Chapter 2

REVIEW OF RELATED LITERATURE

This chapter provides an overview of concepts and studies this

research is grounded on. It primarily focuses on the extent of effectiveness

on health promotion activities implemented in Sitio Patpat, Lumbia and

Nola J. Penders Health Promotion Model. It includes previous studies which

have used the Penders Health Promotion Model, as well as the

respondents profiles to the extent of effectiveness. It also provides literature

that may support some questions of the instrument used for this study. This

chapter also discusses the factors that influence the effectiveness of the

health programs that were implemented to residents of Sitio Patpat,

Barangay Lumbia and to the Level 3 and 4 students of Xavier University

College of Nursing.

Despite a growing literature documenting prevention and health

promotion interventions that have proven successful in well-controlled

researches, few of these interventions are consistently implemented in

applied settings. This is true across preventive counseling services for

numerous target behaviors, including tobacco use, dietary change,

physical activity, and behavioral health issues (e.g. alcohol use,

depression). Goetzel (2006) reported that the United States health spending

reached two trillion dollars. Three-fourths of that spending was attributed

towards treating chronic diseases. It is said that they prefer spending the
 19

money in treating the chronic diseases rather than preventing them.

Goetzel (2006) added that the key element of comprehensive reform

strategy was health prevention. In this way, it will improve the health of the

Americans and at the same time, it reduces the financial problems imposed

by preventable diseases.

In another study of Healthy People (2010), research showed that

promotion of regular physical activity could give advantage to all people.

This led to one of their goals such as improved health, fitness, and quality

of life through daily physical activity. Regular physical activity is associated

in lowering the probability of acquiring heart diseases and diabetes; it is also

increases bone strength, which reduces the probability of falling in the

elderly, which will prevent injury and many more.

Health promotion enables the people to increase control over their

health. It allows the people to improve their ability take action for their

health, make health choices and be healthy. Disease prevention is use

alongside as a complementary term with health promotion. Disease

prevention covers measures not only to prevent the occurrence of disease,

such as risk factor reduction but also to arrest its progress and reduce its

consequences once established (WHO, 2008). Participation is very crucial

to support health promotion action, which is a form of health promoting

behavior. Good health promoting behavior will decrease complications,

 20

mortality and morbidities in the households and promote health

(Aigobokhaode, et. al, 2014).

In this study, the specific health promotion programs implemented in

Sitio Patpat, Lumbia includes hygienic practices, sanitation practices,

management of acute and chronic diseases, herbal medicine and

maternal and child care.

With the help of health promotion, the community health nurses can

reverse unequal health outcomes (Yuill, et al., 2009). It is also associated in

decreasing inequities in health and provide the greatest health in people

(Glanz, et al., 2008). The factors identified that can affect the level of

effectiveness are age, gender, family structure, educational attainment,

economic status, social participation and source of information for the

residents of Sitio Patpat.

Age

One of the factors that influence the effectivity of health promotion

is age. According to the study of Senol, et al. (2014), which agrees to the

opinion as one gets older, the level of health-promoting behaviors

increases. One gains life experience and health consciousness through the

aging process. This was supported by Guler, et al. (2008), whereas age

increases, health promoting behavior also increases. As populations are

aging, older adults are targeted for health promotion programs. The

programs tackled are usually about healthy lifestyle, mental health or injury
 21

prevention among older adults (Arsenijivic, et al., 2016). According to Tseng

and Lin (2008), as age increases, health behavior patterns decreases thus

making the older adults the consumers with high health consciousness. For

example, older adults tend to seek more information on nutrition, thus,

encouragement of empowerment and an improved sense of control to the

totality of health and well-being.

As people get older, they may experience vulnerability to illnesses

and degenerative conditions. Therefore, adults may be motivated to

participate in health promotion behaviors to improve stamina and energy

and to avoid cardiovascular disease (Pender, et al., 2006). One other factor

which could trigger for growing health awareness and protective health

behaviors, especially among men is parenthood (Ek, 2013).

In addition, aging frequently calls for the want to make widespread

lifestyle adjustments, such as taking new medicines, following a modified

food regimen or changing an exercising routine. Older people might also

have specific reasons for making this way of life changes. As an example,

they may no longer desire to be a burden to their circle of relatives and this

can provide an additional incentive for retaining their physical potential.

They will additionally need to stay to peer their grandchildren develop up

for you to have an impact on the following generation. Unlike younger

adults who might not see the impact of their terrible behaviors till the future
 22

older adults might also see instant and doubtlessly lifestyles-threatening

consequences (WHO, 2015)

Economic Status

With respect to economic status, a lot of financial decisions face by

individuals and families are being affected by the present economic crisis

and this is particularly true in terms of health care usage. Working and

retired people are forced to let go of some important needs, for example,

housing and food because of the huge difficulties the situation has

produced. Even those financially stable who are fortunate to continually

purchase basic needs are being forced to choose between health care

and other basic needs. On the other hand, strain is being felt by those

people who were once stable because of the rapidly increasing health

care costs and decreasing economic security. The familys ability to judge

if the health promotion given was effective or not based from their mindset

and if the health promotion given will help them to attain their basic needs

in life is affected (Vogenberg, 2012).

Those families with very low incomes, for example, often lack

resources and access to adequate housing, nutritious food, and working

conditions, which could negatively influence their health. Over time, these

families may also face financial and life stress, which will result to health

consequences such as high blood pressure, or immune and circulatory

complications (WHO, 2007). On the contrary, those who have enough

 23

income and employment are probably to experience health outcomes

that are less dependent on material needs but are nevertheless affected

by the demands they encounter at work and at home and the extent to

which they have control and decision-making impact in those settings. Lack

of resources, skills, social support, connection to the community and

increased exposure could also result to less healthy coping skills and poorer

health behaviors (Adler, 2007).

The greater the income, the lower of likelihood of disease and

premature death. Studies show that Americans with low income are less

healthy that those with higher incomes (Woolf et al., 2015). Low-income

families often have poorer health outcome. In addition, poverty not only

affect the life of young children but also their lives as adults (Gupta et al.,

2007). Economic and social factors like education, income and social

connectedness have a relationship with health wherein all of these can

influence health and improve health behaviors and outcomes. (Public

health agency of Canada, 2008). People with low income can also give

negative effects that can affect psychological or behavioral factors

(Stronks et al., 1998).

Educational Attainment

In line with the health promotion model, health is a multifactorial

phenomenon involving an individuals interactions with their physical and

socio-cultural environments. And, such socio-cultural background includes

 24

the educational attainment of an individual. As emphasized by Cohen and

Syme (2013), educational attainment is a well-established social

determinant of health. One of the contributing factors of the overall health

condition, which comprises either health maintenance or development of

disease, is social class. In return, social class standing is influenced by a

various determinants such as education which then affects morbidity and

mortality across an individuals lifespan. They added that a completion of

a formal education, that is, from pre-school to college, can be a

consideration when it comes to implementing an intervention. It also

improves health literacy and health behavior, sense of control and

empowerment, and life chances. With this fact, cost-benefit analyses and

health impact assessment should be done to policies and program which

then can be helpful in evaluating the benefits of interventions. Cohen and

Syme (2013) also added that early childhood upbringing should be

considered aside from the years of formal education. As education

provides a broader perspective and awareness into an individual, it

empowers them, which then contributes to the perception of the ability to

create better health outcomes.

At the same time, educational attainment contributes to the ability

of the person with regards to health literacy. On a study conducted to

determine relationship among health literacy, health status and health

behavior, there were found to be ill-effects of the inadequate health

 25

literacy. Findings show that individual with such circumstance were older,

had fewer years of schooling, low household income, and were females

(Javadzade, et al., 2012). The study also suggests that an inadequate

health literacy was directly link to poor general health, attesting to the

statement that low health literacy is considered a worldwide health

threat. Decreased optimal health, frequent hospital visit and admission,

deficient self-care skills, and a difficulty with utilization of preventive services

are attributed to individuals with low health literacy. Their ability to interpret,

understand, and process information decrease in efficacy and efficiency

predisposes them to the risks of the undesirable repercussions of

inadequate health literacy. This is further supported by He, et al. (2016),

stating that individuals who lack formal education is disposed to

unemployment resulting to low income and low ability achieve optimum

quality of health.

Education is an important factor for improving ones health because

it decreases the need for health care and dependence. It also aids in

promoting health lifestyles and positive choices (Feinstein et al., 2006).

Studies show that people who are educated have lower morbidity from the

most common acute and chronic diseases like heart condition, stroke

hypertension, cholesterol, emphysema, diabetes, asthma attacks and

ulcer (Picker, 2017). Educated people have better health outcomes for

education, which provides individual more information on the impacts of

 26

health inputs like medical care, exercise, smoking and others that

education have an effect on health behaviors and outcomes (Cesur et al.,

2014). Studies show that people with higher level of educational attainment

are more likely to involve in healthy behaviors and less likely involving in

unhealthy habits. This is proven in relation to diet, smoking, physical and

sexual activity (Higgins et al., 2008).

Other studies directly correlate educational attainment to a persons

susceptibility to a disease. Dinwiddie, et al. (2015) proposes that social,

behavioral, and biologic pathways may prognosticate a possible increase

of C-reactive levels, an important factor in the development of

cardiovascular diseases such as stroke, myocardial infarction, and

atherosclerosis, for a race or ethnic group. Being one of the social pathway,

education is believed to be an aspect which impact health for it is

unaltered by deficiency in health beginning from adulthood, which in

effect influences income and opportunities for high-paying occupations.

Family Structure

A family provides two important resources to a child: money and

time/care. These are the two mediators through which a household

provides possible support for a childs well-being. Here, money is defined in

terms of socioeconomic status and financial resources of a household. The

financial resources of the family determine the living conditions of the

 27

children and their food pattern, exposure to infectious diseases and

treatment-seeking behavior (Kumar and Ram, 2013).

Family structure is considered a social determinant that affects health

behaviors and outcomes. According to Couns (2015), there are four types

of family structure and these are the nuclear, extended, single parent and

step families. The effect of family structure on health-related quality of life

and physiological health measures persist regardless of age, gender,

lifestyle risk factors and social support.

Adolescents in most family structure generally tend to have poorer

effects than the ones in a nuclear family with two parents. Adolescents

living with their biological father however not with their mother have

comparable outcomes to the ones residing with their single, biological

mother. Even though transitioning to a single parent is adversely related to

multiple consequences, few associations are observed for other types of

transitions, and there are few variations in adolescent outcomes through

the family structure. Estimates from models making use of adolescent- and

caregiver-reported final results measures, even though similar in regards to

conduct issues, differ appreciably with regard to physical health and

emotional health such that those the usage of adolescent reports suggest

a stronger relation between own family structure and adolescent well-

being than the ones the usage of caregiver reports (Langton and Berger,

2011).
 28

Much of the existing literature has shown that family structure has

mixed effects on child well-being depending on the context in which the

issue is addressed. In developed countries, a single-parent household

(irrespective of the sex of the head of household) is adversely associated

with child well-being in comparison with the presence of both parents. For

example, a single-parent household headed by either a female or a male

is negatively associated with child well-being due to constraints of time,

poor financial condition and lack of interpersonal communication, which

are basic requirements for child well-being (Amato, 1987; McLanahan and

Booth, 1989; Dawson, 1991; Schiller, 1996). In developed countries, the

presence of a partner provides sufficient time for child care as well as

supporting family financial resources. Therefore, two parents provide a

better environment for child rearing and care for child well-being (Amato,

1987; McLanahan and Sandefur, 1994; Hogan and Lichter, 1995). In

contrast, evidence from developing countries has shown that female

headed families (either single-parent or nuclear) can have positive

influences on child nutritional status and well-being. The argument is that

the female/mother is more concerned about child care than male heads

might be, which influences the well-being of children despite the financial

and time constraints associated with female-headed households (Horten

and Miller, 1989). Moreover, the female-headed family is likely to maximize

their resources to fulfil the needs of children (Dwyer and Bruce, 1988).
 29

Evidence shows that female-headed families consume foods of higher

nutritional quality and spend much of their earnings on child requirements

rather than other consumption (Horton and Miller, 1989; Louat, et al., 1993).

However, evidence is mixed and some studies in developing countries show

similar findings to developed countries, with children of single-parent

households being more likely to be stunted in developing countries, possibly

because the children are not being given the proper nutrients, time and

health care (Bronte-Tinkew and DeJong, 2004). In developing countries, the

presence of both parents has been shown to support better economic

conditions and a higher level of per capita consumption in the family, which

favors child well-being (Lloyd and Gage-Brandon, 1993).

Gender

There has been a longstanding debate about the origin of the

divergent patterns among genders. Women's higher life expectancy in the

U.S. appears to result in part, from their higher propensity towards health

promoting lifestyle behaviors (diet, physician visits), rejection of health

damaging behaviors (i.e. cigarette smoking, drinking, drug abuse) and

gender differences in exposure to a range of health-related hazards (such

as occupational accidents, toxins and carcinogens) (Bird and Rieker 2008;

NCHS 2010; Preston and Wang 2006; Waldron 2009). These factors (social,

cultural and behavioral factors), appear to explain more of mens

disadvantage in mortality and life expectancy than do stratification and

 30

biological/genetic factors (Waldron 2009). Gender frameworks are vital for

understanding not just the differing effects of the determinants of health on

either women or men, but also how health programs should respond in

order to improve health outcomes for either women or men (Krieger 2000).

Moreover, women are usually addressed for health promotion as

they are the primary caregivers in the family. Women are the ones who put

health promotion measures in action, often have more concerns about the

health and well-being of the family as individual or as a whole. However, in

some countries, women have a lower status in the household thus their

ability to make decisions to implement the health promotion measures are

limited. This then result to lesser positive health promotion effect especially

towards the family. Furthermore, other health promotion programs may

be unsuccessful because they fail to adequately account for womens

complex social positions, including gendered and racialized power

imbalances and differential access to material resources (Pederson, et al.,

2010). On the other hand, gender particularly interacts with socio-

economic circumstances that are manifest in women's lower levels of

income across the lifespan, and in relatively subordinate positions of power

and lower levels of decision-making, whether in political arenas,

workplaces or within families. (Whitehead and Diderichsen, 2007)

According to Wellstead (2011), it has been noted that men do not

 31

usually seek health related information due to unwillingness and lack

of motivation both in daily life and in stressful life events. Men tend

to be unmindful of sources of health-related information and have

inadequate competency to search for them because of either pure

ignorance or reluctance, and accordingly low motivation, of seeking out

what they do know to be available. As stated by Ostlin, et al. (2007),

health promotion however can be more effective when it is addressed

to the family as a whole and to the relationships between males and

females of all ages. Health promotion together with disease prevention

needs to address these differences between women and men, boys

and girls in an equitable manner in order to be effective (Ostlin, et al.,

2007). According to Verdonk (2010), men may lack the knowledge to

identify and prevent health problems which influences help seeking and

they may actually be aware of health issues and of their bodily

experiences, but feel uncomfortable when they feel vulnerable.

Sources of Information

The very influential part of mass media in information dissemination

has been known to influence health promotion and health behaviors of its

proponents. This is seen on the wide use of mass media, such as television,

radio, and the Internet in the health campaigns of the Department of

Health. A variety of sources of information are considered, from primary

 32

health care providers to traditional mass media. While online health

information resources lead an increasing following, though physicians are

still considered the most trustworthy sources, traditional mass media such as

magazine and newspapers have a declining usage since most people

nowadays refer to get information from the Internet (Geana, et al., 2012).

According to Lawson, et al. (2011), an individuals trust in various sources of

information and media for information dissemination plays a significant role

in determining the effectiveness of any health promotion. The Internet has

become one of the most preferred source of health information, yet, it is

not highly trusted. Additionally, trust towards sources of health information

increases compliance to medical advices and health teachings. In terms

of health information sources (HIS), trust is defined as message received is

true and reliable and that the communicator demonstrates competence

and honesty in conveying accurate objective, and complete information.

Lastly, he concludes that trust in health information sources (HIS) varies

according to age, employment status, level of education, income, sex and

ethnic group.

Another study suggests that the most used source of health

information is a medical setting succeeded by media technology such as

the Internet and television. But when illness occurs, media becomes the

primary source of information followed by medical setting (Britigan, et al.,

2009). As the effectiveness of health promotion is geared towards the

 33

improvement of health through usage of effective health communication,

it is important to assess the health behavior and communication channels

that an individual makes use by determining sources of information and

assessing health literacy level (Britigan, et al., 2009). Identifying depended

sources of information helps the implementer of health programs to

hypothesize assumptions that will better facilitate in proposing possible

interventions. This establishes a firmer framework for proposed plans of

action and could lead to an increase in the effectivity in meeting the needs

of the community. On the other hand, imparting detailed and culturally

significant health information to the marginalized and minority sectors of

the population has helped improve both health behaviors and outcomes

(Geana, et al., 2012). Moreover, the interaction with health are together

passive and active. It is both passive and active in a way that campaigns

regarding health promotion and disease prevention aims convince passive

audiences into becoming active proponents of the health information and

to take an action into modifying their health behaviors. Individuals who

identify their health necessities usually initiate health-seeking behaviors.

Hence, a combination of all these factors influences the overall

health promotional activities in an individual and in a community. This

paper will assess the relationship among age, economic status,

educational attainment, family structure, gender, social participation, and

 34

sources of information, and a community perception on the effectiveness

of health promotion activities implemented.