increased from 26% to 40%, it was still lagged behind the 45% needed to achieve the MDG target. Therefore, further improvement and discipline was needed to achieve a healthy environment and lifestyle. Proper sanitation had a significant impact that would benefit on health that could greatly reduce the incidences of illness. It was possible if proper education on safe disposal of excreta, sewage and community waste were disseminated to the people and community. Food Preparation. Sanitation within the food industry meant to the adequate treatment of food-contact surfaces by a process that was effective in destroying vegetative cells of microorganisms of public health significance, and in substantially reducing number of other undesirable microorganisms, but without adversely affecting the product or its safety for the consumer (U.S Food and Drug Administration, Code of Federal Regulations, 21CFR110, USA 2010). According to Department of Health (2007), sanitary food preparation remained wanting in most rural households. Lack of sanitation facilities and reckless waste disposal practices undermined environmental sanitation. All these were major factors responsible for the high incidence including outbreaks of water-borne and food-borne diseases such as diarrhea, cholera and typhoid fever. Likewise, Public Health Nursing in the Philippines (2007) emphasized that health promotion and protection under these conditions were urgent needs that must be addressed immediately by the public health system. In order to promote health among people and protect communities from the increasing threats from poor environment, the

26 goals and targets of health included the promotion of healthy environment starting from the homes, schools, workplaces, communities and cities. Simple household practices involving solid and liquid waste management (which continue to be carelessly done at the household level), personal hygiene and food and water supply sanitation should encouraged and promoted because airborne micro-organisms (bacteria, fungi), mites (in sheets or carpets), and (parts of) insects and beetles caused not only diarrhea or foodborne diseases but also respiratory diseases. Therefore, the food eaten should be properly prepared and cooked because infections were also be transmitted through foods people eat. Being conscious and meticulous of the food that people eat was important. Ineffective food preparation definitely caused such illnesses and transmission of infection. Family Hygiene. Seymour (2005) stressed out the family that was healthy gains much more enjoyment and satisfaction from life than the one in which its members were ailing, at cross purposes with one another, and ignorant of how to keep fit and sociable. The health of a community depended largely on the mothers and to a lesser degree on the fathers, since the doctors, hospitals and various medical services deal mainly with those whose health deteriorated, and those who were sick and incapacitated. The vast majority of people were born healthy and this good health needed constantly to be maintained against weather, infecting organisms, accidents, bad feeding customs, dirt, food shortages, and foolish traditions. In the battle for health the housewife was some-times at a loss as to what is the best way to deal with a situation. She cannot always trust old domestic customs because more scientific knowledge showed that better health maintained by newer methods, and for her family's sake she must learn them and how to

27 apply them. On the other hand, Public Health Nursing in the Philippines (2007) stated that family hygiene was very essential to ones health and every health care facility should practice promoting good hygiene. Hygiene Promotion was the planned, systematic attempt to enable people to take action to prevent or mitigate water, sanitation, and hygiene related diseases and provides a practical way to facilitate community participation and accountability in emergencies. Furthermore, World Health Organization, Western Pacific Region (2008) good hygiene, or personal cleanliness, not only helped maintain a healthy self-image, but was important in preventing the spread of infections and disease especially when dealing with respiratory infections. Poor hygiene allowed dried sweat, dirt and sebum to collect on your skin, providing an ideal environment for fungi and bacteria. Hygiene through covering nose and mouth when coughing and sneezing, using tissues and masks with secretions, disposing of tissues and masks in the waste after use, performing hand hygiene after contact with respiratory secretions and contaminated objects/materials and encouraging coughing persons to sit at least 3 feet away from others in common waiting areas when infected with respiratory infections were considered. Therefore, giving a family the proper education regarding hygiene certainly helped to decrease the incidence of disease and spread of infections. Giving the children a strong foundation of learning by their parents regarding proper hygiene such as hand washing, taking a bath, brushing teeth and etc. brought that knowledge until they grew up can be very idealistic for them to grow in a healthy home and environment.

28 Source of Water Supply. Water was a vital natural resource. Public Health Nursing in the Philippines (2007) mentioned that an adequate and safe water supply was essential for daily life functions, such as drinking, food preparation, personal hygiene and sanitation. It was also essential in delivering basic goods and services to the people, including food production, product manufacturing and the maintenance of the ecological system. Furthermore, in the Philippines, although known to have relatively abundant water resources were presently confronted with alarming sustainable development crisis in the water sector. Ensuring the long-term availability of adequate supplies of clean water at a reasonable price was one of the greatest challenges the country needs to address. Rapid population growth, economic development, urbanization, and

industrialization taken its toll on the water resources of the country resulted in an increased competition for water supply, irrigation, and hydropower. Furthermore, increasing water pollution, degradation of the watersheds, and the inadequate government support to the sector programs aggravated the situation. Hence, there was a need for the implementation an integrated, coherent and sustainable water resources management program. (www.watsansolid.com.ph, 2006) Moreover, the Department of Health (2003) revealed that the country had abundant sources of water. It used for domestic purposes (48 percent), irrigation (68 percent), power generation (63 percent), industrial processes (15 percent) and commercial purposes (8 percent) (NWRB2000). From 1960 to the present, there had a significant increase in households with access to safe water at average rate of 2 percent increase yearly. About 87 percent of the total households had access to safe water supplies with 91

29 percent of households from urban areas and 71 percent of households in rural areas (NHDS 2001). Therefore, having a water dilemma in our country was a big issue regarding health. Clean water supply was a basic need each person need, water was even bought by money now a day. Ensuring the people clean availability of water supply was a great need. A clean water supply leaded to a clean environment, proper sanitation and hygiene resulting to lower incidence of diseases. Availability of Sanitation Facilities. According to UNICEF (2008), the Total Sanitation Approach (TSA) or Community-Led Total Sanitation (CLTS) involved facilitating a process to inspire and empower rural communities to stop open defecation and to build and use latrines, without offering external subsidies to purchase hardware such as pans and pipes. CLTS continued to spread within that country and many interesting innovations, as well as some important sustainability issues, emerged. The approach was introduced in at least six different countries in Asia and three in Africa. Moreover, WHO (2007) explained that there must be a clean and reliable water supply for hand washing, personal hygiene and flushing of toilet facilities. The water supply should meet quality standards and be regularly tested to ensure that any contamination discovered quickly and that appropriate remedial action was taken. In addition, McKenzie et. al. (2004) emphasized that maintaining toilets in a hygienic condition was very important since a healthy environment supports a healthy community. Failure to maintain the integrity of toilet facilities can mean epidemics of water borne diseases, illnesses and diseases transmitted through fecal contamination of drinking water or via fecal oral route.

30 Therefore, humans had the power to significantly alter the environment through individual and community activities. Residues and wastes from human activities adversely affected the environment. Responsibilities for cleaning sanitation facilities were very clearly defined. External Environment. According to the Walden University (2004), external environment were conditions, entities, events, and factors surrounding an organization which influence its activities and choices, and determine its opportunities and risks. It was also called as an operating environment. (www.businessdictionary.com) Similarly, Muralidharan (2009) added that external environment composed dimensions in the broader society that influence an industry and the firms within it. The immediate environment consisted house, compound and the surrounding area near home. Moreover, WHO (2007) reported that proper environmental management was the key to avoid the quarter of all preventable illnesses which were directly caused by environmental factors. The environment influenced our health in many ways through exposures to physical, chemical and biological risk factors, and through related changes in our behavior in response to those factors. Thirteen million deaths annually were due to preventable environmental causes. Preventing environmental risk could save as many as four million lives a year, in children alone, mostly in developing countries. Therefore, a healthy environment was important if a person who wanted to stay healthy. Sometimes people kept the environment very dirty with the result that it badly affects their health. Wherever we live, it was important for us to keep it clean to reduce the incidence of illness or disease. Sewerage System. According to Groeniger (2006), it was possible to monitor

31 sewage systems for pathogen occurrence in a community. An epidemiological approach to monitoring sewer systems was especially relevant for an early warning of pathogens used as biological weapons. In many situations, bioterrorist contamination events

resulted in the pathogen shedding to wastewater before a community level epidemic begins. Detecting the organism early allowed government time to respond and eliminate a potential catastrophe. Sewage was water-carried wastes, in either solution or suspension that intended to flow away from a community. Also known as wastewater flows; sewage was the used water supply of the community. It was more than 99.9% pure water and was characterized by its volume or rate of flow, its physical condition, its chemical constituents, and the bacteriological organisms that it contains. Depending on their origin, wastewater classed as sanitary, commercial, industrial, agricultural or surface runoff. Sewage collection and disposal systems transported sewage through cities and other inhabited areas to sewage treatment plants to protect public health and prevent disease. Sewage treated to control water pollution before discharge to surface waters (www.wikipedia.org). The Colorado Department of Environment (2000) revealed that sanitary sewer overflowed due to too much precipitation infiltrating leaky sewer pipes, inadequate system capacity to handle newly-developed residential or commercial areas, blocked or broken pipes, or improperly designed and installed sewer systems. The maintenance of water seals between fixtures and drains and the permanent tightness of soil pipe and drainage systems were important, not only because they prevented the passage of air, but because they prevented the access of insects to the interior of the drains and sewers.

32 Sewage backup not only present unpleasant odor problems, they caused property damage and present unhealthy living conditions. Untreated sewage contained disease-causing organisms such as bacteria, viruses and parasites. Furthermore, Groeniger (2006) explained that respiratory infections and allergic reactions resulted from inhaling associated airborne microorganisms. The air in sewers and drains often contained gases resulting from the decomposition of excreta, soap, fats, and other wastes, together with gases from mineral oils which may come from garages, streets, and industrial establishments. Illuminating gas found its way into sewers through leakage. Among these gases found methane, sulphureted hydrogen, and carbonic oxide. In large amounts those gases were poisonous to the human system and there were physiological objections to breathing them even in small quantities: Violent explosions in sewerage systems and the loss of lives of sewer workers bore testimony to the dangers of sewer air. Again, the odor of these gases was repugnant to human beings. Those who had self-experience know sewer air produced shallow breathing, headache, and even nausea. Any worker in a room with an open sewer connection recognized the necessity of closing the opening. Sewer air, sewer gas, or sewer vapor contained disease-producing bacteria, derived from human excreta and body wastes, often found in sewage. Hence, iris argued by some that escaping sewer air, sewer gas, or sewer vapor has no influence on health. Clean air was essential to life, and the air of sewers or drains kept from entering buildings if for no other reason than the harmful gases which may be poisonous to the human system. Therefore, ensuring safety and security of the sewage system was very important because the lives and health of the people were the one at risk.

33 Garbage Disposal System. According to Reyala et. al (2000), waste management was the collection, transport, processing, recycling or disposal, and monitoring of waste materials. The term usually related to materials produced by human activity, and was generally undertaken to reduce their effect on health, the environment or aesthetics. Waste management also carried out to recover resources from it. Waste management involved solid, liquid, gaseous or radioactive substances, with different methods and fields of expertise for each. On the essay of Mighty Students (2008) waste management was a grave environmental problem of the world today. The worlds human population produced more waste than it can collect and dispose. Thus, waste management was of prime importance in any region. In developing countries, industries were centered on cities. This attracted people from all over the country, creating a gap between the rich and the poor. The City of Manila was the capital of the Republic of the Philippines. Manila was home to a thriving metropolitan area and contained over 10 million people. The city considered an important cultural and economic center. These developments accompanied by the problems of overpopulation, waste management and pollution. Directly, solid wastes contained chemicals or irritants that pose a serious health hazard to the surrounding community. Indirectly, solid wastes were breeding grounds for parasites, vectors and other organisms capable of causing diseases to human hosts. In developed countries, the government as well as the private citizen was aware and instrumental in their waste management programs. However, in developing countries, various factors and problems contributed to a significant difference in terms of policy and implementation. Moreover, Dontigney (2005) emphasized that improper waste disposal

34 contributed to air pollution. Created by emissions from industrial plants, homes, cars, garbage and businesses such as dry cleaners and printers, smog was the most obvious type of air pollution, simply because it was visible. Air pollution was also responsible for acid rain, greenhouse gases, and ozone depletion, and may also play a role in respiratory problems by exacerbating asthma, inflaming lung tissue, and reducing lung function. Therefore, garbage posed serious health hazards either by direct contamination or by indirect means. It considered as one of the threats that greatly affected the health of an individual since human waste and garbage inevitably arise of more than we expected. Community Economic Activities. According to Lutz (2009), socio-economic activities were contemporary practice that considered behavioral interactions of individuals and groups through social capital and social "market and the formation of social norms. Different economic activities had a reflection to ones health due to external stimulus, that might be a good or bad in response to bodys defense mechanism. Multiple logistic regressions used to estimate odds ratios in relation to socio-economic class, using age, sex, a family history of asthma, smoking habits, and occupational exposures to dust, gases and fumes as possible confounders. In addition to, Global Development and Environment Institute (2006) stated that it involved the use of scarce resources in the provision of goods to satisfy unlimited wants. It was a measure for meeting the problem of making a living; other categories of work were not related to this problem. There were differences in nature between one source of livelihood and another but the underlying similarity in all spheres of economic activities was that work performed against ware or remuneration. In the modern social scheme of things, these activities rotated around the financial axis and that was why all the activities

35 involving money earning and money spending called economic activities.

But in order to satisfy the variegated purposes of human life and existence, the arena of man's work widened itself to a much larger extent and he performed many other general duties and functions which did not come under the definition of economic activities as mentioned, for example, the vast area of human worked in a field of painting infrastructure where economics had no as such role to play but the health especially of the respiratory system affected. Moreover, according to the Science Daily (2007), about 40 percent of deaths worldwide were caused by water, air and soil economic activity. Such environmental degradation, coupled with the growth in world population, was major causes behind the rapid increase in human diseases like infections in the respiratory tract, which the World Health Organization has recently reported. Both factors contributed to the malnourishment and disease susceptibility of 3.7 billion people. They added that air pollution from smoke and various chemicals killed 3 million people a year. In the United States alone about 3 million tons of toxic chemicals were released into the environment -contributing to cancer, birth defects, immune system defects and many other serious health problems. Therefore, the continuous growth of population together with degradation of our environment became a threat to health of every individual. Neighborhood Leisure Activities. According to the Public Health Nursing (2007), sedentary lifestyle, a life spent or no physical activity had grave consequences to ones health. The lack of adequate physical activity was associated with increased risk for different disorders. Inactive people died younger. Previous research showed that people

36 on a low income and those from ethnic or racial minorities had the lowest activity levels. There were, however, many barriers to being active. It claimed that people who live in neighborhoods that were unsafe face particular difficulties. They wanted to walk, cycle, or take other forms of outdoor exercise near their home, but they feared they injured as a result of a violent attack. It was usually the poorest members of society who live in unsafe areas. It also known that those poor people who belong to minority racial or ethnic groups were particularly likely to feel unsafe. Furthermore, Dennis (2008) added that smoking and alcohol consumption were the most common leisure of people who were physically inactive. Smoking was a practice where a substance, most commonly tobacco, burned and the smoke tasted or inhaled. It was one of the most common forms of recreational drug used where the most popular type was tobacco and practiced by over one billion people in of all human societies. Many smokers began smoking in social settings and the offering and sharing of a cigarette was often a good excuse to start a conversation with strangers in settings like bars, night clubs, at work or on the street. Lighting a cigarette was often seen as an effective way of avoiding the appearance of idleness. However, in spite of the popularity of smoking, medical studies proved that smoking was among the leading causes of diseases such as lung cancer, heart attacks, and chronic obstructive disease and it also leaded to birth defects. The well-proven health hazards of smoking caused many countries to institute high taxes on tobacco products and anti-smoking campaigns were launched every year in an attempt to curb smoking. Several countries, states and cities also imposed smoking bans in most public buildings. Moreover, Hawamdeh et. al (2003) noted that children were particularly

37 vulnerable to the detrimental effects of smoking if there were group of smokers within the community, as their respiratory systems were structurally and immunologically immature and developed rapidly. The mechanism by which passive smoking increases respiratory symptoms and decreases lung function in children was not known. Parental smoking showed to enhance allergic sensitization in infants and schoolchildren with a close family history of atopic disease. Therefore, inadequate physical activity increased the possible disease that may occur. Also, smoking became the leading activity in which it became a great threat to the health of children; especially they were the usual victims of second hand smoking.

Related Studies According to study of Tupasi et. al (2000), the incidences of acute respiratory tract infection (ARI) and acute lower respiratory infection (ALRI) were 6.1 and 0.5 per child-year, respectively, in children less than 5 years old in a depressed urban community in Manila. The peak age-specific incidence occurred in those children 6-23 months old for ARI and 6-11 months old for ALRI. Age less than 2 years, malnutrition, household crowding, and parental smoking were associated with a statistically significant, though modest, increase in ARI morbidity. The crude mortality rate was 14.3 per 1,000 children 0-4 years old, with a corresponding ARI-specific mortality rate of 8.9 per 1,000. The prevalence of viral infection was 32.8 and that of bacteremic ALRI was 6.7 per 1,000 children with moderate ALRI. Bellos et al. (2010) found the incidence rate of ARI measured in community incidence, finding a ratio of about 5-12 AURI cases to 1 ALRI case: because no age

38 stratification was reported, this study was not easily comparable to non-crisis settings, for which incidence rates among children below 5 years were well described. In three other studies, ALRI incidence rates were in the range of 0.6-1.4 per 1000 person-weeks: however, these reflected only cases presenting for treatment at clinics. Furthermore, in the study released by the Asthma and Respiratory Foundation (2006), indicated that while respiratory illnesses were declining in other developed countries, they were increasing in New Zealand with one in four of children affected. It revealed that among the top 10 causes of potentially avoidable hospital admissions in young New Zealanders, the majority were respiratory conditions. Hospital admission rates for child asthma remained high and rates for Maori and Pacific Islanders increased. Co-editor of the study, Respiratory pediatrician Dr. Cass Byrnes, said that cases of pneumonia, tuberculosis, whooping cough and lung scarring were all on the increase, especially in children. She said that was a real concern because childhood respiratory problems caused a higher death rate in young adults and health problems in adulthood. The studies above pertained to the increased rates of acute respiratory infections in children below five years old in the Philippines and abroad. These studies were related in promoting level of awareness to prevent and treat these infections. Banerji (2009) concluded that respiratory infections were the leading cause for admission, medical evacuation and expenditure for Inuit children in the health care system and resulted in serious health complications for those affected. In her study, she found out that one of the risk factor that contributes to ARIs among Inuit children was overcrowded living conditions which increases the risk of admission due to ARI by 2.5 times.

39 In addition, Kovesi et. al (2007), revealed in their research study that inadequate ventilation and overcrowding contributed to the high incidence of respiratory tract lung infections in young children. Respiratory tract infection was significantly associated with indoor carbon dioxide levels and occupancy. Ventilation rates were below the recommended Canadian standard in 80% of the houses, with carbon dioxide levels often exceeding recommended concentrations. Elevated carbon dioxide was an indication of crowding and reduced ventilation. Smokers were present in 93% of the homes. Moreover, Koch et. al (2003) explained that crowding measured in terms of nighttime crowding was a risk factor for acute respiratory infections. In his study at Greenland, it revealed mixed results for nighttime crowding. An explanation for that could be exposure to infectious agents in the family was most intense when sharing a bedroom with others. The mean area of a dwelling was 74.7 m2, and the median number of rooms per household was three (equivalent numbers for Denmark: 98 m2 and three rooms per household. Thus, with the average house size in Greenland, the number of persons sleeping in the same room, were reduced, and especially by children less than 5 years of age. Taken together, these measures reduced the burden of illness in the youngest group of children. The aforementioned studies explained how overcrowding in a house affect the incidence of acute respiratory infections. It also discussed the effect of overcrowding in terms of inadequate ventilation where carbon dioxide levels were increase. In a population-based survey conducted by Guevara et. al (2002) using the Integrated Management of Childhood Illnesses (IMCI) approach in a marginal community in Mexico, where 239 mother/caretakers of children below five was

40 interviewed at home using a standardized questionnaires, it revealed that common respiratory infections reported by them included: chest congestion (41%), rapid breathing (30%), and cough/cough with blood (15.5%). Only 59% of the mothers took the child to the clinic while the remaining (41%) used medications (self-prescribed and over the counter) and practiced folk medicine. These results highlighted the need to study the relationship between cultural/folk practices used by this community and child health outcomes, in order to identify helpful and non-helpful folk practices. Moreover, Fischer et.al (2008) explained that risk of acute respiratory illness was 65% greater for children of mothers with lower schooling as compared to children of mothers with 9 complete years of schooling. For paternal schooling, after adjusting for the other variables at this level, there was a reduction in the prevalence ratios and a loss of statistical significance. Furthermore, Abul et. al (2000) revealed that prevalence of severe ARI was higher among children born to mothers with primary or less education compared to children of mothers completing secondary or higher education is 5.0 and 8.1 percent respectively. Mother's lower education was a risk factor for severe ARI among under-5 children in Bangladesh. However, using multivariate logistic regression, the effect of household poverty became insignificant meaning that higher severe ARI among poor children was due to the mother's lack of education. Therefore, improving mother's education had significant salubrious effects on severe ARI in children in the developing world, reduced childhood deaths and assisted us in achieving the Millennium Development Goals (MDGs).

41 The aforementioned studies explained how the parents educational attainment contributed to the incidence of acute respiratory infections. It said that parents with low educational attainment were unable to meet the full income they needed to provide proper nutrition to their children thus making them vulnerable to diseases. It also made them hard to identify that the signs and symptoms of respiratory illnesses were occurring. Alper et. al (2008), conducted a study to determine if socioeconomic status (SES) predicted who developed a common cold when exposed to a cold virus. The study was composed of 193 healthy men and women ages 21-55 years. They were assessed for subjective and objective SES, cognitive, affective and social dispositions, and health practices. Subsequently, they were exposed by nasal drops to a rhinovirus or influenza virus and monitored in quarantine for objective signs of illness and self-reported symptoms. And it revealed that increased SES was associated with less susceptibility to acute respiratory infection, and this association was independent of objective SES, suggesting the importance of perceived relative rank to health. In addition, Margolis et. al (2002) had reported that the incidence of lower respiratory illness was 1.41 in the low socioeconomic group, 1.26 in the middle group, and 0.67 in the high group. The prevalence of persistent respiratory symptoms was 39% in infants in the low socioeconomic group, 24% in infants in the middle group, and 14% in infants in the high group. It reflected and came up with a conclusion that the odds of persistent respiratory symptoms in infants of low and middle

socioeconomic status were reduced after controlling for environmental risk factors for lower respiratory illness. Infants of low socioeconomic status were at increased risk of persistent respiratory symptoms.

42 Furthermore, Melville (2010) concluded that more than two thirds of children ages 5 and under from low income families spend a significant amount of time in child care each week. This was significant because the quality of child care available to low income families was much worse than that available to higher income families, and the quality of the child care affected the child's development. High quality, center-based care was expensive and was simply not an option for many low income families. Instead, they turned to informal, sometimes unregulated child care. Child care subsidies were

available in some states, but not available to all low income workers. In other words, low income families often had difficulty accessing support systems that help them balance work and family life. As a result, the children of low income families were not given the same opportunities as their middle class counterparts. The variable of family income maintained an inverse linear relationship with respiratory illness, the higher the income, the lower occurrence of acute respiratory illness. In a study conducted by Higgins (2002), she associated poor housing conditions with a wide range of health conditions including ARI. He suggested public health departments to employ multiple strategies to improve housing, such as developing and enforcing housing guidelines and codes, implementing "Healthy Homes" programs to improve indoor environmental quality, assessing housing conditions, and advocating for healthy, affordable housing. In addition, the London Health Observatory (2003) found out in their study that children living in homes with damp and mould had an increased risk of developing wheezing and chest problems. On his another study found higher levels of several

43 respiratory symptoms for both children and adults living in damp and moldy houses compared to those living in dry dwellings. The quality and safety of houses played an important role that influenced our health. The more families lived in an unhealthy and inappropriate place of living (e.g. squatters area), the more families especially children were at risk of developing respiratory infection. According to Hockenberry (2005), the health status of the person or the ability to resist invading organisms depended on several factors. Deficiencies of the immune system placed the child at risk for infection. Day care attendance, especially if the caregivers smoked, increases the likelihood of infection. In addition, in the study of Roth et. al (2008), inadequate nutrition and acute respiratory infection (ARI) were overlapping and interrelated health problems affecting children in developing countries. Based on a critical review of randomized trials of the effect of nutritional interventions on ARI morbidity and mortality, they concluded that: zinc supplementation in zinc-deficient populations prevented about one-quarter of episodes of ARI, which may translate into a modest reduction in ARI mortality; breastfeeding promotion reduced ARI morbidity; iron supplementation alone did not reduce ARI incidence; and vitamin A supplementation beyond the neonatal period did not reduce ARI incidence or mortality. There was insufficient evidence regarding other potentially beneficial nutritional interventions. For strategies with a strong theoretical rationale and probable operational feasibility, rigorous trials with active clinical casefinding and adequate sample sizes were undertaken. At present, a reduction in the burden of ARI was expected from the continued promotion of breastfeeding and scale-up of zinc

44 supplementation or fortification strategies in target populations. Moreover, Ferrer et. al. (2005) explained that the family contribution to individual health status was measurable and substantial. The shared characteristics of income and health insurance accounted for only a modest portion of the effect. Health policy and interventions placed more emphasis on the family's role in health. Therefore, supplements played an important role in health status of the children. Parents should be aware that children having vitamin deficiency were at great risk to have ARI. Together with proper breastfeeding and vitamin supplementation, cases of ARI were reduced. Fischer et. al (2008) revealed in their study that there was an important association between acute respiratory illness and previous episodes of acute respiratory infections in general, acute respiratory infections, and hospitalization due to pneumonia. The risk of presenting acute respiratory illness for children with a previous history of acute lower respiratory infection was twice as great for children with previous episodes of wheezing, and the increase in the risk of acute lower respiratory illness was directly associated with the number of episodes. These findings confirmed others already described in the literature as to the presence of previous illness. The data in this study showed that children with a personal history of respiratory diseases constitute a high-risk group. Preventive measures and early interventions focused on these children as a priority. In addition, Benti et. al (2000), explained that the common acute infections of the upper and lower respiratory tract range from a simple cold or cough, otitis media, sore throat, laryngitis, to bronchitis, bronchiolitis, and pneumonia. Diphtheria, measles, and

45 pertussis (whooping cough) were also respiratory infections. On average, children under age five experienced between five and eight ARI episodes with durations of 5-7 days a year, which translated into at least 2,000 million episodes each year in the developing world. The majority of ARI episodes were mild and self-limiting, as in the case of coughs and colds. However, about one in every 30 to 50 episodes of cough developed into pneumonia. Without treatment, 10% to 20% of pneumonia cases resulted in death. From the variable of history and reoccurrence of ARI, it showed that there was more possibility for children to have acute respiratory infection if they had previous episodes of wheezes. Therefore, observation and early intervention were the priority. According to the findings of the study conducted by Mitra (2001) strongly pointed towards the importance of basic health promotional measures like hand washing, everyday bathing, house cleaning, proper nutrition of the child and improved general conditions of living in prevention and control of ARI. Tallo (2001) on her study, mothers explained that when cough is not hard, giving the child herbal drinks made the cough soft and productive. Hard cough occurred when the phlegm had 'stuck to the lungs' resulting in rattling chest sounds. Giving herbal drinks when the cough was hard was not usually effective. All mothers agree that hard or rattling cough was a serious condition. When left untreated, the mucus spreaded throughout the lungs and the condition was labeled pneumonia. The removal of mucus was so important that some mothers induced vomiting by putting their finger in the baby's mouth. Moreover, in the study of Bernard et. al (2007), it revealed that meticulous house cleaning especially if chemicals were used like bleach can inactivate common viruses and

46 bacteria that caused respiratory infections. In this cross-sectional study, they evaluated to what extent regular house cleaning with bleach can decrease the influence and risks of respiratory and allergic diseases in children. House cleaning with bleach had effect neither on the sensitization to pollen allergens, nor on the levels of exhaled NO and of serum CC16 and SP-D. This appeared to protect children from the risks of asthma and of sensitization to indoor allergens while increasing the risk of recurrent bronchitis (complication of respiratory infection) through apparently an interaction with parental smoking. As this was one of the most effective cleaning agent to be found, these observations argued against the idea conveyed by the hygiene hypothesis that cleanliness per se increased the risk of asthma and allergy and other respiratory infections. Studies mentioned above pertain to the health status including the family health history and preventive measures in relation to ARI. Parents with insufficient knowledge in preventing such disease were risk of developing ARI. Therefore, health promotion and prevention were raised. Wall (2007) searched on the relation between indoor air pollution exposure and acute respiratory infection (ARI) in children in developing countries. She found out that indoor air pollution from biomass fuels, which was strongly poverty related, was an important risk factor for ARI morbidity and mortality. According to Mann et.al (2002) explained that a poor home environment, parental bronchitis and atmospheric pollution were the best predictors of lower respiratory infections in the first two years after birth and these factors together with later smoking and childhood respiratory infections were the best predictors of lower respiratory tract diseases in adults. It was possible that increased infections in socially disadvantaged

47 populations were related to crowding and increased exposure to infectious agents or to alterations in host immunity In addition to, Netherlands Nutrition Centre (2001) revealed in their study that utensils and other equipments such as the chopping board, knife, dishes, cutlery, work top, dishcloth etc., were also be contaminated by food preparation. Using these tools caused contamination with bacteria existing on foods such as raw meat and vegetables. If a tool was used for another food product, bacteria from the first product were transmitted to the second. Particularly materials used for the preparation of meat form a major source of contamination. Therefore, knives and chopping boards (and all other materials used), which in contacted with raw meat, were rinsed with hot water and treated as dirty dishes afterwards. If these tools were reused immediately, they must be washed in hot water and soap first. So, washability was an important issue when using the utensils again before cooking another type of food. Moreover, Kilabuko and Nakai (2007) biomass fuel in food preparation was linked to Acute Respiratory Infections (ARI) in children. It was not clear whether the use of charcoal and kerosene had health advantage over biomass fuels. In this study, the effects of biomass fuels, charcoal/kerosene on ARI in children under five years old in Tanzania were quantified and compared based on data from Tanzania Demographic and Health survey conducted between 2004 and 2005. Approximately 85% and 15% of children were from biomass fuels and charcoal/kerosene using homes respectively. Average ARI prevalence was about 11%. The prevalence of ARI across various fuel types used for cooking did not vary much from the national prevalence. Odds ratio for ARI, adjusting for childs sex, age and place of residence; mothers education, mothers

48 age at child birth and household living standard, indicated that the effect of biomass fuels on ARI is the same as the effect of charcoal/kerosene (OR 1.01; 95% CI: 0.78-1.42). The findings suggested that to achieve meaningful reduction of ARI prevalence in Tanzania, a shift from the use of biomass fuels, charcoal and kerosene for cooking to clean fuels such as gas and electricity may be essential. Further studies, however, were needed for concrete policy recommendation. The aforementioned studies above explained how the indoor environment and food preparation including the use of biomass fuel, charcoal and kerosene in cooking affect the incidence of ARI in children. As possible, use of electric gas stove was considered especially if the child was already infected with ARI to reduce further development of infections. In the study of Luby et al. (Lancet, 2005) published by the UNICEF last year 2008 suggested that hand washing with soap can reduce respiratory infections in children under five by 50 percent. Another current study found that children under 15 years living in households that received hand washing promotion and soap had half the diarrheal rates of children living in control neighborhoods (Luby et al., Jama 2004). Because hand washing prevented the transmission of a variety of pathogens, it was more effective than any single vaccine. Promoted on a wide-enough scale, hand washing with soap thought of as a do-it-yourself vaccine. However, changing the habits of a lifetime was not so easy and required a huge and concerted effort. In addition to according to Department of Health and Human Services (2009), during period of increased respiratory infection in the community, offer masks to persons who were coughing. Either procedure masks (i.e., with ear loops) or surgical masks (i.e.,

49 with ties) were used to contain respiratory secretions, as well as frequent hand washing was advised. Encourage coughing persons to sit at least 3 feet away from others in common waiting areas. Hygiene was discussed above. Hygiene was taught to children as early as possible to reduce the risk of transmitting infections to other individuals. A proper and strong foundation of teaching them good hygiene started to give the children and their family a healthy environment. In the study of the Sub-Working Group on Water Supply and Sanitation (2008) it revealed that water supply coverage and quality in the Philippines are in dire need of improvement. Filipinos access to safe water supply declined from 87% in 1990 to 85% in 2004, according to the Joint Monitoring Program for Water Supply and Sanitation by UNICEF and WHO. There was no consolidated data on piped water systems but data from various sources suggest that the access of Filipinos to such systems is very low. As of 2000 census, only 27 in every 100 households in the Philippines had connections either through own use faucets or community water systems. Level 3 access (individual household connection) was likely much lower than this figure. In the July 1-3, 2008 consultations on regulation and improving water service coverage, it was reported that water districts under the supervision of LWUA were able to connect on average of only 40% of the population they were mandated to serve. However, the recent increase of groundwater use in the country highlighted the issues and problems that include the intrusion of saline water into aquifer, pollution of groundwater and ground subsidence. The saline water intrusion was due to the insufficient and declining groundwater recharge rate and geological conditions.

50 Furthermore, in the study conducted by Alaska Native Tribal Health Consortium (2008) yielded to the results that a lack of running water use of tap water as drinking water in the home linked to severe respiratory infections among Alaska Natives. Health professionals have thought the benefits of clean water were primarily gastro-intestinal. This study showed that lung and skin infections among Alaska Native persons were also associated with inadequate water service. The studys findings were important because of the seriousness and rates of respiratory illness among Alaska Native infants and children. About 75 percent of all hospitalizations for Alaska Native and American Indian children were due to respiratory problems. The study highlighted the need for sanitation infrastructure in rural Alaska, where about one third of the homes lack modern sanitation facilities. The study, the first of its kind conducted in Alaska, confirmed that flush toilets and piped water lead to improved health status. In addition, Hennessy et. al (2008) found out that lower water services lead to, significantly higher hospitalization rates for pneumonia and influenza, skin infection and respiratory Syncytial Virus, significantly higher hospitalization rates up to one third of infants hospitalized annually for pneumonia and RSV, higher rates of outpatient skin infections and hospitalizations. Moreover, Gupta et. al (2000) revealed that there was an association among high nitrate ingestion from tap water and pathologic changes in bronchi and lung parenchyma. The present study examined a possible correlation among tap water nitrate concentration, methemoglobin levels, cytochrome b5 reductase activity, and acute respiratory tract infection with a history of recurrence (RRTI). Methemoglobin levels alone explained 80% of the variation in the RRTI cases. This study indicated that methemoglobinemia,

51 secondary to high nitrate ingestion in drinking tap water, causes RRTI. Increased production of methemoglobin and free radicals of nitric oxide and oxygen due to nitrate metabolism in the body leaded to alveolar damage and mismatching of ventilation and perfusion, which may be the reason for high mortality in children due to RRTI. Therefore, an access to a safe water supply can improved the health status of the people. But giving them inadequate and unsanitized water leaded to a serious and increase rates of disease and if them is ARI. In the study of Landrigan and Garg (2000) revealed that globally, 2.4 billion people living in peri-urban or rural areas in developing countries, did not have access to any type of sanitation facilities. Coverage estimates for 19902000 showed that little progress was made during this period in improving coverage. The lowest levels of service coverage were found in Asia and Africa, where 31%and 48% of the rural populations, respectively, did not have these services. Examples of sanitation-related diseases included respiratory infections like cough, pneumonia and asthma, as well as cholera, typhoid, schistosomiasis, and trachomaa disease that caused irreversible blindness, and currently affects about 6 million people, with another 500 million at risk of the disease. Furthermore, in the study conducted by Philippine Water Supply and Sanitation Performance Enhancement (2007), on water supply and sanitation systems in selected small municipalities by a multilateral development agency in 1998 found no public sewerage systems in any of those towns. Based on the studys findings, about 60-65 percent of urban households discharged their wastewater into the street drainage system and 25-30 percent into septic tanks from which wastewater seeped into the ground. Such systems mainly consisted of open earth canals, with few concrete-lined canals. All

52 drainage canals emptied into rivers and creeks that traverse the towns. The study noted that the main problem in all the municipalities was the lack of a sewerage system and the inadequacy of the drainage system. But the urban areas in the study were too small in size to justify installation of comprehensive conventional sewerage/drainage systems. These LGUs contended projects for appropriate disposal of wastewater and solid waste were unaffordable without subsidies from the central government. In addition, charging service fees to urban residents would take time to implement and likely prove difficult, considering residents limited ability to pay and their priority for purchasing water supply. According to WHO (2006), the provision of sanitation was a key development intervention without it, ill-health dominated a life without dignity. Simply having access to sanitation increases health, well-being and economic productivity. Inadequate sanitation impacted individuals, households, communities and countries. Despite its importance, achieving real gains in sanitation coverage was slow. Increasing its access to sanitation and improving hygienic behaviors was the key to reducing this enormous disease burden. In addition, such changes increased school attendance, especially for girls, and help school children to learn better. They also had a major effect on the economies of many countries both rich and poor and on the empowerment of women. Most of these benefits accrued in developing nations Moreover, Rahman (2006) explained that quality of life and diseases in any urban areas get reflected by the immediate neighborhood in different parts of the city which depended upon the income strata of the households, their way of living, and their understanding of their household environment. This was because it is the household

53 environment, which exerts the most and immediate influence on the life of the people. This study was carried out in order to assess household environmental conditions (i.e. housing conditions, bathroom and sanitation conditions, water supply conditions, water logging conditions, household garbage and solid waste, household pests, indoor air and indoor noise pollution) and their effect on the health of the resident population of Aligarh city. It revealed that about 55% of the total sampled households suffer from diarrhea/dysentery, 43% jaundice, 42% malaria and 41% respiratory diseases. About 40% suffered from skin diseases, small pox/chicken pox. All these diseases were a result of poor household environmental conditions. Whereas 35% people reported other diseases (i.e. heart disease, hypertension and diabetes), only 14.42% households reported of tuberculosis. The study concluded that there exists a significant positive relationship between income level and household environmental conditions, and also between income and various diseases among sampled households of Aligarh city. The study of Marthet et. al (2000) showed that the routine disposal of waste through dumping or incineration leads to a significant pollution of the environment. The capacity of the present dumps was slowly becoming exhausted thus steadily increasing the significance of alternative methods of waste disposal. In addition to prevention, sorting and recycling, composting of the biological waste components assumed special significance. Presently, a large number of persons were employed in the disposal and manual sorting of waste. All of them were aware of the fact that work in the area of waste management may be associated with health risks. Scientific studies estimated the risks to those employed in this field but also to those of the general population living in the vicinity of the waste disposal industries. In defining the risk, they clearly differentiated

54 between hazard and risk. Hazard was a term, which described the potential damages by a pollutant. It was a qualitative term which provide theoretical information on reaction of the toxic quality by a pollutant but which did not provide information on actually occurring adverse effects. Risk, however, was a quantitative term which provides a causal connection between definite damages and pollutants. It specified the deducible damages and linked them with the intensity of the exposure (dose) or calculated the probability of a damage occurring. Several studies described the hazard to those employed in waste sorting and recycling covering diseases of the lungs, the gastrointestinal tract, mucous membranes, skin and musculoskeletal system. This study was a contribution to the quantitative assessment of the health risk to employees. Moreover, Basavanthappa (2008) discussed that the community advocated for transforming waste into usable products for simply producing garbage and moving towards an integrated system of waste management. People who worked in the community should be aware of the types of environment hazards present. The challenge of maintaining individual family community and worldwide environmental health and safety was tremendous. In addition, Cuevas (2008) explained that Community health workers were in ideal position to detect environmental hazards and to instruct or educate individuals and families and communities on ways to avoid disease or alter environmental hazards. They directly combat these hazards but they did monitor, report, advice community members and served as action-oriented catalysts to initiate community activity. In the study of Slater and Carlton (2000) discussed that Hazardous waste pose serious health problems. Hazardous waste was any discarded material that may pose a

55 substantial threat or potential danger to human health or the environment. Such wastes had properties that make them hazardous to human health such as toxicity, flammability, explosiveness, radioactivity, reactivity, corrosiveness and communicability (the presence of pathogens). Improper disposal of Hazardous waste in Industrial waste led to numerous health problems, communities being evacuated and relocated and community coalitions for environmental health. In addition, Clemen-Stone (2002) explained that nurses need to be aware of hazardous wastes in the community, consider whether community members were exposed, and determine the effect on public health. Hazardous and toxic wastes were linked to deaths, poisoning, acute and chronic illness, cancer, ARI, birth defects, blindness, and sterility. Hazardous wastes had serious effects on human life and health. The above studies revealed that poor sanitation facilities at home and external environment including the garbage disposal may contribute to the incidence of ARI. Sanitation was improved in any areas to prevent disease like respiratory and gastrointestinal infections. People working in the garbage disposal were prone to different infections thus proper precaution measures should be initiated. Lawson (2006) had conducted a study to determine the population of different fields of jobs that are at risk for the, including executives and civil servants at intermediate and higher levels, who were chosen as reference group. Manual workers in industry showed development of asthma, symptoms common in asthma and chronic productive cough. The study comprised 2,341 males and 2,413 females. Cumulative incidences were generally lowest in professionals a significantly increased risk of developing asthma, recurrent wheeze, attacks of shortness of breath or a combination of

56 the two, and chronic productive cough. Manual workers in service showed a similar pattern for attacks of shortness of breath, recurrent wheeze, or a combination of the two, and chronic productive cough. Again, Marthet, al (2000) conducted a number of studies to point out an increased risk to workers in waste employment facilities, emphasizing especially allergic reactions. The study found that the given conditions affected especially the mucous membranes of the upper respiratory tract and the conjunctivae. Allergic diseases, including asthma, played a rather minor role. It stressed that in waste sorting plants, employees suffered more frequently from disorders of the musculoskeletal and respiratory system. The respiratory tract was examined using spirometry, considering especially the allergic component. Allergic diseases manifested themselves in the respiratory tract by obstructive changes which leave clear signs in spirometry. Neither in garbage sorting plants nor in composting facilities, was a statistically significant impairment of lung function found in the examined employees. There was no linear causal relationship between the lung function and the length of employment. The spirometry results of the individual employees were transformed in analogical values (MEF50 60-80% = low lung function; MEF50 >80% = normal lung function) and the calculated relative risk shows an odds ratio of 1.5 which would suggest a clear influence on the lung function. This, in turn, correlates very well with the increased incidence of cough for which an odds ratio of 1.4 was calculated. Mucous membranes are therefore the system which is most sensitive to the effects of the pollutants in the waste treatment industry. According to Schlossberg (2001) on his study on Infections from Leisure-time Activities, he concluded that leisure-time activities expose us to a variety of infections.

57 The traveler confronted new pathogens and vectors. Camping, hiking and gardening had attendant risks, as does exposure to fresh and salt water. Adventure some eating posed gastronomic threats, and pets, sexual exposure and organized sports each contribute distinctive infectious risks to participants. Furthermore, in the study conducted by Yucel et. al (2002), it implied that the direct exposure of the child to smoking, rather than the presence of smoking at home, was a significant predictor of ARI among young children. Even when the quality of indoor air was improved, parents were educated of the importance of avoiding childrens direct exposure to cigarette smoking and/or other indoor pollutants. The cooperative efforts of the health personnel and media against indoor air pollution, cigarette smoking in particular, increased the awareness, and assisted in the education of the public in this matter. Moreover, in a prospective study of 850 infants and children below five years conducted by Hawamdeh et. al (2003), the number of episodes of acute respiratory infection was significantly increased if the parents and neighbors smoked. The overall odds ratio was 1.5 if they smoked at all and 1.8 if they smoked more than 20 cigarettes a day. Children exposed to smoking individuals developed respiratory illness earlier than those of nonsmokers. Children who did not attend daycare nursery were at increased risk from smoking, perhaps because they had more prolonged exposure to smoke. Co-researchers Taylor and Evans (2003) in retrospective analyses of data from the British National Child Health and Education Study confirmed these findings. The increase in lower respiratory disease in childhood caused by passive smoking had important implications for the child in later life. Barker and Osmond, in an important

58 series of studies of the relationship between infant and adult disease, found strong evidence of a direct causal link between acute lower respiratory infection in early childhood and chronic bronchitis in adults. Children exposed to environmental tobacco smoke had more respiratory illness, more middle ear effusion and more viral respiratory illness than unexposed children The aforementioned studies explained how economic and leisure activities like smoking contribute to the incidence of ARI. Even though children do not work and smoke, they are still prone on developing respiratory infections because their immune system is not yet matured and probably due to everyday exposure to persons involved in such activities.

59 Conceptual Framework

Figure 1 presented the conceptual framework as shown in the paradigm of the study. Independent Variables Family-related Factors Number of Family Members Parents Educational Attainment Socio-economic Status Family Income Type of House Dependent Variable

Family Health Status Family History of ARI Preventive Measures Increased Rates of ARI

Environment-related Factors Home Environment Sanitation Practices Food Preparation Family Members Hygiene

Among Children Below Five Years Old

Source of Water Supply Availability of Sanitation Facilities

External Environment Community Sanitation Sewerage System Garbage Disposal System

Community Economic Activities Neighborhood Leisure Activities Fig. 1 Paradigm of the Study

60 The first frame showed the independent variables which is classified as familyrelated factors and environment-related factors. The family-related factors included number of family members, parents educational attainment, socio-economic status and family health status. Socio-economic status was further divided into family income and type of house as well as the family health status which is further divided into family history of ARI and their preventive measures. The environment- related factors included the home environment and the external environment. Home environment includes sanitation practices, source of water supply and availability of sanitation facilities. Sanitation practiced were further divided into two it includes food preparation and family members hygiene. The second sub-variable the external environment is divided into three which are the community sanitation which is further divided into, sewerage system and garbage disposal system, community economic activities and neighborhood leisure activities. The second frame represented the dependent variable that has increased rates of ARI among children below five years old. The solid line postulated that the independent variables affect the dependent variable.

Assumptions In this study, the following were the assumptions: 1. The respondents were honest in giving their answers regarding the increased rates of ARI among children below five years old.

61 2. The increasing rate of ARI is due mainly to the profile of the respondents and environmental-related factors. Definition of Terms The following variables are defined conceptually and operationally: Acute Respiratory Infection (ARI). As described by Hockenberry (2005), it was the infection of the upper or the lower respiratory tract. Infections had often spread from one structure to another because of a contagious nature of mucous membrane lines the entire respiratory tract. Operationally, this disease that accumulated on the respiratory system of a person wherein foreign bodies that affect the system that causes different diseases. Community. According to Merriam-Websters Medical Dictionary (2006), community were a group of people with a common characteristic or interest live together within a larger society. Operationally, large group of people live together in certain regardless of relationship, occupation and status. Educational Attainment. According to Wikepedia (2006), it was a termed commonly used by statisticians to refer to the highest degree of education an individual has completed. Operationally, it was the highest level of reached educational year level of an individual. Environment. According to Merriam-Websters Medical Dictionary (2006), it was a complex of physical, chemical, and biotic factors that acted upon organism or an ecological community and ultimately determined its form and survival. Operationally, it the place where an individual inevitably exist that can influenced ones status.

62 Economic Activity. According to Wikepedia (2007), it involved the use of scarce resources in the provision of goods that satisfied unlimited wants. It was measured for meeting the problem of making a living. Operationally, this pertains to activities of the community where they earned their living for survival. Family. According to Merriam-Websters Medical Dictionary (2006), it was a basic unit in society traditionally consisted of two parents rearing their children. Operationally, they were group of people biologically connected by blood of close ties or can be personal acknowledgement as long as they accept one another. Family Income. According to Wikepedia (2002), it was considered a primary measure of a nation's financial prosperity. Operationally, it pertains to the gross salary of the family that is allotted for their necessities. Food Preparation. According to Sensagent (2008), it was the act of preparing foodstuffs for consumption. Many types of food preparation involved heating the food ingredient, however other types of preparation involved chemical, biological, or mechanical means. Operationally, it was the manner of how a person cooked or present food by fried, boiled, grilled or steam through the use of biomass fuel, charcoal or kerosene. Garbage Disposal. According to Wikepedia (2007), it was a device that gets rid of food wasted by shredding it to tiny bits that washed down. Operationally, has been how garbage are being disposed and segregated. Home Environment. According to Medicine Net (2009), it was the sum of the total of the elements, factors and conditions in the surroundings that had been an impact

63 on the development, action or survival within a place where a family lived. Operationally, it was a place where a family lives, loves, learns and grows as one. Health Status. According to Suite101 (2001), it was the current state of your own health. It included the status of your wellness, fitness, and any underlying diseases or injuries. Operationally, it was the stability of health of an individual whether they healthy or sick. Leisure Activity. According to Merriam-Websters Medical Dictionary (2006), freedom provided by the cessation of activities especially, time free from work or duty. Operationally, these were the past time or relaxation activities of the people in the community. Parents. According to Merriam-Websters Medical Dictionary (2006), they were the one that begets or brings forth offspring. Operationally, it was consisted of Father and Mother that reproduced and gave birth in a child. Sanitation. As defined by Public Health Nursing of the Philippines (2008), it was the study of all factors in mans physical environment, which exercised a deleterious effect of his health well-being and survival. Operationally, how people within the community properly executed actions with cleanliness and system that might affect ones health of an individual. Sanitation Facilities. According to fantaproject (2005), it was a function of excreta disposal facility, typically a toilet or latrine. Operationally, it pertains to specific areas that facilitates in proper disposal of human waste. Sewage System. According to Merriam-Websters Medical Dictionary (2006), it was the treatment works and intercepting sewers, outfall sewers, sewage conveyance

64 systems, and their equipment and appurtenances. Operationally, this facility consisted of a system that carries of liquid and solid waste. Socio-economic Status. According to Wikepedia (2007), it was an economic and sociological combined total measure of a person's work experience and of an individual's or families economic and social position relative to others, based on income, education, and occupation. Operationally, it was the position of ones in the economy in terms of financial stability. Type of House. According to Wikepedia (2008), houses had been built in a ofmee variety of configurations. A basic division is between free-standing or detached dwelling and various types of attached or multi-user dwellings. Both sorts may vary greatly in scale and amount of accommodation provide. Operationally, it pertains to houses classified depending on materials used and quality of convenience a house was build. Water Supply. According to Merriam-Websters Medical Dictionary (2006), a source, means, or process of supplying water (as for a community) usually it includes reservoirs, tunnels, and pipe lines. Operationally, it was the way or system where they supply the needs of peoples proper water service through facilities had been help distribute cleanly the water they needed in every household or establishments.

65 Notes in Chapter II

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67 Adele Pillitteri. Maternal and Child Health Nursing (Care of Childbearing and Childrearing Family) 5th Edition Volume 2. C & E Publishing Inc. p. 1227. 2007. A.M. Fendrick et. al. The Economic Burden of Non-Influenza-Related Viral Respiratory Tract Infection in the United States (2003). www.clevelandclinicmeded.com. Retrieved Oct. 10, 2010. Taj Judavji. A Practical Guide for The Diagnosis and Treatment of Pediatric Pneumonia.Canadian Medical Association Journal. March 2007. Marian Anne Eure. Healthy Home. http://seniorhealth.about.com/od/ prevention/a/home110805_hea.htm. Nov. 9, 2005. Retrieved October 8, 2010. American Lung Association of Upper Midwest. Facts about Indoor Air Quality. http://www.healthhouse.org/iaq/facts.cfm. 2009. Retrieved October 8, 2010. Public Health Nursing in the Philippines 10th Edition. National League of Philippine Government Nurses Incorporated, 2007. World Health Organization. Sanitation. www.who.int/topics/sanitation/en/. Retrieved October 12, 2010 Water Sanitation and Health (WSH) 2008. www.who.int/water_ sanitation_health/hygiene/iys/about/en/index1.html. Retrieved October 9, 2010 WHO - Global Health Observatory. Use of Improved Sanitation Facilities (2008). www.who.int/gho/mdg/environmental_sustainability/situation_trends_sanitation /en/index.html. Retrieved October 10, 2010. U.S Food and Drug Administration. CFR - Code of Federal Regulations Title 21.http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=11 0&showFR=1. Retrieved October 8, 2010. www.doh.gov.ph. 2007. Retrieved October 7, 2010. Rhea Seymour. Health and Hygiene. http://generalhealthtopics.com/. 2005. Retrieved October 10, 2010. www.wpro.who.int/health_topics/water_sanitation_and_hygiene/general_info.htm . 2008. Retrieved October 14, 2010. www.watsansolid.com. 2006. Retrieved November 3, 2010. Health and the Environment. www2.doh.gov.ph/hsra/survey/Health_envi. pdf. 2003. Retrieved October 8, 2010.

68 UNICEF. Africa and Asia: Community Lead Total Sanitation (CLTS)/Total Sanitation Approach. http://esa.un.org/iys/docs/6.%20Global%20Experiences.pdf. 2008. Retrieved October 31, 2010. WHO. Introduction to Fact Sheets on Sanitation. www.sanitationfacts.com . Retrieved December 1, 2010. McKenzie et al. An Introduction to Community Health 4th Edition. 2004. Retrieved December 1, 2010. Sandy Cairncross and Vivian Valdmanis. Water Supply, Sanitation, and Hygiene Promotion. www.dcp2.org/pubs/DCP/41/Section/5928. 2006. Retrieved November 3, 2010. www.businessdictionary.com/definition/external-environment.html. October 10, 2010. Retrieved

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69 Global Development and Environment Institute. Essential Economic Activities. www.eoearth.org. Nov. 2006. Retrieved October 13, 2010. Science Daily. Pollution Causes 40 Percent Of Deaths Worldwide, Study Finds (Aug. 2007). www.sciencedaily.com/releases/2007/08/070813162438.htm. Retrieved Oct. 13, 2010. Anthony Dennis. A Brief Social History http://ezinearticles.com. Retrieved October 11, 2010. of Smoking (2008).

A. Hawamdeh et. al. 25 Effects of Passive Smoking. Eastern Mediterranean Health Journal, Vol. 9, No. 3, 2003. T.E Tupasi et. al. Patterns of Acute Respiratory Tract Infection in Children: A Longitudinal Study in a Depressed Community in Metro Manila. www.ncbi.nlm.nih.gov/. Nov.-Dec. 2000. Retrieved November 5, 2010 Anna Bellos et al. Conflict and Health. Retrieved November 5, 2010. www.conflictandhealth.com. 2010.

Asthma and Respiratory Foundation .Respiratory Illnesses on The Increase. http://tvnz.co.nz/content/702966. Apr. 2006. Retrieved November 3, 2010. Dr. Anna Banerji. Risk Factors For Lower Respiratory Tract Infections in Inuit Children Identified. www.sciencedaily.com. May 2009. Retrieved October 12, 2010. Dr. Tom Kovesi. Poor Ventilation and Crowding in Nunavut Homes Associated With Lung Infections in Inuit Children. Canadian Medical Association Journal. July 2007. Anders Koch et. al. Risk Factors for Acute Respiratory Tract Infections in Young Greenlandic Children. Oxford Journals, American Journal of Epidemiology. Vol. 158 Issue 4. 2003. Kazi Md. Abul et. al. Impact of Mothers Secondary Education on Severe Acute Respiratory Infection (ARI) Among Under-Five Children. www.academic.research .microsoft.com/Paper/5602911.aspx. 2000. Retrieved November 3, 2010 C.M Alper et. al. Objective and Subjective Socioeconomic Status and Susceptibility to the Common Cold. www.ncbi.nlm.nih.gov. March 2008. Retrieved October 15, 2010. P A Margolis et. al. American Journal of Public Health, Vol. 82, Issue 8 11191126. American Public Health Association. 2002.

70

Jennifer D. Melville. Effects of Low Family Income on Children. www.ehow. com/list_6195251_effects-low-family-income-children.html.Apr. 2010. Retrieved October 13, 2010. Krieger J, Higgins. Housing and Health: Time Again for Public Health Action.www.ncbi.nlm.nih.gov. 2002. Retrieved October 9, 2010. London Health November 3, 2010. Observatory.Housing. www.lho.org.uk.2003. Retrieved

Marilyn J. Hockenberry. Wongs Essentials of Pediatric Nursing 7th Edition. Esevier Singapore Pte.Ltd. 2005. Daniel E. Roth et. al. Acute Lower Respiratory Infections in Childhood: Opportunities for Reducing the Global Burden through Nutritional Interventions. www.ncbi.nlm.nih.gov/. May 2008. Retrieved November 6, 2010. Ferrer et. al. The Family Contribution to Health Status. 2005. Benti et. al. Acute Respiratory Infection(ARI) in Developing Countries. www. dcc2.bumc.bu.edu. Retrieved December 1, 2010. Nilanjan Kumar Mitra. Indian Journal of Community Longitudinal Study on ARI among Rural Under Fives. 2001. Medicine.A

Alfred Bernard et. al. Pediatric Allergy and Immunology. House Cleaning With Bleach and The Risks of Allergic And Respiratory Diseases in Children. www.skintherapyletter.com. May 2007. Retrieved April 3, 2011.

Wall S. et. al. Indoor Air Pollution: A Poverty-related Cause of Mortality Among the Children of the World. www.ncbi.nlm.nih.gov. Retrieved Oct. 9, 2010. Scientific Facts on Respiratory Disease in Children. www.greenfacts.org . Retrieved December 1, 2010. Netherlands Nutrition Centre. Hygiene Code for the Private Household. www.nutricion.org/publicaciones/pd. 2001. Retrieved Oct. 10, 2010. James H. Kilabuko and Satoshi Nakai. Effects of Cooking Fuels on Acute Respiratory Infections in Children inTanzania. www.mdpi.com/16604601/4/4/283/pdf. Sept. 2007. Retrieved November 5, 2010.

71 UNICEF. Global: Public Private Partnerships for Hand Washing with Soap. http://esa.un.org/iys/docs/6.%20Global%20Experiences.pdf. 2008. Retrieved Nov. 5, 2010. Infection Control in Healthcare, Home, and Community Settings. www.cdc.gov. Retrieved December 1, 2010. Sub-Working Group on Water Supply and Sanitation. Philippine Statistical Yearbook. http://pdf.ph/downloads/Annex%20A_TOR_111208.pdf. 2007. Retrieved October 8, 2010. Alaska Native Tribal Health Consortium. Groundbreaking Study Links Respiratory Disease with Inadequate Water Service. www.anthc.org. 2008. Retrieved October 9, 2010. Tom Hennessy et. al. American Journal of Public Health. 2008. Sunil Kumar Gupta et. al. Recurrent Acute Respiratory Tract Infections in Areas With High Nitrate Concentrations in Drinking Water. Environmental Health Perspectives Journal. 2000. P. Landrigan and A. Garg, Children Are Not whqlibdoc.who.int/publications/. 2000. Retrieved November 5, 2010. Little Adults.

Philippine Water Supply and Sanitation Performance Enhancement. www.scrib.com . Retrieved December 1, 2010.

Atigur Rahman. Assessing Income Wise Household Environmental Conditions And Disease Profile In Urban Areas: Study Of An Indian City. www.springerlink.com/content/d634105624606178/. 2006. Retrieved November 5, 2010. Egon Marth et. al. Occupational Health Risks To Employees Of Waste Treatment Facilities. www.aaem.pl/pdf/9741_143.pdf, 2000. Retrieved November 5, 2010. Basavanthappa et. al. Community Health Nursing. Jaypee Brothers Medical Company, 2008. Cuevas et. al. Public Health Nursing. Maglaya's Community Health Nursing, 2008. Susan Clemen-Stone. Comprehensive Community Health Nursing: Family, Aggregate & Community Practice. Mosby Inc. 2002.

72 Tony Lawson. The Nature of Heterodox Economics. Cambridge Journal of Economics, 30(4), pp. 483-505. 2006. David Schlossberg. Infections from Leisure-time www.sciencedirect.com. 2001. Retrieved October 9, 2010. Activities.

Alev Yucel et. al. Association of Acute Respiratory Infections and Indoor Air Pollution Among Children Aged 0-24 months in a Semi-urban Area, Ankara, Turkey. www.webstracts.com. 2002. Retrieved October 9, 2010. www.emro.who.int/Publications/EMHJ/0903/PDF/25%20Effects%20of%20passi ve%20smoking.pdf. 2003. Retrieved November 5, 2010. Manilyn J. Hockenberry. Wongs Essentials of Pediatric Nursing 7th Edition. Elsevier Mosby Inc, .2005. Merriam-Websters Medical Dictionary. Merriam Webster Incorporated, 2008.Date of Retrieval: October 11, 2010. Public Health Nursing in the Philippines 10th Edition. National League of Philippine Government Nurses Incorporated, 2007. www.Wikepedia.org. Retrieved October 11, 2010. Bilig et. al. Water and Sanitation Indicators Measurement Guide. www.fantaproject.org. Retrieved October 11, 2010.

73 CHAPTER III

METHODS OF RESEARCH

This chapter presents the research methodology employed in the collection of analysis and interpretation of the data required in the study. Specifically, it includes the research method and techniques, population and sample of the study, data gathering procedure and statistical treatment of the data collected.

Methods and Techniques of the Study This study determined how some selected factors such as family-related factors and environment-related factors in barangay Pto. Rivas, Balanga City during the fiscal year 2010 affect the increased rates of acute respiratory infection among children below five years old. A descriptive-correlational research was used for this study. According to Calmorin and Predad (2008), in descriptive research, it focused the study in the present situation (what is). The purposed was to find new truth and to provide the facts on scientific judgment. It also provided basic knowledge on the nature of the individuals and objects. In addition, Asperas (2005) stated that descriptive research provided an accurate portrayal or account of the characteristics of a particular individual, situation or group. It was also the means of discovering new meanings, describing what exist, determining the frequency with which something occurs and categorizing information. It is usually conducted when little was known about the phenomenon.

74 On the other hand, Knupfer and McLellan (2001) stated that the objects of collecting data for descriptive research were surveys, interviews and observations which can be employed singly or in various combinations. On the other hand, as defined by Waters (2007), a correlational study was a quantitative method of research in which 2 or more quantitative variables from the same group of subjects were available and were trying to determine if there was a relationship (or covariation) between the 2 variables (a similarity between them, not a difference between their means). Theoretically, any 2 quantitative variables can be correlated as long as the researchers had scored on these variables from the same participants. It was a technique that can show whether and how strongly pairs of variables were related. A particular type of correlational research was designed for the researchers to use a factor analysis. Davis (2002) defined it as a statistical procedure which identifies underlying patterns of variables. A large number of variables were correlated and the presence of high inter-correlations indicated a common underlying factor. These methods were applied to figure out and evaluated how family-related factors and environmental-related factors affected the increased rates of ARI among children below five years old in Barangay Pto. Rivas, Balanga through the administration and distribution of a structured questionnaire and documentation analysis.

Population and Sample of the Study This study involved the population of children below five years old of barangay Pto. Rivas, Balanga including Lote, Itaas and Ibaba during the fiscal year 2010. The total population of the area of children below five years old was 1042. Out of these 1042, 410

75 of children were affected by ARI. From among these three sitios, a total of 90 respondents-residences affected with ARI which were composed of the childrens parent from each identified place had selected and employed using a convenience sampling. Accidental or Convenience sampling particularly the snowball method was used for the sample selection. According to Basavanthappa (2004), convenience sampling was a type of a non-probability sampling where participants were selected, in part or in whole, at the convenience of the researcher. The researcher made no attempt, or only a limited attempt, to insure that this sample was an accurate representation of some larger group or population. One type of convenience sampling was the snowball sampling. According to Wikepedia (2010), this method was used to obtain research and knowledge, from extended associations, through previous acquaintances. This method used

recommendations to find people with the specific range of skills that has been determined as being useful. An individual or a group received information from different places through a mutual intermediary. This was referred to metaphorically as snowball sampling because as more relationships were built through mutual association, more connections can be made through those new relationships and a plethora of information can be shared and collected, much like a snowball that rolls and increased in size as it collects more snow. Snowball sampling was a useful tool for building networks and increasing the number of participants. However, the success of this technique greatly depended on the initial contacts and connections made. Thus it was important to correlate with those that were popular and honorable to create more opportunities to grow, but also to create a credible and dependable reputation.

76 In order to conduct this sampling strategy, the researchers first made a letter that was given to the midwife of the Pto. Rival Rural Health Center. The midwife was approached upon presenting the letter to gain contact on the parents with children below five years old affected by ARI. As the researcher contacted the respondents, they were asked to participate in the survey. The snowballing continued until the desired sample was met. The diversity of contacts was ensured by widening the profile of persons involved in the snowballing exercise.

Barangay Pto. Rivas Lote Itaas Ibaba Total

Population of Children Below Five Years Old 347 239 456 1042

Children Affected with ARI 133 89 188 410

Sample 10 10 10 30

Distribution of Respondents by BarangayPto. Rivas, Balanga Table I Table 1 presented the population and sample of the study. It can be deduced from the actual population of children below five years old (as of September 2010) of the three sitios of barangay Pto. Rivas under study. Lote had a population of 347 children below five years old, accumulating 133 children affected by ARI; Itaas had 239 with 89 cases and Ibaba had the largest with 456 having 188 cases. The total population of children affected with ARI was used to get the sample size. The researcher randomly picked the

77 respondents from each sitios with 10, 10 and 10 numbers of respondents respectively having a total of 30.

Research Instruments The main instrument used in this study was the survey- questionnaire. According to Suskie (2005), this instrument focused on the gathering of information regarding the activities, references and attitudes of people through questioning of a sample of respondents. Two tools were used in gathering pertinent data. First was a structured questionnaire and second was documentation analysis. Asperas (2005) stated that a structured questionnaire or close ended has the response already prepared. The respondents merely checked, underlined or ranked the responses as directed. This form was time-saving. It exercised direct influence in securing responses and greatly facilitated the process of tabulating and summarizing the data gathered. This questionnaire was specifically prepared according to the problem raised in the study. The respondents were the parents of the children below five years old. Their response on the questionnaire was treated as primary data and basis for the conclusion and recommendations of this research. To establish coherence of the survey questionnaire, the researcher divided the said instrument into three (3) parts. Part I dealt on the family profile in terms of number of family members, educational attainment, socio-economic status, family health status and history.

78 Part II dealt with the environment in terms of preventive measures, food preparation, family members hygiene, availability of sanitation facilities, sewerage system and garbage disposal system. For determining the attitude and manner, the following Likert Scale was used: Nominal value 5 4 3 2 1 Symbol A VO O S N Description Always Very Often Often Sometimes Never Interpretation Outstanding Very Satisfactory Satisfactory Fair Poor

For availability of materials the following Likert Scale was used: Nominal value 5 4 3 2 1 Symbol HA VA A SA NA Description Highly Available Very Available Available Slightly Available Not Available Interpretation Outstanding Very Satisfactory Satisfactory Fair Poor

Part III dealt with the community economic activities and neighborhood leisure activities. In determining the present activities happening in the community a checklist was used to specify the activities present.

79 Construction and Validation of Instruments The researchers read books, journals, magazines and published thesis and other related reading materials before the construction of the questionnaires will be made. The content of the validation of the questionnaires was made by the researchers to figure out that the problem under study was answered based on the respondents profile, knowledge and experience on their child when he/she is diagnosed with ARI. The researcher-made survey-questionnaires were presented to the research adviser and research instructor who criticized and modifiedd the questionnaires to make it simple, easy and understandable by the respondents. Other Instructors were consulted for further comments and recommendations. Corrections and suggestions from them will were considered. Finally, the instruments were presented again to the panel for the final draft and approval.

Data Gathering Procedure

For the purposed of acquiring data from the parents of the children below five years old, permission to conduct the study was first secured from the office of the Chief Public Health Nurse/Midwife in the Rural Health Unit of Pto. Rivas Balanga, Bataan dated September 20, 2010. The parents involved in the study will be informed regarding the purpose of the study. They will be guided and at the same time, they will be given assurance of the confidentiality of their answer. Right after the survey-questionnaires were answered and collected from the

80 parents, data were tabulated, tallied and analyzed using a tabular form for the realization of the purpose of this investigation.

Data Processing and Statistical Treatment of Data The pertinent data were treated with the most fitted statistical tool/treatment in order to unlock the problem involved in this study. Data from the family profile and environment profile were tabulated, tallied and analyzed. The data were presented through the use of frequency count and percentage and mean to determine the distribution and overall view of respondents response on the given variables. In proving the relationship between the selected factors and the increased rates of acute respiratory infections, the coefficient of correlation was employed. The researchers used the Pearsons Product-Moment of Correlation. This statistical treatment was used to determine the strength and direction of a linear relationship between two variables.

81 Notes in Chapter III

L. Paler-Calmorin and M. L. Calmorin-Predad. Nursing Research. National Bookstore, p. 49. 2008. Carlito Asperas. Introduction to Basic Nursing Research. Giuani Prints House Philippines, p.37. 2005. Nancy Nelson Knupfer and Hilary McLellan. The Handbook of Research for Educational Communication and Technology.AECT (The Association for Educational Communications and Technology). 2001. Janet Water. Correlational Research. Capilano University. www2.capilanou. ca/programs. 2007. Retrieved Decmber 9, 2010. John Davis. Outlines and Descriptions of Psychological Research Methods. clem.mscd.edu. 2002. Retrieved December 9, 2010. B.T Basavanthappa. Nursing Research. Jaypee Brothers Publishing. 2004. Linda A. Suskie. Questionnaire Survey Research, What Works, 2nd Edition, Jallahassee, F L. 2005.

82 CHAPTER IV

PRESENTATION, ANALYSIS AND INTERPRETATION OF DATA

This chapter presents the summary of the data gathered from the survey, the results of both the descriptive and correlational analyses, and the implications of these results. To make the presentation of the findings more coherent, the researcher divided the analysis and interpretation of the results into three correlated parts. Part I dealt with the profile of the family in terms of number of family members, parents educational attainment, socio economic status including their family income and type of house and lastly, their health status which includes the family history of ARI and their preventive measures. Part II contained discussion on the profile of the environment in terms of, first, home environment which includes the sanitation practices, source of water supply and availability of sanitation facilities. Under the sanitation practices, food preparation and family members hygiene are discussed. Second is external environment which includes community sanitation where the sewerage system and garbage disposal system are discussed, community economic activities and lastly neighborhood leisure activities. On the other hand, Part III focused on how may the rates of Acute Respiratory Infection (ARI) described in terms of its incidence in the past four years. Tables 2 to 10 present the frequency and percentage distribution of family profile.

83 Table 2 presents the frequency and percentage distribution of the respondents according to number of family members. Table 2 Frequency and Percentage Distribution of the Respondents According to Number of Family Members Number of Family Members 2 3 4 5 6 7 above Total Frequency 1 6 5 6 2 10 30 Percentage 3.33 20 16.67 20 6.67 33.33 100%

The table shows the distribution of family profile in terms of number of family members and it can be deduced from the table that only 1 or 3.33% respondent had only 2 family members. On the other hand, 6 or 20% of the respondents had 3 family members. Five (5) or 16.67% of the respondents had 4 family members. Six (6) or 20% respondents had 5 family members. Two (2) or 6.67% of the respondents had 6 family members and ten (10) or 33.33% of the respondents had 7 and above family members. Generally, majority of the respondents had 7 and above family members. It is the same with the result of the study of Banerji (2009) in the risk factors for lower respiratory tract infections in Inuit children that one of the risk factor that contributes to ARIs among Inuit children is overcrowded living conditions which increases the risk of hospital

84 admission due to ARI by 2.5 times. In addition, Kovesi et. al (2007), revealed in their research study that inadequate ventilation due to overcrowding may contribute to the high incidence of respiratory tract lung infections in young children. Respiratory tract infection was significantly associated with indoor carbon dioxide levels and occupancy. This finding held true on the grounds that the respondents should be aware that a large number of people or family sharing in a household could be a possible cause of fast transmission of many infections like ARI. By that, there is an evident need to reduce household crowding in order to reduce both the number and severity of cases of acute respiratory illnesses. Table 3 presents the frequency and percentage distribution of number of children five years old and below. Table 3 Frequency and Percentage Distribution of Number of Children Five Years Old and Below Number of Children Five Years Old and Below 1 2 3 4 5 6 above Total Frequency 7 4 6 3 10 0 30 Percentage 23.33 13.33 20 10 33.33 0 100%

The table shows the distribution of family profile in terms of number of children five years old and below and it can be deduced from the table that only 7 or 23.33% of the respondents had only 1 child five years old below. On the other hand, 4 or 13.33% of

85 the respondents had 2 children five years old below. Six (6) or 20% of the respondents had 3 children five years old below. Three (3) or 10% of the respondents had 4 children five years old below. Ten (10) or 33.33% of the respondents had 5 children five years old below and none of them had 6 children five years old below. Generally, majority of the respondents had 5 children five years old and below in their households. It is the same with the result of study of Bulkow et. al (2002) showing that the presence of 4 or more children <5 years of age in the household and a crowding index of 2 or more were associated with increased ARI hospitalization risk. This would lead to nighttime crowding, children sleeping in the same bedroom. In addition to, Koch et. al (2003) explained that exposure to infectious agents in the family may be most intense when sharing a bedroom with others. This finding held true on the grounds that the number of persons sleeping in the same room should, whenever possible, be reduced, and especially by children less than 5 years of age. Taken together, these measures may reduce the burden of illness in the youngest group of children. Table 4 presents the frequency and percentage distribution of family relation to the child. Table 4 Frequency and Percentage Distribution of Family Relation to the Child Family Relation to the Child father mother grandparents others Total Frequency 0 25 2 3 30 Percentage 0 83.33 6.67 10 100%

86 The table shows the distribution of family profile in terms of family relation to the child and it can be deduced from the table that 25 or 83.33% of the respondents were the childrens mothers. On the other hand, 2 or 6.67% of the respondents were their grandparents and 3 or 10% of the respondents were their other relatives. Generally, majority of the respondents were the childrens mothers. This proved that most mothers were left in their house to care of their house and their kids. They usually get in charge when one of her children got sick. They spent longer time with their children than their fathers because they have to fulfill their role to earn money that would fulfill their familys needs. However, the table also revealed that a considerable percentage of respondents were the childs grandparents and other relatives. These showed that as years past, mothers also involve themselves in earning a living and grandparents and other relatives played the role as the childs guardian. Table 5 presents the frequency and percentage distribution of the fathers educational attainment. Table 5 Frequency and Percentage Distribution of Fathers Educational Attainment Educational Attainment (Father) Ed. D GRADUATE M.A Graduate College Graduate High School Graduate Elementary Graduate No Education Total Frequency 0 0 5 14 10 1 30 Percentage 0 0 16.67 46.67 33.33 3.33 100%

87 The table shows the distribution of family profile in terms of fathers educational attainment and it can be deduced from the table that only 5 or 16.67% of the respondents were college graduates. On the other hand, 14 or 46.67% of the respondents were high school graduates. Ten (10) or 33.33% of the respondents were elementary graduates and 1 or 3.33% of the respondents didnt receive an education. Generally, majority of the respondents husbands were highschool graduates. The result is almost the same with the study of I.R. White et. al (2000) who pointed out that long standing illness like Acute Respiratory Infections (ARI) may be associated with educational attainment. Educational attainment may be a marker for childhood socioeconomic circumstances, its association with health may result from occupational characteristics, or education may influence the propensity to follow health education advice. This finding held true on the grounds that a father with a low educational background had a difficulty in getting a good job making them unable to meet the full income they needed to provide proper nutrition to their children thus making them vulnerable to diseases. Table 6 presents the frequency and percentage distribution of the fathers educational attainment. Table 6 Frequency and Percentage Distribution of Mothers Educational Attainment Educational Attainment (Mother) Ed. D GRADUATE M.A Graduate College Graduate High School Graduate Elementary Graduate Frequency 0 3 2 18 7 Percentage 0 10 0.67 60 23.33

88 No Education Total 0 30 0 100%

The table shows the distribution of family profile in terms of mothers educational attainment and it can be deduced from the table that only 3 or 10% of the respondents were M.A graduates. On the other hand, 2 or 0.67% of the respondents were college graduates. Eighteen (18) or 60% of the respondents were high school graduates. Seven (7) or 23.33% of the respondents were elementary graduates and none of them didnt receive an education. Generally, majority of the respondents were highschool graduates. It is the same with study of Abul et. al (2000) that revealed that prevalence of severe ARI is higher among children born to mothers with primary or less education compared to children of mothers completing secondary or higher education is 5.0 and 8.1 percent respectively. This finding held true on the grounds that mothers with low educational background will put the child below five years old at risk for severe ARI because it made them hard to identify that the signs and symptoms of respiratory illnesses are already occurring. Table 7 presents the frequency and percentage distribution of the respondents monthly family income. Table 7 Frequency and Percentage Distribution of the Respondents Monthly Family Income Monthly Family Income P 40,000 above P 30,001 40,000 P 20,001 30,000 P 10,001 20,000 P 10,000 BELOW Frequency 0 1 1 3 25 Percentage 0 3.33 3.33 10 83.33

89 Total 30 100%

The table shows the distribution of family profile in terms of their monthly family income and it can be deduced from the table that only 1 or 3.33% of the respondents had a monthly income of P 30,001-40,000 same with the other 1 respondent who had a monthly income of P 20,001 30,000. On the other hand, 3 or 10% of the respondents had a monthly income of P 20,001-30,000. Twenty-five (25) or 83.33% of the respondents had a monthly income of below P 10,000. Generally, majority of the respondents had a monthly income of below P 10,000. It is the same with the study of Margolis et. al (2002) that revealed that the incidence of lower respiratory illness was 1.41 in the low socioeconomic group, 1.26 in the middle group, and 0.67 in the high group. The prevalence of persistent respiratory symptoms was 39% in infants in the low socioeconomic group, 24% in infants in the middle group, and 14% in infants in the high group. In addition to, Fujii (2009) also revealed that the relationship between family income and child health show that children from poorer families have worse health than those from wealthier families, and that the negative effects of low income on health accumulate during childhood. Greater risk for infectious illness among people with lower socio-economic status is attributable to increased exposure to infectious agents and decreased host resistance to infection. This finding held true on the grounds that the respondents had not enough family income due to unemployment and it could greatly affect the inability to sustain the needs of each family member. Due to circumstances, prioritizing the needs of a family, health is being disregarded. Illness that could be cured is left untreated due to financial problems.

90 Table 8 presents the frequency and percentage distribution of the respondents type of house. Table 8 Frequency and Percentage Distribution of the Respondents Type of House Type Of House Nipa Hut Wood Concrete Semi-Concrete Others Total Frequency 0 5 15 10 0 30 Percentage 0 16.67 50 33.33 0 100%

The table shows the distribution of family profile in terms of type of their house and it can be deduced from the table that 5 or 16.67% of the respondents had a wood type of house. On the other hand, 15 or 50% of the respondents had a concrete house and 10 or 33.33% of the respondents had a semi-concrete house. Generally, majority of the respondents had a concrete type of house. The result is different with the study of Krieger et. al (2002) that shows that poor housing are associated with a wide range of health conditions, including respiratory infections, asthma, lead poisoning, injuries, and mental health. But since the respondents houses were concrete meaning in a good condition, it is still not an assurance that they will not be infected by some health conditions because cleanliness inside the house and its surroundings is also needed to prevent diseases. However, the table also revealed that a considerable percentage of respondents had a wood type of house which is partly on a poor housing condition. This finding held true on the grounds that families living in that type of house would be easily get infected

91 especially if they would not be able to maintain the cleanliness and orderliness of their house and surroundings. Table 9 presents the frequency and percentage distribution of the recent history of ARI in the family of the respondents. Table 9 Frequency and Percentage Distribution of the History of ARI in the Family Family Members Who Had Experienced Ari Grandfather Grandmother Mother Father Uncle Aunt Sibling Cousin Total Frequency 2 1 4 5 0 2 13 3 30 Percentage 6.67 3.33 13.33 16.67 0 6.67 43.33 10 100%

The table shows the distribution of family profile in terms of history of ARI and it can be deduced from the table that 2 or 6.67% of the respondents had grandfathers of their child who experienced ARI. On the other hand, 1 or 3.33% of the respondents had a grandmother of their child who experienced ARI. Six (6) or 20% on mothers, 9 or 30% on fathers, zero on uncles, 2 or 6.67% on aunts, 7 or 23.33% on the siblings and 3 or 10% on the cousins. Generally, majority of the respondents had their childs sibling who experienced ARI. Mostly, children at school age easily acquire infections like respiratory infections because of poor immune defenses and hygiene. Due to that circumstance, other children at home especially their siblings would be easily get infected. This finding held true on

92 the grounds that parents should teach their children proper hygiene like hand washing at early age to prevent disease transmission. Table 10 presents the frequency and percentage distribution of the duration of last experienced cough, colds and flu. Table 10 Frequency and Percentage Distribution of the Duration of Last Experienced Cough, Colds and Flu Duration Of Last Experienced Cough, Colds And Flu 2 3 Days 4 6 Days 1 Week And Above Others Total

Frequency 13 6 5 6 30

Percentage 43.33 20 16.67 20 100%

The table shows the distribution of family profile in terms of the duration of last experienced cough, colds and flu and it can be deduced from the table that 13 or 43.33% of the respondents family member experienced cough, colds and flu for 2-3 days. On the hand, 6 or 20% of the respondents family member experienced cough, colds and flu for 4-6 days. Five (5) or 16.67% experienced cough, colds and flu for 1 week and 6 or 20% experienced it longer. Generally, majority of the respondents family member experienced cough, colds and flu for 2-3 days. It is probably due to measures imposed by the parents to cure and prevent further complications of ARI like pneumonia. According to study of Benti et. al (2000), on average, children under age five experience between five and eight ARI episodes with a duration of 5-7 days a year, which translates into at least 2,000 million episodes each year in the developing world. The majority of ARI episodes are mild and

93 self-limiting, as in the case of coughs and colds. However, about one in every 30 to 50 episodes of cough will develop into pneumonia. Without treatment, 10% to 20% of pneumonia cases will result in death. Table 11 presents the mean and verbal interpretation of family profile according to knowledge on preventive measures. It can be deduced from the table that the quality of preventive measures as perceived by the respondents was often as manifested by the average mean of 3.988. The finding proved that the respondents often perform those measures in order to prevent being infected by any disease or infection. It is the same with the study of Mitra (2001), where in the findings shows the importance of basic health promotional measures like hand washing, everyday bathing, house cleaning, proper nutrition of the child and improved general conditions of living like maintaining the good indoor ventilation in prevention and control of ARI. The hand is the part of the body that transmits most of the organism. Hand washing with soap and running water removes the foreign bodies that accumulated in the skin that causes infection. He also added that proper ventilation is a must. The house is a more or less closed off area. The composition of the air inside depends on the sources of air pollution in the house, the degree of ventilation, and the composition of the outdoor air. The temperature of indoor air affects the amount of oxygen and carbon dioxide inside. Increased level of carbon dioxide inside the house causes respiratory infections. Table 11 Mean and Verbal Interpretation of Family Profile According to Knowledge on Preventive Measures Variables Mean Verbal Interpretation

94 1. Ensures good indoor ventilation 2. Covers mouth and nose when coughing or sneezing 3. Keeps the body clean and takes shower every day 4. Keeps the household tidy and clean 5. Brings the child to the hospital or clinic for regular check-up Average Mean 4.47 3.90 3.97 4.67 2.93 3.988 Always Often Often Always Sometimes Often

The item that received the highest mean of 4.67 or often is - Keeps the household tidy and clean. This only went to show that respondents strictly maintain their house cleanliness. The findings are similar with the study of Bernard et. al (2007) that meticulous house cleaning especially if chemicals were used like bleach can inactivate common viruses and bacteria that causes respiratory infections. In this cross-sectional study, they evaluated to what extent regular house cleaning with bleach can decrease the influence and risks of respiratory and allergic diseases in children. House cleaning with bleach had effect neither on the sensitization to pollen allergens, nor on the levels of exhaled NO and of serum CC16 and SP-D. This appears to protect children from the risks of asthma and of sensitization to indoor allergens while increasing the risk of recurrent bronchitis (complication of respiratory infection) through apparently an interaction with parental smoking. As this is one of the most effective cleaning agent to be found, these observations argue against the idea conveyed by the hygiene hypothesis that cleanliness per se increases the risk of asthma and allergy and other respiratory infections. On the other hand, the item that registered the lowest mean of 2.93 or sometimes is - Brings the child to the hospital or clinic for regular check-up. This suggests that respondents do not give a particular attention of their childs regular need for a check-up whenever a child fells well or not. Sometimes, parents did not mind to consult a doctor

95 due to financial insufficiency so they will do their own way of attending their childs health needs like using herbal medicines or consulting an albulario. However, the findings also suggested that programs should be implemented to reach out for families who do not have the capabilities to bring their child for a regular check up. Hence, the findings stress out the importance of what Fredrick (2003) stated that consulting a doctor promptly should be encouraged if there are respiratory symptoms such as fever, malaise, chills, headache, joint pain, dizziness, rigors, cough, sore throat and runny nose may the child an early treatment and prevent the complications. A doctor can evaluate whether symptoms are due to a bacterial infection and determine whether a child needs antibiotics. Table 12 presents the mean and verbal interpretation of environment-related

factors particularly on the home environment according to knowledge on food preparation. It can be deduced from the table that the quality of food preparation as perceived by the respondents was always as manifested by the average mean of 4.462. The findings proved that the respondents always ensure the foods are prepared properly and ensures the safety of the family with regards on keeping the food away from the insects and other bodies that causes infections. The findings are similar with the study of the Netherlands Nutrition Centre (2001) when they found out that airborne micro-organisms (bacteria, fungi), mites (in sheets or carpets), and (parts of) insects and beetles may be the cause of respiratory diseases. Table 12 Mean and Verbal Interpretation of Home Environment According Food Preparation

96 Variables Washes the raw foods before cooking Washes equipments and utensils for cooking Washes hand before cooking Provides separate spoon for the foods in the table Takes care that insects wont go to the served foods Average Mean Mean 4.97 5.00 4.60 2.87 4.87 4.462 Verbal Interpretation Always Always Always Sometimes Always Always

1. 2. 3. 4. 5.

The item that received the highest mean of 5.00 or always is - Washes equipments and utensils for cooking. This only went to show that respondents always see to it that equipments and utensils where clean before using them in cooking as set by the Republic Act No. 3720, An Act To Ensure The Safety And Purity Of Foods, Drugs and Cosmetics stating that sanitation within the food industry must have the adequate treatment of foodcontact surfaces by a process that is effective in destroying vegetative cells of microorganisms of public health significance, and in substantially reducing number of other undesirable microorganisms, but without adversely affecting the product or its safety for the self including the family and consumer. The finding also upheld the view of Netherlands Nutrition Centre (2001) when they found out that improper food preparation not only causes food-borne diseases like diarrhea and typhoid but also respiratory infections. Hence, utensils and other equipments such as the chopping board, knife, dishes, cutlery, work top, dishcloth etc., were also contaminated by food preparation. Using these tools causes contamination with bacteria existing on foods such as raw meat and vegetables. If a tool is used for another food product, bacteria from the first product are transmitted to the second. Particularly materials used for the preparation of meat form a major source of contamination. Therefore, knives and chopping boards (and all other

97 materials used), which have been in contact with raw meat, should be rinsed with hot water and treated as dirty dishes afterwards. If these tools are to be reused immediately, they must be washed in hot water and soap first. So, washability is an important issue when using the utensils again before cooking another type of food. On the other hand, the item that registered the lowest mean of 2.87 or sometimes is - Provides separate spoon for the foods in the table. The findings suggested that respondents sometimes use serving spoons or separate spoon on serving their food. For sanitary reasons, some families use separate spoons on main dishes because they do not want sticking their fork or spoon in the main dish after they have put it in their mouth. Other reason is that they do not want to get infected when one family member had cough or colds because surely, infection will be transmitted to well family health members. In some circumstances, like with the study of Alcantara et. al (2005) about respiratory infection revealed that transmission can occur when an infected person shares food with others during mealtime without a serving spoon aside from droplets method when other people breathe in the viruses and indirect method when a person touches a surface with flu viruses on it (for example, a door knob) and then touches his or her nose or mouth. The implication of the findings suggests that families should be encouraged to use serving spoons and other measures to reduce infection transmission within family members. Table 13 presents the mean and verbal interpretation of environment-related factors particularly on the home environment according to family members hygiene. It can be deduced from the table that the quality of family members hygiene by the respondents was often as manifested by the average mean of 3.946. The findings

98 proved that the respondents often perform personal hygiene to ensure that they will not transmit any organisms or infection to other family members. The findings are the same with the study of Luby et al. (Lancet, 2005) published by the UNICEF last year 2008 that suggests that hand washing with soap can reduce respiratory infections in children under five by 50 percent. Another current study found that children under 15 years living in households that received hand washing promotion and soap had half the diarrheal rates of children living in control neighborhoods (Luby et al., Jama 2004). Because hand washing can prevent the transmission of a variety of pathogens, it may be more effective than any single vaccine. Promoted on a wide-enough scale, hand washing with soap could be thought of as a do-it-yourself vaccine. However, changing the habits of a lifetime is not so easy and requires a huge and concerted effort. Table 13 Mean and Verbal Interpretation of Home Environment According To Family Members Hygiene Variables Takes a bath once or twice daily Covers mouth and nose when coughing or sneezing Washes hands thoroughly with soap Uses antiseptics (e.g. alcohol and hand sanitizer) Uses handkerchief when coughing or sneezing Average Mean Mean 4.93 4.30 4.47 2.53 3.50 3.946 Verbal Interpretation Always Often Always Sometimes Often Often

1. 2. 3. 4. 5.

The item that received the highest mean of 4.93 or always is - Takes a bath once or twice daily. This only went to show that respondents had good hygienic measures. The finding is the same with World Health Organization, Western Pacific Region (2008) who revealed that good hygiene, or personal cleanliness, not only helps maintain a healthy self-image, but is important in preventing the spread of infections and disease especially

99 when dealing with respiratory infections. Poor hygiene allows dried sweat, dirt and sebum to collect on your skin, providing an ideal environment for fungi and bacteria. On the other hand, the item that registered the lowest mean of 2.53 or sometimes is - Uses antiseptics (e.g. alcohol and hand sanitizer). The findings suggested that respondents sometimes use antiseptics as part of their personal hygiene probably because alcohol and sanitizer is an additional expense in ones budget. The findings are quite different from the study of Parlikar (2005) in her study that those who used alcohol and hand sanitizers had a 59 percent lower incidence of respiratory illnesses and secondary GI illnesses compared to those who did not use it. Hand sanitizers do have their advantages. For one thing, other studies have shown that soap and water does not kill rotavirus, a virus that causes GI infection in a childcare setting. Alcohol, the active ingredient in hand sanitizers, does reliably kill this virus. The findings implied that proper hygiene should not only be performed inside the house but should also be performed wherever you go like the use of hand sanitizers when hand washing is not possible to do because it is convenient and it can be placed in a purse, bag, or car, are also particularly useful when you cant get to a sink. Table 14 presents the frequency and percentage distribution of water supply. Table 14 Frequency and Percentage Distribution Home Environment According to Water Supply Source of Water Supply Water dispenser Tap water Free flow Recycled water or re-used water Water pump Frequency 0 14 2 0 5 Percentage 0 46.67 6.67 0 16.67

100 Others Total 0 30 0 100%

The table shows the distribution of respondents water supply and it can be deduced from the table that 14 or 46.67% of the respondents were using tap water. On the other hand, 2 or 6.67% of the respondents were using free flow and 5 or 16.67% of the respondents were using water pump. Generally, majority of the respondents were using tap water as their water supply. The result is almost the same with the study of Gupta et. al (2000) indicating that an association among high nitrate ingestion from tap water and pathologic changes in bronchi and lung parenchyma. The present study examined a possible correlation among tap water nitrate concentration, methemoglobin levels, cytochrome b5 reductase activity, and acute respiratory tract infection with a history of recurrence (RRTI). Methemoglobin levels alone explained 80% of the variation in the RRTI cases. This study indicates that methemoglobinemia, secondary to high nitrate ingestion in drinking tap water, causes RRTI. Increased production of methemoglobin and free radicals of nitric oxide and oxygen due to nitrate metabolism in the body lead to alveolar damage and mismatching of ventilation and perfusion, which may be the reason for high mortality in children due to RRTI. However, there were respondents who also use free flowing and water pump as their water supply due to inadequate running water. But upon using those for drinking, ensure that water is clean by boiling it first. Table 15 presents the mean and verbal interpretation of environment-related factors according to availability of sanitation facilities.

101 It can be deduced from the table that the availability of sanitation facilities was available as manifested by the average mean of 3.086. The findings proved that the respondents had available sanitation facilities in their own houses. The findings are not similar with the study of Landrigan and Garg (2000) revealing that globally, 2.4 billion people living in peri-urban or rural areas in developing countries, do not have access to any type of sanitation facilities. Examples of sanitation-related diseases include respiratory infections like cough, pneumonia and asthma, as well as cholera, typhoid, schistosomiasis, and trachomaa disease that causes irreversible blindness, and currently affects about 6 million people, with another 500 million at risk of the disease. It availability is useless if cleanliness is not maintained and also, assurance that facilities are in a good condition. Facilities like kitchen should be cleaned almost everyday. Bathrooms, latrines and water pump (if available) should be cleaned at least once a week. Table 15 Mean and Verbal Interpretation of Availability of Sanitation Facilities Variables 1. bathroom 2. latrines 3. kitchen 4. garbage trucks 5. water pump Average Mean Mean 3.06 3.10 3.70 2.70 2.87 3.086 Verbal Interpretation Available Available Very Available Available Available Available

The item that received the highest mean of 3.70 or very available is - kitchen. This only went to show that respondents had very available kitchen counters. Oftentimes, some people who does not have burners or electric stoves uses biomass fuel, charcoal or kerosene in cooking their foods. The findings were linked to the study of Kilabuko and Nakai (2007) that revealed that biomass fuel in food preparation has been linked to Acute

102 Respiratory Infections (ARI) in children. Approximately 85% and 15% of children were from biomass fuels and charcoal/kerosene using homes respectively. Average ARI prevalence was about 11%. The prevalence of ARI across various fuel types used for cooking did not vary much from the national prevalence. Hence, the findings implied that it is not enough that you had a kitchen because it is in the quality of the facility and the quality of the appliances or cooking devices. As much as possible, it is recommended that if there is a 5 year old child, it is not advisable to use charcoal/kerosene in cooking instead electric stoves and burners are advised. On the other hand, the item that registered the lowest mean of 2.70 or available is garbage trucks. The findings suggested that respondents had available garbage trucks to collect their garbage only for Monday, Wednesday and Friday. Even though garbage collectors were not always available, there were still other ways to dispose them like disposing them naturally like growing vegetables and composting the remains back to the soil, then there are waste less fuel and have less impact than tying them up in a plastic bag, spending gas to haul them to a dump, and more gas is burying them. Hence, the problem is when chemicals were dig up and turned them into something else. Like with global warming, taking carbon out of the ground and putting it into the atmosphere. Some products, such as DDT and other pesticides do as much harm when used as intended, it affect the mans health especially in their respiratory system. Table 16 presents the mean and verbal interpretation of environment-related factors according to sanitation of sewerage system. It can be deduced from the table that the quality of their sewerage system was only seldom as manifested by the average mean of 2.374. The findings proved that the

103 respondents seldom clean and check the quality of their sewerage system. It is the same with the study of Groeniger (2006) which explained that respiratory infections and allergic reactions may also result from inhaling associated airborne microorganisms from sewers and drains that often contains gases resulting from the decomposition of excreta, soap, fats, and other wastes, together with gases from mineral oils which may come from garages, streets, and industrial establishments. Illuminating gas may also find its way into sewers through leakage. Among these gases may be found methane, sulphureted hydrogen, and carbonic oxide. In large amounts those gases are poisonous to the human system and there are physiological objections to breathing them even in small quantities. Table 16 Mean and Verbal Interpretation of Sanitation of Sewerage System Variables 1. Keeps the drains and pipes from blockage or leakage 2. Removes stagnant water from the canals 3. Replaces broken pipes or drains 4. Visits / checks drains and pipes monthly 5. Avails siphoning service yearly Mean 2.77 4.33 1.97 1.30 Verbal Interpretation Sometimes Often Seldom Never

1.5 Seldom Average Mean 2.374 Seldom As opined by the Colorado Department of Environment (2000), sanitary sewer

may overflow due to too much precipitation infiltrating leaky sewer pipes, inadequate system capacity to handle newly-developed residential or commercial areas, blocked or broken pipes, or improperly designed and installed sewer systems. The maintenance of water seals between fixtures and drains and the permanent tightness of soil pipe and drainage systems are important, not only because they prevent the passage of air, but because they prevent the access of insects to the interior of the drains and sewers. Sewage

104 backups not only present unpleasant odor problems, they may cause property damage and present unhealthy living conditions. Untreated sewage contains disease-causing organisms such as bacteria, viruses and parasites. The item that received the highest mean of 4.33 or often is removes stagnant water from canals. This only went to show that respondents often clean their canals to prevent it from being stagnant. Stagnant water is oftentimes the site where mosquitoes and other insects breed. The findings were the same with Saul (2009) opinion that the increased water pooling has a significant effect in increased mosquito-borne infections, especially Ross River virus. The findings implied that if there is increased stagnant water, there would be an increased mosquito-borne infections. But since respondents often remove stagnant water in their canal, the risk for mosquito-borne infections were decreased. On the other hand, the item that registered the lowest mean of 1.30 or never is visits or check drains and pipes monthly. The findings suggested that respondents never visit nor check their drains and pipes every month. The findings were quite the same with the study of Rahman (2006) to assess the household environmental conditions of their neighbors. It revealed that about 55% of the total sampled households suffer from diarrhea/dysentery, 43% jaundice, 42% malaria and 41% respiratory diseases. About 40% suffer from skin diseases, small pox/chicken pox. All these diseases are a result of poor household environmental conditions due to failure on cleaning their canals and checking their drainage, dwellings, water pipes and sewage at least once a month. Table 17 presents the mean and verbal interpretation of environment-related factors according to garbage disposal.

105 It can be deduced from the table that the quality of their garbage disposal was sometimes as manifested by the average mean of 3.34. The findings proved that the respondents sometimes disposed their garbage properly. As the findings of the Mighty Students (2008), the City of Manila was considered to be an important cultural and economic center. These developments have been accompanied by the problems of overpopulation, waste management and pollution. Directly, solid wastes may contain chemicals or irritants that pose a serious health hazard to the surrounding community. Indirectly, solid wastes were breeding grounds for parasites, vectors and other organisms capable of causing diseases to human hosts. In developed countries, the government as well as the private citizen is aware and instrumental in their waste management programs. However, in developing countries, various factors and problems contribute to a significant difference in terms of policy and implementation. Table 17 Mean and Verbal Interpretation of Garbage Disposal Variables 1. Disposes garbage at home 2. Disposes wastes to garbage trucks 3. Separates biodegradable from non biodegradable garbage 4. Throws garbage properly at garbage cans 5. Recycles other plastics and re-usable trash Average Mean Mean 4.53 5.00 3.60 1.97 1.53 3.34 Verbal Interpretation Always Always Often Seldom Seldom Sometimes

The item that received the highest mean of 5.00 or always is Disposes wastes to garbage trucks. This only went to show that respondents often clean their canals to prevent it from being stagnant. The findings were not similar to the study of Dontigney (2005) emphasizing that improper waste disposal contributes to air pollution. Created by

106 emissions from industrial plants, homes, cars, garbages and businesses such as dry cleaners and printers, smog is the most obvious type of air pollution, simply because it is visible. Air pollution was also responsible for acid rain, greenhouse gases, and ozone depletion, and may also play a role in respiratory problems by exacerbating asthma, inflaming lung tissue, and reducing lung function. Therefore, garbage poses serious health hazards either by direct contamination or by indirect means. It is considered to be one of the threats that may greatly affect the health of an individual since human waste and garbage inevitably arise of more than we expect. On the other hand, the item that registered the lowest mean of 1.53 or seldom is recycles other plastics and re-usable trash. The findings suggested that respondents seldom recycle other plastics and re-usable trash. The findings were the same with the study of Marthet et. al (2000) showing that the routine disposal of waste through dumping or incineration leads to a significant pollution of the environment. The capacity of the present dumps is slowly becoming exhausted thus steadily increasing the significance of alternative methods of waste disposal. In addition to prevention, sorting and recycling, composting of the biological waste components assumes special significance. Presently, a large number of persons are employed in the disposal and manual sorting of waste. All of them are aware of the fact that work in the area of waste management may be associated with health risks. Scientific studies must estimate the risks to those employed in this field but also to those of the general population living in the vicinity of the waste disposal industries. In defining the risk, we must clearly differentiate between hazard and risk. Hazard is a term, which describes the potential

107 damages by a pollutant. It is a qualitative term which provides theoretical information on reaction of the toxic quality by a pollutant but which will not provide information on actually occurring adverse effects. Risk, however, is a quantitative term which provides a causal connection between definite damages and pollutants. It specifies the deducible damages and links them with the intensity of the exposure (dose) or calculates the probability of a damage occurring. Several studies have described the hazard to those employed in waste sorting and recycling covering diseases of the lungs, the gastrointestinal tract, mucous membranes, skin and musculoskeletal system. This study is a contribution to the quantitative assessment of the health risk to employees. Hence, the findings implied that there should be an awareness of hazardous and nonhazardous wastes and biodegradable and non-biodegradable wastes in the community, consider whether community members have been exposed, and determine the effect on public health because hazardous and toxic wastes have been linked to deaths, poisoning, acute and chronic illness, cancer, ARI, birth defects, blindness, and sterility. While recycling non-biodegradable waste helps decreased pollution that significantly contributes to the occurrence of infections including respiratory infections. Table 18 presents the mean and verbal interpretation of environment-related factors according to community economic activities. It can be deduced from the table that the quality of their community economic activities was often as manifested by the average mean of 3.906. The findings proved that the respondents often do their economics activities in order to earn a living. The findings were the same with the findings of the Science Daily (2007) that about 40 percent of deaths worldwide were caused by water, air and soil economic activity caused by water,

108 air and soil economic activity. Such environmental degradation, coupled with the growth in world population, was major causes behind the rapid increase in human diseases like infections in the respiratory tract, which the World Health Organization has recently reported. Both factors contributed to the malnourishment and disease susceptibility of 3.7 billion people. They added that air pollution from smoke and various chemicals kills 3 million people a year. Table 18 Mean and Verbal Interpretation of Community Economic Activities Variables 1. Smokes fish for tinapa 2. Dries fish along the road 3. Sells grilled and cooked foods in the sidewalks 4. Uses public vehicles that emits too much smoke 5. Sells and uses cigarette Average Mean Mean 3.6 3.2 3.63 4.5 4.6 3.906 Verbal Interpretation Often Seldom Often Always Always Often

The item that received the highest mean of 4.57 or always is Sells and uses cigarette. This only went to show that neighbors always sell cigarette in order for them to earn a living. The findings were the same with the study of Dennis (2008) that selling cigarettes is the number one reason why smoking within the community is still not eradicated. Many smokers begin smoking in social settings and the offering and sharing of a cigarette is often a good excuse to start a conversation with strangers in settings like bars, night clubs, at work or on the street. Lighting a cigarette is often seen as an effective way of avoiding the appearance of idleness. However, in spite of the popularity of smoking, medical studies have proven that smoking is among the leading causes of diseases such as lung cancer, heart attacks, and chronic obstructive disease and it can also

109 lead to birth defects and it causes diseases also to passive smokers like respiratory infection in younger groups. Hence, the findings implied that countries should institute high taxes on tobacco products and anti-smoking campaigns should be launched every year in an attempt to curb smoking. Several countries, states and cities have also imposed smoking bans in most public buildings. The item that received the lowest mean of 3.20 or seldom is dries along the road. This only went to show that neighbors seldom dry their fishes along the road. Fish drying does not contribute to the occurrence of respiratory infections. The findings were not similar with the study of Lawson (2006) stating that manual workers in industry showed development of asthma, symptoms common in asthma and chronic productive cough. Cumulative incidences were generally lowest in professionals a significantly increased risk of developing asthma, recurrent wheeze, attacks of shortness of breath or a combination of the two, and chronic productive cough. Manual workers in service showed a similar pattern for attacks of shortness of breath, recurrent wheeze, or a combination of the two, and chronic productive cough. Since respondents seldom dries fish along the road which is considered a manual job, they have low risk of developing respiratory infections. Table 19 presents the mean and verbal interpretation of environment-related factors according to community leisure activities. It can be deduced from the table that the quality of their community leisure activities was often as manifested by the average mean of 3.762. The findings proved that the respondents often do their leisure activities in order to give themselves a little break.

110 The findings were the same with the study of Schlossberg (2001) on Infections from Leisure-time activities, concluding that leisure-time activities expose us to a variety of infections like for example, a traveler confronts new pathogens and vectors. Camping, hiking and gardening have attendant risks, as does exposure to fresh and salt water. Adventuresome eating poses gastronomic threats, and pets, sexual exposure and organized sports each contribute distinctive infectious risks to participants. Table 19 Mean and Verbal Interpretation of Community Leisure Activities Variables 1. Smokes 2. By stands at the streets 3. Eats raw or half cooked foods during drinking sessions 4. Shares utensils during drinking sessions 5. Mingles with a crowd of people with and without diseases in a gambling Average Mean Mean 4.57 4.4 3.87 3.77 2.2 3.762 Verbal Interpretation Always Often Often Often Seldom Often

The item that received the highest mean of 4.57 or always is Smokes. This only went to show that as to the respondents observation that neighbors always smokes during their free time. The findings were the same with the study of Yucel et. al (2002) implying that the direct exposure of the child to smoking, rather than the presence of smoking at home, is a significant predictor of ARI among young children. Even when the quality of indoor air could not be improved, parents should be educated of the importance of avoiding childrens direct exposure to cigarette smoking and/or other indoor pollutants. In addition to, Hawamdeh et. al (2003) revealed that a number of episodes of acute respiratory infection is significantly increased if the parents and neighbors smoked. The overall odds ratio was 1.5 if they smoked at all and 1.8 if they smoked more than 20

111 cigarettes a day. Children exposed to smoking individuals developed respiratory illness earlier than those of nonsmokers. Hence, the findings implied that cooperative efforts of the health personnel and media against indoor air pollution, cigarette smoking in particular should be pushed through to increase the awareness, and assist in the education of the public in this matter. The item that received the lowest mean of 2.20 or seldom is Mingles with a crowd of people with and without diseases in a gambling. This only went to show that gambling per se is not practiced in their place and is not a risk a factor for the occurrence of ARI but when a person with ARI mingles with another person without taking precautions, probably the person will be infected. Transmission of infection through droplet is possible and opined by the study of Greene (2007) that there is an increased risk of having respiratory infection when the infected person sneezes or coughs without using any precaution like a handkerchief or tissue. Moreover, his co-researcher Gerberding (2007) added that even though transmission of infection is fast, there is no evident findings that droplet transmission is enough to cause disease because it depends on how strong the viruses or bacteria were. Table 20 presents the incidence of ARI in past four years in Brgy. Pto. Rivas Balanga City, Bataan. The table only shows that as years past, number of children five years old and below increases and was still the number disease in those children. The findings were similar with the study of World Health Organization (2007) that ARIs were still the leading causes of infectious disease morbidity and mortality in the world. And it was alarming that almost four million people die from ARIs each year, with 98% due to lower

112 respiratory tract infection. The mortality rates were particularly high among infants, children and the elderly, predominantly in low and middle-income countries. Likewise, ARIs were among the most frequent causes of consultation or admission to HCFs, particularly in pediatric services. Furthermore, in the WHOs report (2009) , the incidence of ARI in children aged less than 5 years old was estimated to be 0.29 and 0.05 episodes per child year in developing and industrialized countries, respectively which translates into 151 million new episodes each year respectively. While in the Philippines, as stated by the WHO Western Pacific Region, 6 out of 10 leading causes of acute illnesses and mortality in the country are caused by the infections in the respiratory tract. Table 20 Incidence of ARI in the Past Four Years Population of Children Five Years Old and Below 1260 1294 1223 Children Affected with ARI 284 350 418 Percentage of Population of Children Five Years Old and Below Affected with ARI 22.5% 27.0% 34.2%

Fiscal Year 2007 2008 2009

2010 1042 410 39.3% The findings suggested that a more careful prevention, treatment and control should be done by the health sectors in the community relation to the prevalence of ARI which is still the cause why most children die because of complications. They should have the goal to eradicate or at least try to decrease the incidence of ARI by promoting awareness regarding the said illness. In the local setting, according to the health officials of the Pto. Rivas Rural Health Unit, cases of acute respiratory infections increases as the cold season is approaching.

113 This is due to reason that the childs immune system did not fully adapt with the changes in the temperature of the environment because of immaturity and insufficiency to vitamins. Second is because of the reason that mothers did not usually bring their child to the clinic for check up and whenever they did, the childs case is usually worse and had already infected others usually their siblings. This only implies that health care providers should educate and inform the parents regarding the importance of having regular check up for their childs health. It would be better also if health sectors will push the provisions of free vitamins within their community. Vitamins helps boost the childs immune system and having regular check up especially when the child has an illness, detects the problem and etiology of the disease at its early phase and by that, treatment is can be given in order to cure the disease. As shown in the table, percentages of ARI cases among children five years old and below is increasing in the past four years as the population of children decreases. This finding is due to reason that transmission of infection is fast because children below five years old were still immature and are still unable to maintain proper hygiene. This only implies that parents should also exert their effort regarding how to prevent and control the spread of any infection. As parents, they should be responsible in teaching their child about proper hygiene at their young age. This only means to should that health sectors as well as parents should work hand in hand in order to prevent spread of infection and to control the existing ones.

114 Notes in Chapter IV

Dr. Anna Banerji. Risk Factors For Lower Respiratory Tract Infections in Inuit Children Identified. www.sciencedaily.com. May 2009. Retrieved October 12, 2010. Dr. Tom Kovesi. Poor Ventilation and Crowding in Nunavut Homes Associated With Lung Infections in Inuit Children. Canadian Medical Association Journal. July 2007. Lisa R. Bulkow, MS et. al. Risk Factors for Severe Respiratory Infection Among Alaska Native Children. Pediatrics Vol. 109 No. 2, pp. 210-216. February 2002. Anders Koch et. al. Risk Factors for Acute Respiratory Tract Infections in Young Greenlandic Children. Oxford Journals, American Journal of Epidemiology. Vol. 158 Issue 4. 2003. I.R. White et.al. Educational Attainment, Deprivation-affluence and Self Reported Health in Britain. www.jech.bmj.com. 2000. Retrieved December 3, 2010. Kazi Md. Abul et. al. Impact of Mothers Secondary Education on Severe Acute Respiratory Infection (ARI) Among Under-Five Children. www.academic.research .microsoft.com/Paper/5602911.aspx. 2000. Retrieved November 3, 2010 P A Margolis et. al. American Journal of Public Health, Vol. 82, Issue 8 11191126. American Public Health Association. 2002. J. Krieger and D.L. Higgins. American Journal of Public Health 2002 Housing and Health: Time Again for Public Health Action. www.ncbi.nlm.nih.gov. Retrieved October 10, 2010. Benti et. al. Acute Respiratory Infection(ARI) in Developing Countries. www. dcc2.bumc.bu.edu. Retrieved December 1, 2010.

Nilanjan Kumar Mitra. A Longitudinal Study on ARI among Rural Under Fives. Indian Journal of Community Medicine. 2001. Alfred Bernard et. al. Pediatric Allergy and Immunology. House Cleaning With Bleach and The Risks of Allergic And Respiratory Diseases in Children. www.skintherapyletter.com. May 2007. Retrieved April 3, 2011.

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A.M. Fendrick et. al. The Economic Burden of Non-Influenza-Related Viral Respiratory Tract Infection in the United States (2003). www.clevelandclinicmeded.com. Retrieved Oct. 10, 2010. REPUBLIC ACT No. 3720 - Food, Drug, www.doh.gov.ph/node/146/prin. Retrieved April 3, 2011. and Cosmetic Act.

Netherlands Nutrition Centre. Hygiene Code for the Private Household. www.nutricion.org/publicaciones/pd. 2001. Retrieved Oct. 10, 2010. Alberto K. Alcantara et. al. Influenza Surveillance in Manila, Republic of the Philippines During 2004-2005. www.hpb.gov.sg/diseases/article.aspx. Retrieved April 3, 2011. UNICEF. Global: Public Private Partnerships for Hand Washing with Soap. http://esa.un.org/iys/docs/6.%20Global%20Experiences.pdf. 2008. Retrieved Nov. 5, 2010. www.wpro.who.int/health_topics/water_sanitation_and_hygiene/general_info.htm . 2008. Retrieved October 14, 2010. Urmila Parlikar, MS. Instant Hand Sanitizers Reduce the Spread of Respiratory and Secondary GI Infections in Families with Children in Daycare. Somerset Medical Journal. EBSCO Publishing. 2005. Sunil Kumar Gupta et. al. Recurrent Acute Respiratory Tract Infections in Areas With High Nitrate Concentrations in Drinking Water. Environmental Health Perspectives Journal. 2000. P. Landrigan and A. Garg, Children Are Not whqlibdoc.who.int/publications/. 2000. Retrieved November 5, 2010. Little Adults.

William. C. Groeniger. Dangerous Bacteria is Sewage Differs from Harmful Gases in Sewer. ASSE Year book. 2006. Atigur Rahman. Assessing Income Wise Household Environmental Conditions And Disease Profile In Urban Areas: Study Of An Indian City. www.springerlink.com/content/d634105624606178/. 2006. Retrieved November 5, 2010. www.mightystudents.com/essay/ Retrieved October 12, 2010. Eric Dontigney. The Effects of Improper Disposal of Waste. www.ehow. com/about_5068278_effects-improper-disposal-waste.html. 2005. Retrieved October 12, 2010.

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Egon Marth et. al. Occupational Health Risks To Employees Of Waste Treatment Facilities. www.aaem.pl/pdf/9741_143.pdf, 2000. Retrieved November 5, 2010. Science Daily. Pollution Causes 40 Percent Of Deaths Worldwide, Study Finds (Aug. 2007). www.sciencedaily.com/releases/2007/08/070813162438.htm. Retrieved Oct. 13, 2010. Anthony Dennis. A Brief Social History http://ezinearticles.com. Retrieved October 11, 2010. of Smoking (2008).

Tony Lawson. The Nature of Heterodox Economics. Cambridge Journal of Economics, 30(4), pp. 483-505. 2006. David Schlossberg. Infections from Leisure-time www.sciencedirect.com. 2001. Retrieved October 9, 2010. Activities.

Alev Yucel et. al. Association of Acute Respiratory Infections and Indoor Air Pollution Among Children Aged 0-24 months in a Semi-urban Area, Ankara, Turkey. www.webstracts.com. 2002. Retrieved October 9, 2010. A. Hawamdeh et. al. 25 Effects of Passive Smoking. Eastern Mediterranean Health Journal, Vol. 9, No. 3, 2003. Dr. Allan Greene and Julie Louise Gerberding. Faster . . . but Fast Enough? Responding to the Epidemic of Severe Acute Respiratory Infection. The New England Journal of Medicine. May 2003. World Health Organization. Infection Prevention and Control of EpidemicAnd Pandemic-Prone Acute Respiratory Diseases in Health Care. www.who.int/ csr/resources/publications/WHO_CDS_EPR_2007_6c.pdf. 2007. Retrieved November 4, 2010. World Health Organization (WHO). Acute Respiratory Infections. www.who. int/vaccine_research/diseases/ari/en/index.html. Sept. 2009. Retrieved September 2, 2010

117 CHAPTER V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

This chapter contains a summary of the findings of the study, the conclusions that were drawn from them and recommendations based on the results which were derived from the statement of the problem presented in Chapter 1 of this investigation. This is a descriptive survey study. The main focus of the study was to determine how some selected factors such as family-related factors and environment-related factors in barangay Pto. Rivas, Balanga City during the fiscal year 2010 affect the increased rates of acute respiratory infection among children below five years old. Specifically, the study sought to answer the following questions: 1. How may the family-related factors be described in terms of: 1.1. number of family members; 1.2. parents educational attainment; 1.3. socio economic status and 1.3.1. family income and 1.3.2. type of house? 1.4. family health status 1.4.1. family history of ARI and 1.4.2. preventive measures? 2. How may the environment-related factors be described in terms of: 2.1. home environment and

118 2.1.1. sanitation practices and 2.1.1.1. food preparation and 2.1.1.2. family members hygiene? 2.2.2. source of water supply 2.2.3. availability of sanitation facilities? 2.2. external environment 2.2.1. community sanitation, 2.2.1.1. sewerage system and 2.2.1.2. garbage disposal system? 2.2.2. community economic activities and 2.2.3. neighborhood leisure activities? 3. How may the rates of Acute Respiratory Infection (ARI) be described in terms of its incidence in the past four years? 4. What is the implication of this study to the nursing profession?

The study concentrated in the vicinity of barangay Pto. Rivas, Balanga, Bataan. The area was chosen due to high incidence of ARI cases in children below five years old. The study had 30 household respondents chosen by a convenience method. Specifically, the study described the profile of the family in terms of number of family members, parents educational attainment, socio economic status including their family income and type of house and lastly, their health status which includes the family history of ARI and their preventive measures. Hence, the profile of the environment also described in terms of, first, their home environment which includes the sanitation

119 practices, source of water supply and availability of sanitation facilities. Under the sanitation practices, food preparation and family members hygiene will be discussed. Second is their external environment which includes community sanitation where the sewerage system and garbage disposal system was described, community economic activities and lastly neighborhood leisure activities. Survey-questionnaires, frequency count and percentage were utilized to describe the profile of the each family and the environment and also the increased rates of ARI among children below five years old. The result of the study had been used to determine the significant relationship of the family and the environmental profile to the increased rates of ARI among children below five years old.

Summary of Findings Using the above mentioned statistical procedures, the major findings of the study can be summarized as follows: 1. The family related factors described in terms of: 1.1. Number of Family Members; The result revealed that for the number of family members, the highest was 7 and above members with 33.33% and the lowest had 2 members with 3.33%. The result revealed that majority of the respondents had 5 children five years old and below in their households having 33.33%. 1.2 Parents Educational Attainment The result revealed that for the educational attainment of fathers, the

120 highest was high school graduate with 46.67% and the lowest was Ed. D Graduate and M.A. Graduate with 0%. The result revealed that for the educational attainment of mothers, the highest was high school graduate with 60% and the lowest was Ed. D Graduate and No education with 0%. 1.3. Socio Economic Status 1.3.1. Family income The result revealed that for the family income, the highest was P 10,000 below with 83.33% and the lowest was P 40,000 Above with 0%. 1.3.2. Type of house The result revealed that for the type of house, the highest percentage was Semi concrete with 43.33% and the lowest was Nipa hut with 0%. 1.4. Family Health Status 1.4.1. Family History of ARI The result revealed that for the family history of ARI, the highest percentage was the sibling with 33.33% and the lowest was uncle with 0%. 1.4.2. Preventive Measures The item that received the highest mean of 4.67 or often is Keeps the household tidy and clean. On the other hand, the item that registered the lowest mean of 2.93 or sometimes is - Brings the child to the hospital

121 or clinic for regular check-up. 2. The environmental related factors described in terms of: 2.1. Home Environment 2.1.1. Sanitation Practices 2.1.1.1. Food Preparation The item that received the highest mean of 5.00 or always is - Washes equipments and utensils for cooking. On the other hand, the item that registered the lowest mean of 2.87 or sometimes is - Provides separate spoon for the foods in the table. 2.1.1.2. Family Members Hygiene The item that received the highest mean of 4.93 or always is - Takes a bath once or twice daily. On the other hand, the item that registered the lowest mean of 2.53 or sometimes is - Uses antiseptics (e.g. alcohol and hand sanitizer). 2.2.2 Source of Water Supply The result revealed that for the source of water supply, the highest was the use of tap water with 46.67% and the lowest was Recycled water or re-used water with 0%. 2.2.3. Availability of Sanitation Facilities The item that received the highest mean of 3.70 or very available is - kitchen. On the other hand, the item that registered the lowest mean of 2.70 or available is garbage trucks.

122 2.2. External Environment 2.2.1. Community Sanitation, 2.2.1.1. Sewerage System The item that received the highest mean of 4.33 or often is removes stagnant water from canals. On the other hand, the item that registered the lowest mean of 1.30 or never is visits or check drains and pipes monthly. 2.2.1.2. Garbage Disposal System The item that received the highest mean of 5.00 or always is Disposes wastes to garbage trucks. On the other hand, the item that registered the lowest mean of 1.53 or seldom is recycles other plastics and re-usable trash. 2.2.2. Community Economic Activities The item that received the highest mean of 4.57 or always is Sells and uses cigarette. The item that received the lowest mean of 3.20 or seldom is dries along the road. 2.2.3. Neighborhood Leisure Activities The item that received the highest mean of 4.57 or always is Smokes. The item that received the lowest mean of 2.20 or seldom is Mingles with a crowd of people with and without diseases in a gambling. 3.1Rates of ARI be described in terms of its incidence in the past 4 years The finding shows that as years past, number of children five years old and below increases and was still the number disease in those children.

123 Conclusions In view of the findings presented, the following conclusions were drawn within the limitations and scope of the study: 1. The number of family members, parents educational attainment as well as the family income had significant relationship on the increasing rates of ARI. While the type of house, family history of ARI and preventive measures had no significant relationship on the increasing rates of ARI. 2. The sanitation practices, source of water supply, availability of sanitation facilities, sewerage system, garbage disposal, community economic activities as well as the neighborhood leisure activities has no significant relationship on the increasing rates of ARI. 3. Cases of ARI among children below 5 years old were increasing.

Recommendations In light of the above findings and conclusions, the following recommendations were presented; 1. Encouraging the parents to visit more frequently their childs physician or any health care provider in able to supervised properly the health of their children. Also, giving their children proper and complete immunization wherein it would greatly help to protect their childs immunity against any infectious disease. Government as well as Non Government Organization has different projects, services and budget intended for the people. Parents can be encouraged to consult their childs health status by conducting different health projects such Frequent Medical Missions, Free/ cheaper Medicines and Feeding Program. These projects

124 may be joined together in able for the parents to be attracted and encouraged more to supervise their childs heath status. 2. In relation to the environmental related factor, the researcher proposes that: 2.1. Giving proper education and discipline to every parent and other adults will help build a healthy environment to our children. This could be done if there would be Health Education Seminars in every community can be done frequently wherein different health care providers would share their knowledge in caring of their health. .Also, proper education disseminations can be conducted wherein different materials could be used such as posters, flyers, tarpaulins and handbooks in able for the people to be more aware in preventing and managing properly in treating different Acute Respiratory Infections. Also, teaching the parents especially mother the home remedies that could be done to prevent or treat different respiratory infections. 3. Acute Respiratory Infections was gradually increasing in the past 4 years. With this, certain preventive measures could be done to combat the continuous increasing rates of ARI. In partnership with the government and non government organization different programs are possible to conduct in every community such as proper education dissemination, expanded program for immunization, encouraging weekly or monthly visit at their designated health care centers, giving free/ cheaper medicines, weekly community cleaning, feeding programs and free medical missions. 4. For future researchers who will wish to take Acute Respiratory Infections (ARI) as their research, the researchers advise that:

125 4.1 When gathering for some information regarding ARI within the target community, give the head of the community or the health center an overview about the research to be conducted for them to be guided of what data should be given to you as part of the research. Take down notes of what they are telling you and do not be afraid to raise some questions to verify the data. Ask for any written reports or data regarding ARI like number of cases per month or year and the age groups that were most likely affected. Also, take the latest statistics of ARI available internationally and locally. 4.2 When creating a statement of the problem, choose variables that are specific and prcised which are related to ARI where there were available resources, related literatures and studies to be used. Like for the family health status, future researchers can include the respondents history of immunization and hospitalization if any and family history of any medical condition that can contribute to ARI. 4.3 When conducting a survey, the best way to approach the respondents is to visit them in their house, let them answer the questionnaire and afterwards, raise some questions regarding to his or her answer. At the same time, observe their way of living, for example, do they practice proper hygiene like hand washing. 4.4 Upon evaluation of the findings, coordinate with the community and health sector for the ideas that the researchers seemed to be useful to help them prevent and control any infections occurring.