Professional Documents
Culture Documents
Unit 1
COMMUNITY HEALTH NURSING: AN OVERVIEW
What is a community?
- a group of people with common characteristics or interests living together
within a territory or geographical boundary
What is health?
1. Health-illness continuum
2. High-level wellness
3. Agent-host-environment
4. Health belief
5. Evolutionary-based
6. Health promotion
7. WHO definition
- aims:
1. health promotion
2. disease prevention
3. management of factors affecting health
What is nursing?
- Maglaya, et al
1. The community is the patient in CHN, the family is the unit of care and there
are four levels of clientele: individual, family, population group (those who
share common characteristics, developmental stages and common exposure
to health problems e.g. children, elderly), and the community.
5. CHN is a part of health care system and the larger human services system.
Clinician, who is a health care provider, taking care of the sick people at
home or in the RHU
Health Educator, who aims towards health promotion and illness prevention
through dissemination of correct information; educating people
In the event that the Municipal Health Officer (MHO) is unable to perform his
duties/functions or is not available, the Public Health Nurse will take charge of
the MHOs responsibilities.
Responsibilities of CHN
Unit 2
LEVELS OF CLIENTELE IN CHN
Individual
1. Atomistic
2. Holistic
1. Biological
a. unified whole
b. holon
c. dimorphism
2. Anthropological
a. essentialism
b. social constructionism
c. culture
3. Psychological
a. psychosexual
b. psychosocial
c. behaviorism
d. social learning
4. Sociological
b. social groups
Family
Models:
1. Developmental
2. Structural-Functional
Environmental Factors
Health threats:
conditions that are conducive to disease, accident or failure to realize
ones health potential
Health deficits:
instances of failure in health maintenance (disease, disability,
developmental lag)
Problem Prioritization:
Preventive potential
High
Moderate
Low
Modifiability
Easily modifiable
Partially modifiable
Not modifiable
Salience
High
Moderate
Low
Population Group
Vulnerable Groups:
Specialized Fields:
Components:
Unit 3
ASSESSMENT OF COMMUNITY HEALTH NEEDS
Community Diagnosis
- A process by which the nurse collects data about the community in order
to identify factors which may influence the deaths and illnesses of the
population, to formulate a community health nursing diagnosis and
develop and implement community health nursing interventions and
strategies
STEPS:
Preparatory Phase
1. site selection
2. preparation of the community
3. statement of the objectives
4. determine the data to be collected
5. identify methods and instruments for data collection
6. finalize sampling design and methods
7. make a timetable
Implementation Phase
1. data collection
2. data organization/collation
3. data presentation
4. data analysis
5. identification of health problems
6. priority zation of health problems
7. development of a health plan
8. validation and feedback
Evaluation Phase
Biostatistics
A. Demography
* Sources:
Census complete enumeration of the population
De jure De facto
People were assigned to the place where People were assigned to the place
they usually live regardless of where they where they are physically present at
are at the time of census. the time of census, regardless, of
their usual place of residence.
COMPONENTS:
Population size
Population composition
* Age Distribution
* Sex Ratio
* Population Pyramid
* Median age
age below which 50% of the population fall and above which 50% of the
population fall. The lower the median age, the younger the population
(high fertility, high death rates).
* Age Dependency Ratio
used as an index of age-induced economic drain on human resources
* Other characteristics:
- occupational groups
- economic groups
- educational attainment
- ethnic groups
Population Distribution
* Urban-Rural
shows the proportion of people living in urban compared to the rural areas
* Crowding Index
indicates the ease by which a communicable disease can be transmitted
from 1 host to another susceptible host.
* Population Density
determines congestion of the place
B. Vital Statistics
the application of statistical measures to vital events (births, deaths and
common illnesses) that is utilized to gauge the levels of health, illness and
health services of a community.
Fertility Rate
Mortality Rates
Morbidity Rates
Prevalence Rate
Incidence Rate
C. Epidemiology
- the study of distribution of disease or physiologic condition among
human population s and the factors affecting such distribution
- the study of the occurrence and distribution of health conditions
such as disease, death, deformities or disabilities on human
populations
Basic Concepts:
1. Epidemiologic Triad
2. transmission
3. incubation period
4. herd immunity
Epidemic
a situation when there is a high incidence of new cases of a specific
-
disease in excess of the expected.
- when the proportion of the susceptibles are high compared to the
proportion of the immunes
Epidemic potential
- an area becomes vulnerable to a disease upsurge due to causal
factors such as climatic changes, ecologic changes, or socio-
economic changes
Endemic
- habitual presence of a disease in a given geographic location
accounting for the low number of both immunes and susceptibles
e.g. Malaria is a disease endemic at Palawan.
- the causative factor of the disease is constantly available or present
to the area.
Sporadic
- disease occurs every now and then affecting only a small number
of people relative to the total population
- intermittent
Pandemic
- global occurrence of a disease
Descriptive VS Analytical
Intervention
* Correlational * Case Reports Observational (Experimental)
studies
*Case Series * Case control * Trials
* Ecologic *Cross-sectional * Cohort
surveys
Unit 4:
NATIONAL HEALTH SITUATION
Health Indices
I. Basic Health Indicators
A. Nutrition
B. Disease Patterns
Leading Causes of Morbidity
Leading Causes of Mortality
Categories:
Department of Health
Vision: Health for all by year 2000 ands Health in the Hands of the
People by 2020
Mission: In partnership with the people, provide equity, quality and access
to health care esp. the marginalized
5 Major Functions:
1. Ensure equal access to basic health services
2. Ensure formulation of national policies for proper division of labor and
proper coordination of operations among the government agency
jurisdictions
3. Ensure a minimum level of implementation nationwide of services
regarded as public health goods
4. Plan and establish arrangements for the public health systems to
achieve economies of scale
5. maintain a medium of regulations and standards to protect consumers
and guide providers
Private Sector
-Composed of both commercial and business organizations, non-business
organizations
NGOs
assumes the following roles:
- Policy and Legislative Advocates
- Organizers, Human Rights Advocates
- Research and Documentation
- Health Resource Development Personnel
- Relief and Disaster Management
- Networking
FOUR QUESTIONS:
Unit 5
THE NATIONAL HEALTH PLAN
PROBLEMS
POLICY THRUSTS
STRATEGIES
THRUSTS
(Acronym: PPST)
GOAL :
to enable the Filipino population to achieve a level of health which will allow
Filipino to lead a socially and economically-productive life, with longer life
expectancy, low infant mortality, low maternal mortality and less disability through
measures that will guarantee access of everyone to essential health care
Broad Objectives:
23 IN 1993
refers to the 23 programs, projects, activities of the DOH for the year
1993, which marks the beginning of its journey towards DOH vision
National
Multi-sectoral
advocacy
aimed at
Building supportive environments thru -- community action
networking
BARRIO
Residents actively participate in attaining good health; they are
PARTNERS in health care
CITY
The physical environment in the workplace, streets, and public
places promotes health, safety, order, and cleanliness through
structural manpower support
EATING PLACE
Safe properly - Prepared
An eating place where Stored
Nutritious Transported
foods & drinks are served.
MARKET
adequate water supply
proper drainage
well-maintained toilet facilities
proper garbage and waste disposal is observed by vendors
cleanliness maintained
affordable quality foods
has a well-organized and honest market system
WORKPLACE
Physical Environment: clean, orderly, well-ventilated, adequately-lighted,
smoke-free and adequately-secured which promotes and protects the safety
and health of the family members
Psychosocial Environment: its management encourages professional,
personal and spiritual growth, which promotes harmonious relationships and
productive work
HOSPITAL
A CENTER OF WELLNESS
Promotes preventive care
provides clean and adequate resources, affordable and accessible services
Patient-centered
Governed by competent health team members and personnel
HOME
A safe, sanitary, peaceful place where God-fearing household members are
provided with the basic physical, social, economic, emotional, mental, moral
and spiritual needs by their responsible parents/guardians
SCHOOL
Health instructions provided through classroom/extra-curricular activities
Maintains adequate, basic health services to both pupils, teachers, and other
personnel
Sample School Initiative : Little Doctor Program
- outstanding students are chosen yearly on the bases of their healthy
conditions and lifestyles
PRISON
Physical Environment: clean, safe detention place with adequate facilities
Psychosocial Environment: services address the mental, spiritual, physical,
social and economic needs of inmates; has an atmosphere that actively
promotes JUSTICE, PEACE, REHABILITATION and a HEALTHY LIFESTYLE
PORT
Physical Environment: clean, spacious, and secure, with public waiting
areas, passenger terminals, safe drinking water, sanitary food shops and public
toilets; conveniently and economically-accessible
NOT a FRONT for gambling, smuggling, prostitution, and other vices
HOTEL/MOTEL
Physical Environment: clean, safe, pleasant place; conforms with a set of
guidelines and standards; provides comfort and security
RESORT
Clean, safe, affordable resort
Provides recreation, rest, relaxation and wholesome entertainment
Promotes and maintains favorable environmental and health conditions
STREET
Well-maintained roads and public waiting areas
Well-marked traffic signs and pedestrian crossing lane and visible street
names
Clean and obstruction-free sidewalks
With minimal traffic problems
With adequate strict law enforcement
Project: Pook-Tawiran (Kapag ikaw ay nahuli, walang sisihan)
Goal : To promote and reorient people especially erring pedestrians on the use
of pedestrian crossings
VEHICLE
Clean, safe, comfortable, smoke-free, well-ventilated, in good running
condition
Manned by a reliable and dependable licensed operators
With posters on health promotion and illness prevention
MOVIE HOUSE
Provides rest, recreation, and wholesome entertainment
Has sanitary toilets and adequate communication facilities
Unit 6
STRATEGIES AND METHODOLOGIES IN CHN:
Marginalized people are those who live geographically and culturally isolated
areas; are victims of poverty, armed-conflict, man-made and natural disasters
and poor environmental conditions. Vulnerable sector of the population is
composed of infants (0 mo-1 yr) and children (1-4 y/o), women or reproductive
age (15-44 y/o), youth and adolescents and the elderly (65 and above).
1. Health Promotion
2. family wellness
3. community wellness
4. environmental wellness
5. societal wellness
2. Disease Prevention
Screening Methods:
* mass screening
* case-finding
* contact-tracing
* multi-phasic screening
* surveillance
3 Levels of Prevention
3. Community Organizing
Levels of Awareness:
Political socialization
Political mobilization
Interest aggregation
Interest articulation
Culture of silence/passivity
Framework
Peoples Empowerment and Partnership is the
Key Strategy to achieve the goal, Health For all Filipinos by the year 2000
And Health in the Hands of the People by the year 2020
Criteria: Feasible
Acceptable, Affordable
Complex
Effective
Safe
Scope-wise
Herbal Medicine:
aromatic
astringent tasting
bitter-tasting
seeds
grass family
10 MEDICINAL PLANTS:
Lagundi Sambong
Olasimang-Bato Ampalaya
Bawang Niyog-niyogan
Bayabas Tsaang gubat
Yerba-buena Akapulko
(Acronym: LOBBY SANTA)
Unit 7
STRATEGIES AND METHODOLOGIES IN CHN
Strategies/Programs to Promote Health of the Vulnerable Sectors of the
Population
Strategies:
A. Provision of Regular and Quality Maternal Care Services
regular and quality pre-natal care
- hx-taking, utilization of HBMR (Home-Based Mothers Record)
as a guide in the identification of risk factors
- PE: weight, height, BP-taking
- Perform head-to-toe assessment, abdominal exam
- Tetanus Toxoid Immunization
- Fe supplementation: given from 5th mo. of pregnancy to two
months postpartum (100-120 mg orally/day for 210 days)
- Laboratory exam: Heat-acetic acid test. Benedicts test
- Oral/Dental exam
Pre-natal counseling
Schedule:
At birth: BCG
1 months: First doses of DPT, Hep B, OPV
2 months: Second doses of DPT, Hep B, OPV
3 months: Third doses of DPT, Hep B, OPV
Tetanus Toxoid:
First Pregnancy: TT1- 5th to 6th mo of pregnancy, after 4 weeks TT2 (3 years
immunity)
Second Pregnancy: TT3 (1st booster dose) 5th to 6th (5 years immunity)
Third Pregnancy: TT4 (2nd booster dose) 5th to 6th (10 years immunity)
Fourth Pregnancy: TT5 (3rd booster dose) 5th to 6th (life-long long immunity)
Administration:
Side Effects:
Q: What is the eligible age for giving immunization (up to what age can we give
the immunization)?
A: Before the child reaches 6 years old
* a booster dose of BCG shall also be given to all school entrants both in
private and public schools REGARDLESS of presence of BCG scar.
Q: What if the 2nd dose of Tetanus Toxoid was not given to the mother, when is
the best time to give the dose?
A: It has to be given after birth in order to protect the mother and the succeeding
pregnancies.
Q: What if the child has fever of <38.5 C, mild respiratory infections and
diarrhea, should the child be given the vaccine?
A: The abovementioned conditions are not to be considered as a
contraindication to immunization. Thus, vaccine can still be given.
COLD CHAIN
A system used to maintain the potency of a vaccine from that of manufacture
to the time it is given to child or pregnant woman.
Principles:
I. Storage
Type
Expiration date
Duration of Storage
# of times they have been brought out to the field
U Damaged by
T heat and
I freezing
Hepa-B Liquid
Damaged by
Least Tetanus Liquid 20 dose/vial heat or
Sensitive Toxoid freezing
to heat
The vaccine stored the LONGEST AND THOSE THAT WILL EXPIRE
FIRST should be distributed or used 1st.
It is MUST to mark ampules / vials with an X mark each time they are
carried to the field, because if a VACCINE IS NOT USED on the third trip,
it must already BE DISCARDED.
II. Transport
DOH STRATEGIES:
- 23 in 93
National Immunization Day Slogan: Ceasefire for Children: Support
National Immunization Day!
Concept: No shooting of bullets, only shooting of vaccines
Project included: Polio Eradication Project
Goal of the project to immunize 9m. children with OPV to completely
eradicate polio by 1995
Disease Eradication: Measles, Rabies, Polio, Neonatal Tetanus
Formalization of plans for an improved Biologic Production Service is done
to develop self-sufficiency in vaccine production decreasing
dependence on imported vaccines.
LEGAL MILESTONES:
PD 996 Compulsary, Basic Immunization for children 8 years old
and below (0-8 y/o), thus covers 2 age groups - infants
School entrants
PP # 6 Universal Law on Immunization strengthens the EPI
PP # 147 National Immunization Day; every organized Patak Center
will cater to 1,000 population (1:1000 population). The team will be
composed of:
1 organizer
1 vaccinator
1 recorder
1 health educator
1 sanitary inspector
PP # 46 Launched the POLIO CONTROL PROGRAM OF THE
PHILIPPINES
Polio Eradication Knock-out Polio Zero-Polio Philippines
Project (PEP) (KOP) (95-00)
infants
school entrants
Solve: Total population = 6000, determine DPT vaccine to be used for infants.
SURVEILLANCE
B. Oresol Therapy
3 CLASSIFICATIONS:
Mild - 5 - 10 unformed stools/24 hours
Moderate - 10 - 15 unformed stools/24 hours
Severe - > 15 unformed stools/24 hours with associated
signs/symptoms
Dehydration
ORS, assess after 4 6 hours
Intravenous fluids
If NOT possible, assess if the child can drink (give ORS and refer for IV)
If cannot drink ( give fluids via NGT)
If no NGT, refer immediately!
ORS :
1 pack
1 L of water
Contains:
glucose for Na absorption
NaCI for fluid retention
NaHCO3 to serve as a buffer system
KCL for smooth muscle contraction
Home-made Oresol:
1 L of water: or 1 glass of water
8 tsp. of sugar: 2 tsp. of sugar
1 tsp. of salt 1 pinch of salt
Remember:
Infant must be given - cup every after LBM
Child must be given - 1 cup every after LBM
Adult must be given 1 or more cup every after LBM
- Breastfeed infants
- Provide appropriate supplemental feeding
- Handwashing
- Utilize clean and potable water
- Clean toilet and observe proper feces disposal
- Immunize the child with measles
C. Breastfeeding
B Fresh
Reduced allergic reaction Emotional bonding
Economical Easily established
Always available Digestible
Safe/maintains the stool soft Immunity
Temperature always right Nutritious
GIT disorders are decreased
BREASTMILK VS FORMULA*
CHO > CHO
CHON (LACTALBUMIN) < CHON (CASEIN)
FATS = FATS
Linoleic acid content (3x) > Linoleic acid content
MINERALS < MINERALS
* the high CHON and mineral content of cows milk may overwhelm the
newborns kidney, thus it still needs to be diluted. Casein is more difficult
to digest.
LEGAL MILESTONES:
EO 51 MILK CODE OF THE PHILIPPINES
RA 7600 MOTHER-CHILD FRIENDLY HOSPITAL
- part of 23 in 93 which aims to sustain breastfeeding
efforts immediately after delivery
D. Immunization (see EPI)
Assessment:
History:
Age, cough (since when), fever (since when), stop feeding?, convulsions?
Physical Examination:
Assess for fast breathing:
RR of 60/min (below 2 months)
50/min (2months to 1 year)
40/min (1 to 5 years)
stridor, wheeze
level of consciousness
stop feeding
malnutrition
Unit 8
STRATEGIES TO ADDRESS SPECIFIC HEALTH PROBLEMS
Communicable Disease Prevention and Control
Communicable Diseases
Key Policies:
Prevention
BCG vaccination under the EPI Program
Annual identification of at least 45% of its prevalence
Public health education re: PTB mode of transmission, methods of control,
and importance of early diagnosis
Provide outreach services for home supervision of patients in Multi-Drug
Therapy and also for preventive treatment of contacts
Case Finding
Direct sputum microscopy for identified TB symptomatics
X-ray exam of TB symptomatics who are (-) after 2 or more sputum exam
Establishment of passive and active collection points for sputum samples
of all identified TB symptomatics, as well as validation centers to ensure
the standard and quality of sputum exam
Case finding and treatment services shall be made available in the
BHS/RHUs
Treatment
All TB cases must be treated for free, on ambulatory and domiciliary
(home) basis, except those with acute complications and emergencies
All sputum positive and cavitary cases shall be given priority for short
course chemotherapy or SCC for 6 mos.
Standard Regimen or SR for a year or intermittent SCC for 6 mos. shall be
given to all infiltrative but sputum negative.
Categories:
6 SCC
Patient will be:
Rifampicin Rifampicin
2 mos. on Isoniazid + 4 mos.
Pyrazinamide Isoniazid
8 SCC
Patient will be:
4 SCC
Patient will be:
Rifampicin Rifampicin
2 mos. on Isoniazid + 2 mos.
Pyrazinamide Isoniazid
Rifampicin
1 - Intensive Phase 2 mos. on Isoniazid
Pyrazinamide
Diagnostic: Sputum Exam
if (+), proceed to
Rifampicin
2 - Maintenance Phase + 4 mos. on
Isoniazid
if still (+) TB Colonies proceed to
Rifampicin
3 - Extensive Phase up to 12 mos. on
Isoniazid
Strategies done:
Ensure that every microscopy and treatment center has the ff:
Exnal microscope
Microscopist trained within the last 3 years
A 90% agreement rate in microscopy reading
between the microscopist and validator
Available NTP manual of procedures
Drugs for at least 6 months supply
Reagents, sputum cups for at least 6 months
Utilization of an itinerant team composing of at
least 2 microscopists, nurse, midwife, and a
medical officer who will stay for 2 3 days in
far flung communities to identify TB and start
treatment
Key Policies:
- MDT as the core strategy for the National Leprosy Control Program
- Procurement and supply of MDT Drugs, IEC and Training Materials by
CDCS
- Health education
- Supervision and Control of leprosy Control Activities
Strategies:
Prevention
- Health Education
- BCG vaccination
- Case Finding
- Validate old registered cases
- Early referral of suspected leprosy patients
- Epidemiologic investigation
Treatment
- Ambulatory
- Domiciliary chemotherapy through the use of MDT as embodied in RA
4073 which advocates home treatment
MDT Treatment Regimen
Paucibacillary Multibacillary
Supervised dose: Supervised dose:
Rifampicin 600 mg Rifampicin 600 mg
Dapsone 100 mg Lamprene 300 mg
Taken once/month in the clinic Dapsone 100 mg
Self-administered Taken once/month in the
clinic
Dapsone 100 mg Self-administered dose
Taken OD, daily by the patient at home Lamprene 50 mg
Dapsone 100 mg
Take OD, daily at home
Leprosy Patients must be taught ways to prevent secondary injury
caused by burns and rough sharp objects
Emphasize importance of sustained therapy, correct dosage,
effects of drugs and the need for medical check-up from time to
time
Provide mental and emotional support to the families of leprosy
patients
Refer patients as needed
Rehabilitation:
Imbibe patients participation in occupational activities
Family and community health (PD 304)
o non-segregation of leprosy patients
o counseling and guidance
I - Vector-Control
Highlight
In 24 in 94
Project: Kalusugan ng Kalikasan, Kalusugan ng Mamamayan
National Focus: Awareness and prevention of mosquito borne disease day
Community Action Campaign Acronym CLEAN
Chemically treated mosquito nets
Larva-eating fish
Environmental clean-up of stagnant water
Anti-mosquito soap
Neem trees
Chemoprophylaxis Chloroquine 1-2 weeks before entering an area
then continuous until 4-6 weeks after leaving the area
2 - Detection and Early Treatment of Cases
Early Recognition, Prevention, and Control of Malaria epidemics
a system which will recognize impending malaria epidemics
Early diagnosis and prompt Treatment
identification of a patient with malaria as soon as he is
examined.
AO 89-A s. 1990
provided the Guidelines for the Philippine Cancer Control
Program specifying its program policy, components, implementing
guidelines and timetable.
6 Pillars:
Public Information and Health Education
Cancer Prevention and Early Detection
Cancer Epidemiology and Research
Cancer Treatment
Cancer Pain Relief
DOH Strategies:
In Health for More in 94,
Kayang-kaya ang Cancer
National Focus: Cancer Awareness and Prevention Day
Araw ng Pag-iwas sa Kanser
Cancer Project: Public information and health education on Cancer
Cancer information desk nationwide
Kalusugan ng Kababaihan, Kalusugan ng Bayan
Women are encourage to undergo the following screening procedures
regularly
- Breast Self-Examination
- Regular Pap Smear
Nationwide demonstration on how to correctly do self breast-
examination
Information dissemination also on Urinary Tract Infection, Sexually
Transmitted Diseases, AIDS
Program objective:
decrease the prevalence of smoking-related diseases and subsequent premature
deaths
Program components:
Information and Education on Campaign and Social Mobilization
Policy Development and Legislation
Training of Counselors in Smoking Cessation Clinics for Specialty
Hospitals
Resource Management and Monitoring
Strategies:
National Anti-Smoking Campaign
o World No Tobacco Day
o National No Smoking Month
o Yosi Kadiri Campaign
3. Renal Disease
In 23 in 93
Preventive Cardiology and Nephrology
Enhance public awareness thru health education regarding healthy
lifestyles
Improve access to basic health services
4. Cataract
Goal:
Coverage:
Philippine Food and Nutrition Programs
Fortification for
Iodine
Deficiency
ELimination
Thus;
= 85-18%
1st degree Malnutrition
Degrees of Malnutrition
skinfold measurement
indicates amount of body fat with the use of fat-caliper
sites: triceps, biceps, subscapular, suprailiac
MUAC
estimates lean body mass or skeletal muscle reserves
Legal Milestones:
PD 491 Nutrition Act of the Philippines
Essential drugs are medicinal preparations necessary to fill the basic health
needs of the population.
Legal Milestones
Environmental Sanitation
Goal:
to eradicate and control environmental factors in disease transmission
through the provision of basic services and facilities to all households.
Components:
2 Major Components:
Garbage
Those having a tendency to decay and give off foul odor
Rubbish
Broken glass, bottles, papers
Policies:
Food establishment are subject to inspection (approved of all food sources
containers and transport vehicles)
Comply with sanitary permit requirement
Comply with updated health certificates for food handlers, helpers, cooks
All ambulant vendors must submit a health certificate to determine present
of intestinal parasite and bacterial infection
3 Points of Contamination
Place of production processing and source of supply
Transportation and storage
Retail and distribution points
Goal:
To prevent the risk of contraction contracting nosocomial infection from
type disposal of infectious, pathological and other wastes from hospital
Creating awareness
Creating motivation
Decision making action
Operational Strategies:
Program components:
Case-finding
Case management
Training
Monitoring
Reporting system
Operations research
Streetchildren
Victims of Torture or violence
Internal refugees
Victims of aimed conflict
Victims of natural and man-made disasters
DOH Events:
Buwan ng Kabataan, Pag-asa ng Bayan,
featured in Health for More in 94
National Focus: National Mental Health Week:
Linggo ng Lusog-Isip
Rationale:
Stresses in the environment of children such as times of disasters
and national calamities, disintegration of the values, structure and
functions of the family and urbanization, migration, drugs and
physical and sexual abuse and poverty have direct effects on
physical and mental health.