ROUGH DRAFT OF REPORT

HEALTH AS A MULTIFACTORIAL PHENOMENON

Submitted by: Group # 6 - DLC TATING, Gwen C. TIANGCO, Patricia C. TIAMSON, Justine D. TIONGQUICO, Chaira S. URMAZA, John Carlo G. VILLAMOR, Norberto T. YLAGAN, Veronica Samantha G.

Submitted to: Mrs. Marilyn C. Dulig-Cabanes, RN, PhD Primary Health Care Professor

A. FACTORS AFFECTING HEALTH

A.1 POLITICAL A.2 CULTURAL / BEHAVIORAL Culture is defined as learned behavior which has been socially acquired and in other words it is the shared and organized body of customs, skills, ideas and values, transmitted socially from one generation to other. Culture plays an important role in human societies. It lays down norms of behavior and provides mechanisms which secure for an individual, his personal and social survival. Culture includes everything which one generation can tell, convey or hand down to the next. Culture has three parts. It is an experience that is learned, shared and transmitted. Acculturation refers to culture contact. There are various ways by which the acculturation can occur, like in the way of trade and commerce, industrialization, propagation of religion, education and conquest to name some. Cultural factors in health and disease have engaged the attention of medical scientists and sociologists. Every culture has its own customs which may have significant influence on health and oral health. The increased incidence of lung cancer because smoking, cirrhosis because of alcoholism in many developed countries, the surge in the incidence of oral cancer in India due to pan chewing habits are some classical examples to demonstrate the influence of culture on health and oral health. It is now fairly established that the cultural factors are deeply involved in the whole way of life, like in the matters of nutrition, immunization, personal hygiene, family planning, child rearing, seeking early medical care, disposal of solid wastes and human excreta etc. All cultural practices are not harmful. Every human has the culturally ingrained habit of cleaning or brushing the teeth early in the morning. The use of soap for personal hygiene, oil massaging, exposure of the new born to sunlight etc are some cultural practices that needs to be encouraged. The inclination to get into the habits of smoking, alcoholism, drug addiction in the name of civilization among the younger generation needs to be countered at the earliest, otherwise, it may have a huge

deleterious impact on the health status of the generation to come. Keeping in mind, the very significant role, the culture plays on health and oral health, this paper is an attempt to review the effects of key cultural factors on health and oral health. Role of family: Family is the primary unit in all societies. It is a group of biologically related individuals living under the same roof and eating from the common kitchen. Family as a cultural unit reflects the culture of the wider society of which it is a part and determines the attitude and behavior of its members. Joint family system is commonly seen in Asia, Africa, the Far East and Middle East countries, more so, in the rural areas than in urban places. The presence of parents, grandparents, uncles, aunts, and other near relatives plays a vital role in child rearing as well as in shaping the attitude and behavior of the child. Nuclear family systems seen predominantly in most of the western countries and urban areas in developing countries, place a greater burden on the parents in bringing up the child due to the absence of other members in the family. This problem is magnified especially if both the parents are earning members. The lack of parental attention in the nuclear families and peer pressure may provoke the child into deleterious habits like smoking, alcoholism, drug addiction, dating etc at an early age (a common practice seen in most developed countries). These adverse cultural practices in turn increase the incidence of oral cancers, venereal diseases and mental illnesses. Beliefs in the family: The rural folk in a developing country like India have many misconceptions related to the family size and structure. Many believe that children are gods gifts, the number of children in the family is determined by god, children are poor mans wealth, and the family is not complete without the birth of a male child. These misconceptions may lead to large families which has a significant impact on the economic status and thereby, on health as well as oral health of an individual. The close birth intervals here may result in maternal malnutrition, nutritional anemia, low birth weight and increased maternal and infant mortality rates. Sex and marriage: Sexual customs vary among different religious and ethnic groups. Muslims have religious restrictions on oro-genital sex and intercourse during

menstruation. Similarly, orthodox Jews are forbidden to have intercourse for seven days after menstruation ceases. This may have an influence on oral health and family planning. The practices of polygamy (marrying of one man to several women) and polyandry (marrying of one woman to several men) seen in many tribal communities of the country (Todas of Nilgiri hills, Nayars of Malabar coast, the inhabitants of Jaunsar Bhawar in Uttar Pradesh) attribute to the high rate of venereal diseases and affect the oral health. United States of America is termed as the genetic melting pot due to

excessive racial mixing. This may result in high frequencies of jaw and tooth size discrepancies leading to malocclusion. This may be the cause for high rate of malocclusion in U S A compared to any other primitive population lacking racial mixing. Maternal and child health: Mother and child health (MCH) is surrounded by a wide range of customs and beliefs all over the world. The various customs in the field of MCH have been classified as good, bad, unimportant and uncertain. Prolonged breast feeding, oil bath, massage and exposure to sun are among the good customs. The avoidance of foods such as papaya, milk, fish, meat, egg and leafy vegetables among pregnant women in some parts of the country, more so in Tamil Nadu and Pondicherry, with the misconception that they may induce heat in the body, which may have an adverse influence on the fetus are amongst the bad customs. Punching of ear and nose, application of oil or turmeric on the anterior fontanel of the fetus are some unimportant customs. The application of kajal or black soot mixed with oil to the eyelids partly for beautification and partly for warding off of the evil eye are amongst the uncertain habits. Adverse practices in child rearing: The deliveries conducted by untrained dais, who have very minimal knowledge on asepsis and sterilization, and whom the villagers trust more than the trained health care workers in many rural areas of the country may increase the incidence of maternal and infant mortality. The child is not put into breast feeding in the first three days after birth in some rural parts of the country (Gwalior region of Madhya Pradesh) due to the misconception that colostrum is harmful. Here instead, the child is put on water. This may prevent the transfer of maternal antibodies and thereby increase the risk for many opportunistic infections in the infant. Adulteration

of milk, delay in the start of weaning foods are other misconceptions related to child rearing that may result in protein energy malnutrition and adversely affect the childs health and oral health. There are some beliefs that diarrhea among children is common during teething and does not need to be taken care of. They also believe that diarrhea will take off the heat from the body and hence the child should not be fed milk and other liquids. This result in dehydration. Food habits: Food habits are amongst the most deeply entrenched habits in any culture having deep psychological roots, religious influence and influence of the local conditions in the form of climate and soil. The family plays a vital role in shaping the food habits and this runs in the families from generation to generation. Ariboflavinosis due to deficiency of riboflavin is common among the population whose staple diet is rice, seen predominantly in the eastern and southern parts of the country.
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Pellagra

due to niacin deficiency is more in the population (Telangana region of Andhra Pradesh) whose staple diet is maize or jowar. This occurs because of the amino acid imbalance caused by excess leucine among jowar and maize eaters. 8 The high concentration of molybdenum in jowar facilitates retention of fluoride in the body, and thereby, may increase the severity of fluorosis among the population whose staple diet is jowar than in the population whose staple diet is rice, especially in an endemic fluoride belt. Vegetarianism is given a place of honor in Hindu religion. Orthodox Hindus are pure vegetarians and hence may not take any foods of animal origin including the milk. This may result in Vitamin B12 deficiency leading to Moellers glossitis. 11, 12, 13 Adulteration of milk, though is done with the motive of economic gain, there are some disbeliefs that if the pure milk is boiled, it may dry the secretion in the donor animal. This results in over dilution of the milk, thereby reducing its nutritive value which may result in protein energy malnutrition among the consumers. 1 Adverse cultural practice in the cooking and preparation of foods such as discarding the cooking water from cereals, which is commonly seen in the rural areas of the country, reduces the nutritive value of food.

Religious restrictions in food habits: Hindus dont eat beef, thinking it is a sacred animal and Muslims dont eat pork, thinking it is a scavenging animal that feeds on human excreta and garbage. These habits are protective as they prevent the occurrence of taeniasis caused by an adult form of Taenia Saginata and cystecercosis which manifest as edematous oral ulcers, gingival bleeding and lesions mimicking mucocles. Dietary habits: Tribal and primitive populations have diet patterns which are coarse and fibrous in nature and free from refined carbohydrates. This may reduce the risk for dental caries and also facilitate adequate stimulation of the jaws, jaw muscles and teeth eruption which may reduce the risk for malocclusion to some extent. The western diet on the other hand consists of refined foods which increase the risk for caries as well as malocclusion due to inadequate stimulation of jaw and jaw musculature. Scandinavian food habits mainly include variety of fishes, cheese etc which may offer some anticaries benefit. Similarly, the Caribbean food habits in the form of local fruits and vegetables, cassava (a starchy root) and great deal of fishes offer them some protection against dental caries. The trona salt is used extensively as a preservative, tenderizer, flavoring agent in food as well as for medicinal purposes (in the treatment of dyspepsia) by Africans. This salt contains high concentration of fluoride (as high as 7900 PPM) and it may increase the risk for dental fluorosis. Fasting is a frequent practice among orthodox Hindus. Muslims do fast during the time of Ramzan. Excessive fasting leads to gastritis, peptic ulcer, malnutrition, nutritional anemia, and loss of weight, which may have deleterious impact on health and oral health. 1 Men eat first and women last and poorly, in many rural families. This leads to maternal malnutrition, leading to high maternal and infant mortality rates. 1 Excessive consumption of spicy food in the form of green chilies is commonly seen in some regions of Andhra Pradesh and Northern Karnataka. This may predispose to the occurrence of peptic ulcer, oral sub mucous fibrosis and oral malignancies as well. Personal hygiene: Majority of the people in the rural areas use open fields for defecation. The villagers are averse to the idea of latrines due to the misbelief that the latrines are meant for city dwellers where they lack open fields. They are often ignorant

about the ill effects of improper disposal of human excreta which may result in water, food, soil contamination, favor the breeding of mosquitoes and flies. Villagers allow the solid wastes to accumulate and decompose in the vicinity of their houses. This also may result in food and water contamination as well as favor the breeding of flies and mosquitoes. The well water is the major source of drinking water for a large segment of the Indian population in rural areas along with tanks and ponds to some extent. These sources are notoriously subject to contamination due to human activities like bathing, washing of clothes and utensils. These are often the places where animals also are given a bath and drink which contaminates the water. Some rivers are considered to be holy. People go on pilgrimage, carry samples of holy water in bottles, preserve them for long duration and carry them over long distances to be distributed among the relatives and friends. This is also cause for epidemics of cholera and gastroenteritis. The rural houses are usually damp, ill- lighted and ill ventilated with lack of separate kitchen, latrine, and proper drainage. Animal keeping is common practice in the villages. All these may increase the risk for most of the communicable diseases among them. Sedentary life style: Lack of physical exercises among the upper class people is the main cause for obesity, which in turn predispose the person for many cardiovascular diseases, diabetes mellitus etc. These diseases have deleterious impact on oral health. Cola and Khat chewing: These habits are widely seen in African countries. The cola has tannin, Theo bromine, and Caffeine. This may facilitate healing of oral mucosal lesions where as Khat chewing causes dry mouth, thirst, pain, buccal keratosis and clicking in the temporomandibular joint region. Alum rinsing and fomentation: Alum rinsing done with the belief that it may make the gingiva stronger may have an adverse effect in the long run. Fomentation for reducing the pain associated with a decayed tooth may not worsen the pain at times, but it may result in cellulitis. CONCLUSION: Health is a consequence of an individuals lifestyle as well as a factor in determining it. Every one of us, have our own beliefs and practices concerning health

and disease irrespective of the area of residence (whether residing in urban or rural areas). Not all cultural practices are harmful. Some of these practices like adequate nutrition, good sleep, regular physical exercise etc are based on centuries of trial and error and have positive values. Achievement of optimum health demands adoption of healthy lifestyles.
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We have to identify the cultural factors that are deleterious and

beneficial. We, the health professionals have to discourage the unhealthy practices through intensive health education and promote the adoption of healthy practices. The primary health workers and school teachers can a play a vital role in creating the awareness on the adverse effects of deleterious cultural practices among the general population and students. The mass media in the form of radio, television, newspapers, health exhibitions, role plays etc go a long way in changing the attitude and behavior of the people and this demands more patience as well as persistence from the health care workers, as the cultural practices are deep rooted and requires a very long time to change or modify.

A.3 HEREDITY A.4 TYPES OF HEALTH CARE SERVICES Health care services have been established to make it easier for patients to receive proper care. In order to receive the best care, patient should establish a relationship with a primary care physician whom they can consult regarding their health concerns. Types of Health Care Services Primary care Primary care is the term for the health care services which play a role in the local community. It refers to the work of health care professionals who act as a first point of consultation for all patients within the health care system. Such a professional would usually be a primary care physician, such as a general or family physician, or a nonphysician primary care provider, such as a physician assistant or nurse practitioner If the issue cannot be resolved by the primary care physician they may refer the patient to a specialist. Primary care can be divided into three categories: Internal

Medicine, Family Medicine, and Pediatrics. Internal Medicine refers to doctors who focus on the care and treatment of adults. They have received special training that deals specifically with adult diseases and preventive care. Family Medicine refers to physicians who treat the family unit from babies to adults. Pediatrics is the division of physicians who focus on treating children from birth through adolescence. Primary care involves the widest scope of health care, including all ages of patients, patients of all socioeconomic and geographic origins, patients seeking to maintain optimal health, and patients with all manner of acute and chronic physical, mental and social health issues, including multiple chronic diseases. Secondary Care Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists. The "secondary care" is sometimes used synonymously with "hospital care". However many secondary care providers do not necessarily work in hospitals, such as psychiatrists, clinical psychologists, occupational therapists or physiotherapists, and some primary care services are delivered within hospitals. It includes acute care: necessary treatment for a short period of time for a brief but serious illness, injury or other health condition, such as in a hospital emergency department. It also includes skilled attendance during childbirth, intensive care, and medical imaging services. Allied health professionals, such as physical therapists, respiratory

therapists, occupational therapists, speech therapists, and dieticians, also generally work in secondary care, accessed through either patient self-referral or through physician referral. Tertiary care Tertiary care is specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel

and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Examples of tertiary care services are cancer management, neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative and other complex medical and surgical interventions.

Quaternary care The term quaternary care is also used sometimes as an extension of tertiary care in reference to medicine of advanced levels which are highly specialized and not widely accessed. Experimental medicine and some types of uncommon diagnostic or surgical procedures are considered quaternary care. These services are usually only offered in a limited number of regional or national health care centers.

Home and community care Many types of health care interventions are delivered outside of health facilities. They include many interventions of public health interest, such as food

safety surveillance, distribution of condoms and needle-exchange programs for the prevention of transmissible diseases. They also include the services of professionals in residential and community settings in support of self care, home care, long-term care, assisted living, and treatment for substance use disorders and other types of health and social care services. Community rehabilitation services can assist with mobility and independence after loss of limbs or loss of function. This can include prosthesis, orthotics or wheelchairs.

A.5 ENVIRONMENT

A.6 SOCIO ECONOMIC STATUS Socioeconomic status (SES) is defined as the social standing of an individual or group in terms of their income, education and occupation. An individuals income, education and occupational status are often closely interrelated. Research suggests that both physical and mental health are associated with SES. In particular, studies suggest that lower SES is linked to poorer health outcomes. Poor health may in turn decrease an individuals capacity to work, thus reducing their ability to improve their SES.

Low SES is associated with increased morbidity and mortality (Adler et al., 1994; Adler & Coriell, 1997).

Low income individuals are 2-5 times more likely to suffer from a diagnosable mental disorder than those in the top SES bracket (Bourdon, Rae, Narrow, Manderschild, & Regier, 1994; Regier et al., 1993).

Within families, economic hardship can lead to marital distress and disrupted parenting that in turn may increase mental health problems among children, such as depression, substance abuse and behavior problems (Conger et al., 2002).

Educational and employment opportunities may be hindered by mental health problems (Murray & Lopez, 1997).

Access to health insurance and preventive services are part of the reason for socioeconomic health disparities (McGinnis, Williams-Russo, & Knickman, 2002).

Those with low SES often experience barriers to obtaining mental health services, including lack of or limited access to mental health care, child care and transportation (McGrath, Keita, Strickland, & Russo, 1990).

B. FACTORS INFLUENCING HEALTH CARE

B.1 HIERARCHY OF NEEDS Psychologist Abraham Maslow first introduced his concept of a hierarchy of needs in his 1943 paper "A Theory of Human Motivation" and his subsequent book Motivation and Personality. This hierarchy suggests that people are motivated to fulfill basic needs before moving on to other, more advanced needs. This hierarchy is most often displayed as a pyramid. The lowest levels of the pyramid are made up of the most basic needs, while the more complex needs are located at the top of the pyramid. Needs at the bottom of the pyramid are basic physical requirements including the need for food, water, sleep, and warmth. Once these lowerlevel needs have been met, people can move on to the next level of needs, which are for safety and security. As people progress up the pyramid, needs become increasingly psychological and social. Soon, the need for love, friendship, and intimacy become important. Further up the pyramid, the need for personal esteem and feelings of accomplishment take priority. Like Carl Rogers, Maslow emphasized the importance of self-actualization, which is a process of growing and developing as a person in order to achieve individual potential.

Types of Needs Maslow believed that these needs are similar to instincts and play a major role in motivating behavior. Physiological, security, social, and esteem needs are deficiency needs (also known as D-needs), meaning that these needs arise due to deprivation. Satisfying these lower-level needs is important in order to avoid unpleasant feelings or consequences. Maslow termed the highest-level of the pyramid as growth needs (also known as being needsor B-needs). Growth needs do not stem from a lack of something, but rather from a desire to grow as a person. Five Levels of the Hierarchy of Needs There are five different levels in Maslows hierarchy of needs: 1. Physiological Needs These include the most basic needs that are vital to survival, such as the need for water, air, food and sleep. Maslow believed that these needs are the most basic and instinctive needs in the hierarchy because all needs become secondary until these physiological needs are met.

2. Security Needs These include needs for safety and security. Security needs are important for survival, but they are not as demanding as the physiological needs. Examples of security needs include a desire for steady employment, health insurance, safe neighborhoods and shelter from the environment.

3. Social Needs These include needs for belonging, love and affection. Maslow considered these needs to be less basic than physiological and security needs. Relationships such as

friendships, romantic attachments and families help fulfil this need for companionship and acceptance, as does involvement in social, community or religious groups.

4. Esteem Needs After the first three needs have been satisfied, esteem needs become increasingly important. These include the need for things that reflect on self-esteem, personal worth, social recognition and accomplishment.

5. Self-actualizing Needs This is the highest level of Maslows hierarchy of needs. Self-actualizing people are self-aware, concerned with personal growth, less concerned with the opinions of others and interested in fulfilling their potential. B.2 MAJOR DEVELOPMWNTAL LEVELS AND TASKS B.3 DEVELOPMENTAL STAGES AND TASKS BY FREUD AND ERIKSON B.4 TYPE OF CONDITION AFFECTING THE PARENT B.5 PERSONAL RESOURCES The social and personal or psychological resources an individual can draw on can modify behavior risk factors or even reduce the health disadvantages of low socioeconomic status. Substantial evidence that such resources reduce the risk of various morbidity and mortality outcomes has accumulated over the past 25 years. The influence of these factors does not diminish at older ages: as Mendes de Leon and Glass (2004) document, such social factors as greater social integration and social engagement, as well as such psychological characteristics as beliefs regarding one's personal mastery and efficacy, continue to be important in old age. Personal psychological characteristics are also related to health risks. Personal mastery beliefs, beliefs that one has the ability to control outcomes, have been shown to predict lower mortality in both U.S. and European populations. Given that most adults spend a large portion of their time in a work setting, it is not surprising that aspects of

control with respect to one's job are particularly consequential with respect to risks for cardiovascular disease, as well as mortality. The biological plausibility of a link between perceptions of control and health is suggested by a number of experimental studies showing that exposure to situations characterized by lower control is associated with enhanced physiological stress reactivity. Interventions designed to enhance perceptions of control in both work environments and nursing homes provide suggestive evidence that enhancing control can reduce health risks. Several studies in Sweden have suggested that interventions within the work environment can lower cardiovascular risk profiles. In nursing home studies, demonstrated increased activity and well-being and reduced mortality among residents who are given greater opportunities to control their environment. Self-efficacy beliefs represent a similar construct to control beliefs, focusing on the perception of one's ability to successfully perform various activities. Stronger selfefficacy characterizes individuals who believe they have more power to affect events and alter outcomes in their lives. Individuals with weaker self-efficacy beliefs are at significantly greater risk, at older ages, of cognitive and physical impairments. One possible reason for this finding is that older adults with stronger self-efficacy beliefs are more likely to exercise regularly. Such exercise has potentially far-reaching health effects because regular physical activity reduces risks for many health outcomes, including heart disease and physical and cognitive impairment, as well as overall mortality. Interventions to encourage adoption and persistence of regular exercise of some typeespecially needed given that 40 percent or fewer older adults report regular physical activitymay need to consider whether self-efficacy beliefs can be reinforced.

B.6 EXTENT OF ACTUAL OR PERCIEVED CHANGE IN BODY IMAGE B. 7. CLIENTS AND FAMILYS STAGES OF ADAPTATION B.8. CLIENTS HISTORY Body image refers to a subjective concept of one's physical appearance based on self-observation and the reaction of others. "Ideal" body image is the phrase used to

refer to the body size determined by one's cultural group to epitomize beauty and/or success in achievement of the optimum physical state as defined by that group. The "ideal" body image can vary between cultural groups, within ethnic groups, and within any other group to which one belongs. Where do Americans derive their perception of ideal body image? What are some of the factors that influence the perception of ideal body image as one develops along the life span? How can health professionals, parents, teachers, and friends affect the development of healthy, positive body images among American youth? This article examines a variety of the influences affecting the development of the American ideal body image perceptions at different stages of the life cycle. The identified influences might have similar effects on the population in other countries that purchase American products, watch American television and movies, listen to American music, read American periodicals, and visit our country. The globalization of today's marketplace hastens the popularity of selected role models and the pursuit of the ideal body image in vogue at the time. Understanding the factors influencing the development of a healthy body image is of interest to many disciplines, educators, and target groups throughout the world. Body Image Satisfaction and Dissatisfaction The concept of ideal body image directly impacts a person's body image satisfaction or dissatisfaction. For the purposes of this article, body image satisfaction refers to one's personal body image being similar to one's concept of his/her ideal body image. In addition, one's ideal body image represents the physical ideal that one seeks to emulate, be that a high-fashion model, celebrity, movie star, elite athlete, fitness professional, or other such role model. Body image dissatisfaction refers to the degree one's personal body image differs from one's perceived ideal body image or one's subjective feelings of dissatisfaction with one's physical appearance. Body

dissatisfaction is a precursor for negative self-perception or self-worth and can lead to the development of eating disorders.

Body Mass Index Changes Over Time As stated previously, Americans are heavier now than ever before. More than 66% of adults in the United States are overweight, and more than 32% are obese. Anthropometry is one way to assess nutritional status in children and adults. Body mass index is commonly used as a method to evaluate healthy body weight and to simply express the relationship of weight-to-height. Body mass index is the weight in kilograms divided by the height in meters squared or weight in pounds times 705 divided by the height in inches squared The lowest health risk category occurs with BMI between 20 and 25. People with a BMI within this range have lower rates of chronic disease. The ideal BMI for US women is between 21.3 and 22.1, and for US men, between 21.9 and 22.4. The international classification for overweight is a BMI of greater than or equal to 25.0, and for obese, a BMI greater than or equal to 30. Underweight is classified as a BMI of less than 18.5. Weight, height, BMI, and girth measurements all have their place in evaluating health status and level of nutritional risk. Unhealthy Body Image Body image describes how an individual conceptualises his or her physical appearance. The body image a person has results from the interaction between the persons thoughts, beliefs, feelings and behaviours regarding their own body, and their perception of what counts as the ideal body within their own social and cultural setting. Unhealthy body image can affect men and women, children and the elderly from all backgrounds. While there is no single or standard definition, unhealthy body image can be taken to involve dissatisfaction with ones physical appearance leading to unhealthy responses which can include poor eating behaviors, changing levels of physical activity, substance abuse or reduced social interactions. This description emphasizes that, from a health and medical point of view, the important difference between healthy and unhealthy body image is the nature of the behavioral and health-related consequences of the body image a person has.

There is potential for body image issues to arise at an early age. Evidence suggests that self-awareness starts to emerge around the age of eighteen months, though this remains an area of research and debate. The age or stage of development when a child begins to evaluate their body for acceptability is still being investigated. The onset of puberty is a period of both substantial physical change and altered peer-relationships. It can be a period of major transition in a persons body image. Body image satisfaction has been identified as the greatest single predictor of self-esteem for adolescents. Mission Australias National Survey of Young Australians has identified body image as one of the leading issues of concern to young Australians of both genders. Children and young people with physical and developmental disabilities can also experience body image concerns. Unhealthy body image affects lifestyle choices and negatively affects mental and physical health, and social functioning. It can lead to unhealthy dieting, eating disorders, excessive exercise or under-exercise, substance use, and the desire for unnecessary surgical intervention. Once established, an unhealthy body image can continue through adult life. Eating Disorders Eating disorders can result from unhealthy body image. Such disorders include anorexia nervosa and bulimia nervosa. The former is characterised by self imposed starvation coupled with an intense fear of weight gain (despite continued weight loss). The latter involves episodes of binge eating followed by purging (such as self-induced vomiting, laxative or diuretic misuse and excessive exercise). The health consequences of the food restriction and starvation associated with anorexia and bulimia include impairment of bone mineral acquisition leading to osteoporosis, fertility problems, kidney dysfunction, reduced metabolic rate, cardiac irregularities, muscle wasting, oedema, anaemia, stunting of height / growth and hypoglycaemia and reduced mental functioning. The Influence of the Popular Media

Research is continuing into the range of individual and social factors that might contribute to the development of unhealthy body image and eating disorders. It is generally recognised that the popular media is a significant social and cultural factor that influences the development of peoples self-perception and body image. Young people especially, are susceptible to social pressures to conform to ideal stereotypes. The public is constantly presented in the popular print and electronic media with images of attractive, thin women and athletic, handsome men. These idealised images do not truly reflect the bodies of most people in the community, and can contribute to unrealistic perceptions about appropriate physical appearance which may lead to body dissatisfaction and eating disorders. Repeated exposure to these images could have a cumulative impact on vulnerable individuals. There is no national system of regulation relating to the portrayal of body image in the print and electronic media, nor the use of digital manipulation techniques such as airbrushing. This is despite growing community concern and debate around issues such as the use in advertising of very young and / or extremely underweight fashion models. The development of national industry standards may be an effective step along the way to responsible body image portrayal in the media. The Role of Medical Practitioners According to the World Health Organisation Collaborating Centre for Mental Health and Substance Abuse, medical practitioners have an important role in fostering healthy beliefs about body weight and shape by challenging unrealistic thoughts, beliefs and values, providing education and providing referral for therapy. Medical practitioners play an important role in the early detection and management of individuals at risk of developing unhealthy body image or eating disorders. Doctors can identify symptoms of eating disorders or body image problems which would otherwise appear unrelated. Early intervention may lead to a more complete recovery, and reduce the risk of an eating disorder becoming chronic. Doctors have opportunities to educate patients on the benefits of healthy eating and appropriate physical activity, and to advise parents about healthy eating and healthy weight for children and adolescents. Doctors are aware of

the complex processes of behaviour change needed to establish and maintain a healthy weight, and can advise those with body image concerns about the risks and likely successes of various weight control diets. Modeling Industry and Idealized Body Type Another strong influence on developing ideal body image perceptions comes from the modeling industry. Ultrathinness has been the ideal body image projected by the modeling industry for many years. The "lean" body type is the predominant body image sought in the hiring of models to market clothing, jewelry, cosmetics, and other products because of the seemingly ideal thin body image conveyed in the print media and supported by popular demand. In 2006, Madrid's Fashion Week banned models considered dangerously thin from catwalk shows. The ban in Spain came weeks after 22-year-old Uruguay model, Luisel Ramos, with a BMI of 14.5, died of a heart attack in August 2006 moments after stepping off a catwalk. Her death came shortly before Brazilian model Ana Carolina Reston died at the age of 21 years in November 2006 with a BMI of 13.4. Reston was 5 ft 8 in tall and weighed only 88 lb at the time of her death. Models auditioning for Madrid Fashion Week are now examined by doctors, and those with a BMI that is too low are not permitted on the runway. Guidelines now state that fashion models in Madrid, Spain, as well as in Milan, Italy, need to have a BMI of 18 or higher to work as a model. In March 2008, Italy also introduced a US $1.5 million campaign against eating disorders. Italy also has banned newspaper and television stations showing women who are under size 4 to 6 in an effort to provide the public with realistic images of women. The Health Minister of Germany has issued guidelines for fashion model sizes to be at least a size 2 and the models to be older than 16 years to walk on runways.

C. LEVELS OF HEALTH CARE PREVENTION

Primary Prevention

Providing specific protection against disease to prevent its occurrence is the most desirable form of prevention. Primary preventive efforts spare the client the cost, discomfort and the threat to the quality of life that illness poses or at least delay the onset of illness. Preventive measures consist of counseling, education and adoption of specific health practices or changes in lifestyle. Examples: a. Mandatory immunization of children belonging to the age range of 0 50 months old to control acute infection diseases. b. Minimizing contamination of the work or general environment by asbestos dust, silicone dust, smoke, chemical pollutants and excessive noise. Secondary Prevention It consist of organized, direct screening efforts or education of the public to promote early case finding of an individual with disease so that prompt intervention can be instituted to halt pathologic processes and limit disability. Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise result for the individual and the family from advanced illness and its many complications. Examples: a. Public education to promote breast self-examination, use of home kits for detection of occult blood in stool specimens and familiarity with the seven cancer danger signals. b. Screening programs for hypertension, diabetes. Uterine cancer (pap smear), breast cancer (examination and mammography), glaucoma and sexually transmitted disease. Tertiary Prevention

It begins early in the period of recovery from illness and consists of such activities as consistent and appropriate administration of medications to optimize therapeutic effects, moving and positioning to prevent complications of immobility and passive and active exercise to prevent disability. Continuing health supervision during rehabilitation to restore an individual to an optimal level of functioning. Minimizing residual disability and helping the client learn to live productively with limitations are the goals of tertiary prevention.

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