Health in Comminities

# 2008 University of South Africa All rights reserved Printed and published by the University of South Africa Muckleneuk, Pretoria CMH2602/1/2009 ±2011 98316532 (iii) __________________________________ __________________________________ Contents WELCOME AND INTRODUCTION (vii) PART 1: THEORETICAL FOUNDATIONS IN COMMUNITY HEALTH 1 LEARNING UNIT 1: 2 1. 1 1. 2 1. 3 1. 4 1. 5 1. 6 1. 7 1. 8 1. 9 CONCEPTS AND THEORIES/MODELS IN COMMUNITY HEALTH Introduction Theoretical thinking as a language Choosing a theory/model to apply to community health The dimensions model of community health nursing Orem's self-care deficit theory of nursingNeuman's systems model/theory Pender's health promotion model Gordon's functional health pattern framework Conclusion 2 2 3 4 5 8 9 10 11 PART 2: THE INDIVIDUAL AND FAMILY AS CLIENT 13 LEARNING UNIT 2: 14 2. 1 2. 2 2. 3 2. 4 2. 5 2. 6 2. 7 2. 8 2. 9 2. 10 Introduction Defining the concept of family Structure of the family Types of families Stages of family d evelopment The family as social system Cultural values in the family Family functions Roles of the family Conclusion LEARNING UNIT 3: 3. 1 3. 2 3. 3 3. 4 3. 5 3. 6 3. 7 3. 8 3. 9 3. 10 3. 11 THE FAMILY AS CLIENT ASSESSING FAMILY HEALTH IntroductionAssessment of the family The biophysical dimension The psychological considerations The physical environmental considerations The socio-cultural dimension The behavioural considerations The health system considerations Diagnostic reasoning and the family as a client Planning, implementation and evaluation Conclusion 14 14 15 16 17 19 20 21 21 21 23 23 23 25 25 27 28 30 31 31 31 32 (iv) LEARNING UNIT 4: INFANTS FROM BIRTH TO 18 MONTHS 4. 1 Introduction 4. 2 Definition of child health 4. 3 Growth and development during infancy 4. 4 Developmental tasks 4. 5 Infant nutrition 4. 6 Cognitive-perceptual patterns . 7 Child abuse 4. 8 Stress in infancy 4. 9 Pathological processes 4. 10 Immunisation 4. 11 Conclusion 34 34 34 34 35 36 37 37 38 38 38 41 LEARNING UNIT 5: THE TODDLER (18 ±36 MONTHS) 5. 1 Introduction 5. 2 Age and physical changes 5. 3 Nutrition in toddlers 5. 4 Elimination and exercise patterns 5. 5 Sleep and rest pattern 5. 6 Cognitive-perceptual pattern 5. 7 Self-perception-self-concept pattern, roles-relationships pattern, child abuse, sexuality-reproductive pattern, coping with stress, and values and beliefs 5. 8 Pathological processes 5. 9 Social processes 5. 10 Conclusion 43 43 43 44 44 44 45LEARNING UNIT 6: THE PRE-SCHOOL CHILD 6. 1 Introduction 6. 2 Age and physical changes 6. 3 Cognitive-perceptual patterns 6. 4 Self-perception-self-concept pattern, roles-relationships pattern, sexuality-reproductive pattern, coping-stress pattern and values-beliefs pattern 6. 5 Pathological processes 6. 6 Social processes 6. 7 Conclusion 48 48 48 49 LEARNING UNIT 7: THE SCHOOL-AGE CHILD 7. 1 Introduction 7. 2 Age and physical changes 7. 3 Cognitive-perceptual pattern 7. 4 Self-perception-self-concept pattern, roles-rel ationships pattern, sexuality-reproductive pattern, coping-stress pattern and values-beliefs pattern 7. Pathological processes and social processes 7. 6 Conclusion 52 52 52 53 LEARNING UNIT 8: THE ADOLESCENT 8. 1 Introduction 8. 2 Age and physical changes: Gordon's functional health patterns 8. 3 Gordon's functional health patterns in adolescents 8. 4 Pathological processes in the adolescent 8. 5 Social processes 8. 6 Conclusion 56 56 56 57 58 59 59 45 46 46 46 49 50 50 51 54 55 55 (v) LEARNING UNIT 9: GENDER HEALTH 9. 1 9. 2 9. 3 9. 4 9. 5 9. 6 9. 7 Introduction The status of women Women's health status The lesbian/gay, bisexual and transgender (LGBT) client Men's health statusThe epidemiology of health for gay, bisexual and transgender men Conclusion LEARNING UNIT 10: CARE OF THE CLIENT IN THE WORK SETTING 10. 1 10. 2 10. 3 10. 4 10. 5 Introduction The objectives of occupational health The occupational health nurse's scope of practice Nursing care of working populations Conclusion LEARNING UNIT 11: THE OLDER ADULT 11. 1 11. 2 11. 3 11. 4 11. 5 11. 6 11. 7 11. 8 11. 9 11. 10 11. 11 11. 12 11. 13 11. 14 11. 15 11. 16 Introduction Age and physical changes Goals of health promotion Pattern of health perception-health management Nutritional metabolic patternElimination pattern Activity-exercise pattern Sleep-rest pattern Cognitive-perceptual pattern Self-perception-self-concept pattern Roles-relationships pattern Sexuality-reproductive pattern Coping-stress tolerance pattern and values-beliefs pattern Pathological processes Social processes Conclusion 60 60 61 62 63 63 64 64 65 65 66 66 66 67 68 68 69 70 70 70 70 70 70 71 71 71 71 71 71 72 72 PART 3: THE COMMUNITY AS CLIENT 75 LEARNING UNIT 12: HEALTH PROMOTION IN THE COMMUNITY 76 12. 1 12. 2 12. 3 12. 4 12. 5 12. 6 12. 7 12. 8 12. 9 12. 10 12. 11 12. 12 Introduction Definition of a communityDefining the term community health The community as a client Goals of community-oriented practice Strategies for improving community health Community partnerships Community-focused nursing process Planning Implementation Evaluation Conclusion 76 76 77 77 77 79 79 79 80 81 83 83 (vi) LEARNING UNIT 13: INTERVENTIONS FOR HEALTH PROMOTION IN THE FAMILY 13. 1 13. 2 13. 3 13. 4 13. 5 13. 6 13. 7 13. 8 13. 9 Introduction Definitions of health promotion Interventions for health promotion The purpose of health education The health educator Principles for health education Implementation of the educational planEvaluation of the educational process Conclusion LEARNING UNIT 14: ISSUES IN COMMUNITY HEALTH 14. 1 14. 2 14. 3 14. 4 14. 5 14. 6 14. 7 14. 8 Introduction Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (Aids) Tuberculosis (TB) Poverty Homelessness Violence Community resources Conclusion 84 84 84 85 85 86 88 89 89 90 92 92 92 93 94 94 95 95 97 BIBLIOGRAPHY 98 ANNEXURE A: FEEDBACK FOR SCENARIO IN LEARNING UNIT 3 ? LEARNING UNITS 4 ±12 99 ANNEXURE B: FACTS ABOUT IMMUNISATION 106 ANNEXUR E C: THE REVISED EXPANDED PROGRAMME ON IMMUNISATION IN SOUTH AFRICA (EPI-SA) SCHEDULE 08 ANNEXURE D: PLANS TO ADD TWO NEW VACCINES TO PREVENT PNEUMONIA AND DIARRHOEA IN BABIES 110 ANNEXURE E: PRIVATE VACCINES SCHEDULE 111 (vii) Welcome and ____________________________ introduction ____________________________ Welcome to this second-level module on health in communities. You will learn about the concepts and theories/models involved in community health to equip you with a theoretical foundation for this module. The aim of this module is to equip you with knowledge about the life span of the individual in order to give you skills to work with families in the community.You will also gain a holistic approach towards critical issues in the community. You should grow and develop into a competent and skilful practitioner who can identify needs and problems relating to family health and respond to them in an innovative way. Working through this module will enrich your life not only professi onally, but also personally. The nature of this study guide This study guide has been designed in an interactive way with the aim of guiding you through two prescribed books. As you work through this study guide you should integrate the information in the study guide with the information in your prescribed books.The Internet has a wealth of information and you are advised to use the Internet as often as possible to broaden your knowledge on certain topics. Prescribed books You are expected to purchase the following prescribed books for this module: Clark, MJ. 2008. Community health nursing: advocacy for population health. 5th edition. Englewood Cliffs, NJ: Prentice-Hall. Edelman, CL & Mandle, CL. 2006. Health promotion through the lifespan. 5th edition. St Louis: Mosby. Edelman and Mandle (2006) has very valuable information on health promotion and covers the entire life span, from birth to death.In addition to your study guide, this book is very important: you will find a wealth of information. Clark (2008) is a book on community health nursing that emphasises the dimensions model of community health nursing right through. This is a very valuable model which will help you to gain a holistic and systematic approach towards the individual, family and community. (viii) The information in these two books is complementary. Together with the study guide it will help you to gain the knowledge and skills you will need to supply health care to individuals, families and communities.Activities The activities are planned to either reinforce content, to guide you to tackle upcoming content, or to motivate you to think about issues. You will note that in part 2 of the study guide there is only one activity at the end of each learning unit: here we want you to apply the dimensions model of community health to a member of the family. Feedback on all these activities will be given in annexure A. This CMH2602 module runs parallel with the practice module for Community Health, CMH2126. The theory cannot be separated from the practice. IconsYou will find a series of icons in the text to guide you as you progress with your studies. Activity When you see this icon, you will know that you must complete an activity. We may ask you to read a specific section in the prescribed literature, apply given information, think about topics that have not been introduced, find your own information or ask other people for information. Please read the instructions carefully. Assessment criteria This icon indicates the questions that you can use to assess your own understanding of the work. These questions are adapted from the outcomes.You are told what you should do to prove that you have met the learning outcomes. Prescribed reading When you see this icon, study or read the prescribed book as indicated, before continuing with the next section. Learning outcome This icon tells you how you will benefit in the field of practice if you know the content of the specific learning unit. The outcomes tell you what you will be able to do after you have studied the work. h Feedback This icon tells you what was expected from you when you did the activity. It will not necessarily give you all the facts but will give you guidelines on how to answer the question.Not all of the activities will have feedback because many of the answers are given in your prescribed books. (ix) Conclusion This module is designed to enable you to work with families in the community. It is based on the needs and problems of the family. It covers individuals who are part of the family and the family as part of the community. After completion of this module, together with the practice module, you will be able to take responsibility for practising as an independent community nurse in any community setting. PART 1 THEORETICAL FOUNDATIONS IN COMMUNITY HEALTH 2 Learning unit 1Concepts and theories/ models in community health Outcomes Since theories/models provide you with the knowledge you nee d to practise community health in a scientific way, it is essential for you to be familiar with the various theories/models in the field to be able to apply them to community health. When you have worked through this learning unit you will be able to: * * * * 1. 1 describe various concepts in theoretical thinking explain selected theories/models in detail describe the key concepts and themes of the selected theories/models apply the theories/models to community healthIntroduction While we will discuss theories/models in general in this learning unit, we will also deal with several selected theories in more depth in order to indicate how they can be applied to community health. It is currently accepted that theories form the basis of community health. Since theories provide us with the knowledge we need to practise community health in a scientific way, it is essential for the community nurse to be familiar with the various theories/models in the field and to be able to apply them to community health. 1. 2 Theoretical thinking as a languageThe terms theory, model, conceptual framework, conceptual model are often used synonymously in literature. The literature reflects various conflicting opinions about the terms, their usage and meaning. According to Polit and Beck (2008:141) a conceptual model or a conceptual framework represents a more informal mechanism for organising and discussing phenomena or concepts, while theories are more formal in nature. Conceptual theories, frameworks and models are composed of concepts or constructs. These concepts or constructs are interdependent because they systematically demonstrate the relationship between variables.A model is a symbolic representation of concepts or variables with an interrelationship. A phenomenon is the abstract concept under study, often 3 used by qualitative researchers, while a concept is a description of the objects or events that form the basis of a theory. Both models and theories can describe and pre dict the relationship between phenomena. Models and theories are terms that are often used interchangeably in literature. The term theory is often used to refer to the subject content that student nurses must be taught in the lecture room to acquire the information they need to perform the nursing tasks in practice.Researchers such as Polit and Beck (2008:768) define theory as â€Å"an abstract generalisation that presents a systematic explanation about the relationships among phenomena†. Theories include principles for explaining, predicting and controlling phenomena. In all disciplines theories serve the same purpose. This purpose is to make scientific findings meaningful, and to make it possible to generalise. A theory is composed of concepts and constructs that are systematically related and that are also goal-oriented (Stanhope & Lancaster 2006:196). Types of traditional theories include grand theories and middle-range theories.Grand theories describe and explain large s egments of the human experience which are very broad. Middle-range theories explain more specific phenomena such as stress, self-care, health promotion and infant attachment. Metatheory is a term used to label theory about the theoretical process and theory development (Polit & Beck 2008:141). Metaparadigm refers to the main concepts that identify the phenomena or ideas of interest to a discipline, in this case the discipline of nursing. They provide the boundaries for the subject matter of the discipline.The metaparadigm concepts for nursing include person, environment, health and nursing (Clark 2008:67). However, current literature suggests that a four-concept metaparadigm for the discipline of nursing is too limited and suggests additional concepts such as transitions, interaction, nursing process, nursing therapeutics, self-care, adaptation, interpersonal relationships, goal attainment, caring, energy fields, human becoming and other concepts. The best-known and most used concep ts are however the first four: person, environment, health and nursing. 1. 3 Choosing a theory/model to apply to community ealth Choosing a suitable theory or model is not always an easy task ? especially when most theories are geared towards the care of individuals and were never designed to apply to groups or communities. The theory or model that is chosen must be flexible enough to be adapted to the community health situation and its aim must be to provide guidance for those who practise community health. The importance of the family or community network and the social network must both be clearly reflected, and the theory or model must be realistic and simple enough to understand and apply.In addition, the theory/model should harmonise with the community nurse's views about the individual, the environment, personal health and community health. You may find that the theory that is chosen may not always fulfil all your expectations and that it may also not be applicable to all cir cumstances. You may often be required to make adjustments or to develop your own personal model on the basis of existing theories. 4 Activity Explain why community health nursing should be based on a model or theory. h Feedback You should have considered the following points: * * * * * 1. 4A systematic approach is needed. Theories/models assist community nurses to evaluate health status and to plan, implement and evaluate effective nursing care. The model/theory used directs attention to relevant aspects of the client situation and to appropriate interventions. Epidemiologic models help in examining factors that influence health and illness. Nursing models suggest interventions to protect, improve and restore health. The dimensions model of community health nursing Clark's (2008:69) dimensions model of community health nursing is one of the few models designed for community health.This model is described in detail in your prescribed book (Clark 2008) and will therefore only be summa rised here. This model is a revision of the previously titled Epidemiologic Prevention Process Model. The dimensions model incorporates the nursing process and the levels of prevention as well as an epidemiologic perspective on the factors influencing health and illness. The dimensions model consists of three elements: the dimensions of health, the dimensions of health care and the dimensions of nursing. The dimensions of health include: * * * * * * the the the the the he biophysical dimension psychological dimension physical environmental dimension socio-cultural dimension behavioural dimension health system dimension The dimensions of health care include: * * * primary prevention secondary prevention tertiary prevention The dimensions of nursing include: * * * * cognitive dimension interpersonal dimension ethical dimension skills dimension 5 * * process dimension reflective dimension You should study this model to enable you to assess the health status of individuals, families or communities and to guide your nursing interventions.Prescribed book Study chapter 4 in Clark (2008, or later editions), on the dimensions model of community health nursing. Activity (1) Name the three elements of the dimensions model of community health nursing. (2) List the dimensions included in each element. (3) Give an example related to the dimensions in each element that addresses the health of a population group. 1. 5 Orem's self-care deficit theory of nursing Orem proposes a general theory of nursing which she calls the theory of self-care deficit. Orem's theory focuses on people's ability to practise self-care.The dominant theme of her philosophy of health is that people should be empowered and encouraged to practise their own self-care by means of their own efforts or with the help of significant others. Orem's self-care deficit theory of nursing consists of three interrelated theories: the theory of selfcare, the theory of self-care deficit and the theory of nursing syste ms. This theory is consistent with community health, based on the following premises: * * * Individuals and groups must accept responsibility for their own health and consequently care for themselves.The community nurse should provide the necessary training and support that will enable individuals or communities to do this. The community nurse should intervene only when a deficit or need arises in the selfcare framework. The World Health Organization (WHO) also strongly emphasises that self-care and selfresponsibility play an important role in achieving the goal of optimal health. 1. 5. 1 Theory of self-care In order to understand the theory of self-care, one must first understand the concepts of self-care, self-care agency, basic conditioning factors and therapeutic self-care demand.Self-care include those activities and decisions which a person undertakes in order to maintain life, health and well-being. These activities are acquired by learning, and they contribute to the mainten ance of human development and functioning. 6 Self-care agency refers to the ability of a person to exercise self-care in daily life. The ability to care for oneself is affected by basic conditioning factors: age, gender, developmental state, health state, socio-cultural factors, health care system factors, family system factors, patterns of living, environmental factors and resource adequacy and availability.Therapeutic self-care demand is the sum total of the measures which are called for at a particular time for the promotion and maintenance of health, development and general well-being. In the case of self-care, purposeful actions and steps are taken. Although selfcare should benefit an individual's health, his or her perception of self-care may not always promote good health, as is the case with a person who smokes in the belief that it reduces his or her stress levels. Self-care requisites refer to the reasons for which self-care is undertaken.The three categories of self-care requisites include universal, developmental, and health deviation. Universal self-care requirements include those processes which are essential for the normal functioning and maintenance of health and life, such as the following processes: * * * * * * having and maintaining sufficient fresh air/oxygen, water and food intake finding the balance between exercise and rest, and having social interaction avoiding dangers and obstacles that can compromise human functioning and well-being promoting human functioning and development in a group roviding care associated with elimination processes and personal hygiene keeping a balance between being alone and social interaction Developmental self-care requisites are divided into two categories: * * The first concerns the maintenance of those conditions which are favourable to a person's normal growth and development. The second is concerned with the prevention of those negative conditions, forces, influences and factors which can hinder and ob struct normal development. Awareness of such requirements reflects a person's level of development and his or her general capacity for self-care.Health deviation self-care is necessary for preventing illness, injury and retardation. It involves taking whatever steps are necessary for preventing or treating illness or disability effectively. The requisites for health deviation self-care include: * * * * * * seeking and securing appropriate medical assistance being conscious of and attending to the effects and results of pathologic conditions conducting medically prescribed diagnostic, therapeutic and rehabilitative measures attending to or controlling the negative effects of prescribed medical treatment effectively ccepting oneself as being in a specific state of health and in need of particular forms of health care developing and sustaining health-optimising lifestyles 1. 5. 2 Theory of self-care deficit The theory of self-care deficit forms the core of Orem's general theory of nurs ing. According to this theory, an adult who is unable to practise self-care requires dependent care; this refers to an adult who does not have the ability to meet his or her own needs or 7 only has partial ability to take care of himself or herself. This may happen or example when a person falls ill and this illness generates new demands, requiring the implementation of complex measures and specialised knowledge. Orem cites the following examples of support or help which can be offered in such circumstances: * * * * * acting on behalf of a person or undertaking certain activities for this person until he or she can once again care for himself or herself more independently providing guidance and direction in the new situation providing physical and psychological support creating and maintaining a new environment which supports personal development providing appropriate relevant instructionsA self-care deficit occurs where there is a discrepancy between the need for self-care and the ability to manage this self-care. In such circumstances the individual needs to be assisted and educated to administer whatever self-care he or she may need. In short, a self-care deficit occurs when a person is unable to practise appropriate self-care on his or her own or without external assistance. 1. 5. 3 Theory of nursing systems The theory of nursing systems consists of two components: the nursing agency, and nursing systems.The nursing agency refers to the characteristics of people who are trained as nurses that enable them to act, to know and to help others meet their therapeutic self-care demands by developing their own self-care agency. Nursing systems are created when nurses use their knowledge and skills to plan and implement nursing care where there are deficiencies in self-care. The aim of intervention by the nurse is to compensate for the self-care activities which the individual, family or community cannot maintain at an optimal level. These compensatory activities a re classified into: * * *The wholly compensatory system where the community nurse becomes the self-care agent to compensate for the client's inability to maintain his or her own self-care. The community nurse cares for and supports the client wholly. For example, this would happen where a person is in a coma and cannot consciously look after himself or herself. The partly compensatory system where the client is capable of certain self-care measures but only to a limited degree. The aim of health care intervention is to lend support and carry out certain activities on behalf of the client until he or she is able to resume them again.The supportive/educational system where the client can manage self-care but needs the support and guidance of the community nurse. The community nurse regulates the selfcare agent's performance and development so that he or she can function more independently (George 2002:126). Activity (1) Describe the different components of the self-care deficit theory of nursing. 8 (2) Explain what is meant by a self-care deficit. (3) A mother and her two-month-old baby visit your clinic. The baby is not gaining sufficient weight and the mother appears tired and stressed. Identify the self-care deficit in this particular case. h FeedbackYou should have covered the following points in your answer: (1) The mother is not able to care for herself with the demands of a new baby. (2) She therefore needs health education and advice on how to handle the situation. 1. 6 Neuman's systems model/theory According to Neuman, her personal philosophy of helping each other live contributed to development of the holistic systems perspective of the her systems model. Neuman's theory is based on: * * the two main components of stress and the individual or his or her body's reaction to that stress the community's reaction to certain stress factors (stressors) in the environmentNeuman based her systems model on a general systems theory and regards the client as an op en system which reacts to stressors in the environment. Stressors may be intra-personal, inter-personal or extra-personal. Intra-personal stressors occur within the client system boundary and correlate with the internal environment (eg feelings such as anxiety or anger within a person). Inter-personal stressors occur outside the client system boundary and have an impact on the system (eg stimuli between people such as role expectations). Extrapersonal stressors also occur outside the ystem boundaries, but are further away from the system than the inter-personal stressors (eg work or finances). Environment includes all the external and internal influences that surround the client system. The external environment exists outside the client system and the internal environment exists within the client system: * * * * The client system contains a basic structure or core construct (individual, family community) which is protected by lines of resistance. The basic structure includes system variables such as physiological, psychological, socio-cultural, developmental and spiritual variables.Penetration of the basic structure results in death. The normal level of health is identified as the normal line of defence which refers to the client's usual state of wellness and represents stability over time. When the normal line of defence is invaded or penetrated, the client system reacts, for example with symptoms of illness. The flexible line of defence prevents stressors from invading the system and is a dynamic state of wellness that changes over time. It can for example be altered in a relatively short period of time by factors such as inadequate sleep or food.The lines of resistance protect the basic structure and become activated when the normal line of defence is penetrated by environmental stressors. If sufficient energy is 9 * available, the normal line of defence is restored; but if the lines of resistance are not effective, death may follow. Reconstitution involves stabilisation of the system and movement backwards to the normal line of defence. Health care intervention takes place in the prevention modalities, that is the primary, secondary and tertiary levels of prevention. (Clark (2008:67)) Prescribed reading Study Neuman's model in Clark (2008, or later editions).Activity (1) (2) (3) (4) Explain what Neuman means by client variables. Describe the concepts of line of resistance and normal line of defence. Describe Neuman's view on health. Define the term stressor. This theory/model can also be applied to community health because a preventive approach is followed and because of its flexibility. 1. 7 Pender's health promotion model Pender described a model which is applicable to community health in particular. This model is based on principles of health promotion and, to a certain extent, corresponds with the Health Belief Model.Pender's health promotion model comprises three basic concepts, namely individual perceptions, variables which can influence healthy behaviour and the probability that actions will be taken to promote health: * * * Individual perceptions include factors such as how important health is seen to be, perceptions on control and effectiveness, the definition of health, the state of health, the advantages inherent in preventive measures, and possible obstacles. Variables include factors such as demography, income, literacy, culture and family health patterns.The probability that action will take place includes matters such as ? ? ? ? how highly the person rates or values action any previous experience with health personnel the availability and affordability of preventive services the threat that the condition holds for the individual or family Prescribed reading Study Clark (2008, or later editions), the section on Pender's health promotion model. 10 Activity (1) Name the variables which can affect the preventive actions that a family and a community may take. (2) Write short notes on individual perce ptions and indicate how they can influence health-promoting actions.Pender's model is applicable to community health because the promotion of health is taken as the starting point and factors which influence the measures for promoting health are defined and emphasised. The model can guide and lead the community health nurse in promoting health. On the grounds of the variables and perceptions that are identified, she/he can make decisions on the degree of intervention that is necessary. For example a degree of knowledge and motivation may seem necessary to allow the community to take certain promotive actions, or to decide whether or not the available options are acceptable.The community health nurse's task could then be to give the community the necessary information or to influence them to modify perceptions that are detrimental to their health. Depending on the specific problems or behaviour that deviates from a healthy living pattern, the culture of the community, the level of li teracy and so on, the community health nurse can plan a programme or develop his or her own model based on Pender's promotive model. (Clark 2008:257) 1. 8 Gordon's functional health pattern frameworkHistorically, conceptual models in nursing have employed Gordon's health-related behaviours and developed them into an assessment model with 11 functional health patterns. Your prescribed book (Edelman & Mandle 2006) uses this framework throughout in the assessment of each developmental stage. The 11 functional health patterns include: * * * * * * * * * * * pattern of health perception-health management nutritional-metabolic pattern elimination pattern activity-exercise pattern sleep-rest pattern cognitive-perceptual pattern self-perception-self-concept pattern roles-relationships pattern sexuality-reproductive pattern oping-stress tolerance pattern values-beliefs pattern (Edelman & Mandle 2006:131) Read Edelman and Mandle (2006 or later edition), the section on functional health pattern s: assessment of the individual. 11 1. 9 Conclusion Various theories/models applicable to community health were discussed in this learning unit. It is very important that you as a community health nurse have an understanding of these theories/models and how they could be applied to community health. Assessment criteria (1) Define the following terms: ? ? ? ? ? theory model conceptual framework phenomenon concept (2) (3) (4) (5) 6) Define the different constructs of Orem's theory. Explain the defence mechanism in Neuman's theory. Describe the principles on which Pender's promotion of health model are based. Name the three elements of the dimensions model of community health nursing. Name the dimensions of the dimension of health in the dimensions model of community health nursing. (7) List the functional health patterns in Gordon's functional health pattern framework. Note: Application of selected models/theories will be assessed in part 2 of the study guide. 12 PART 2 THE INDIVIDUAL AND FAMILY AS CLIENT 14 Learning unit 2The family as client Outcomes When you have worked through this learning unit you will be able to: * * * * * * * 2. 1 describe the concept of family describe the structure of the family describe different family types and their characteristic features describe the stages of family development discuss family functions describe the family as a social system discuss cultural values in the family Introduction The family is the basic social unit in any community. Family members usually share living arrangements, responsibilities, goals, the continuity of generations, and a sense of belonging and affection.How well a family works together and meets any crisis depends on the composition of the family (the structure), the activities or roles performed by family members (the functioning) and how well the family is able to organise itself against potential threats. 2. 2 Describing the concept of family Clark (2008:318) states: â€Å"A family is a compo sed of two or more persons who are joined by bonds of sharing and emotional closeness and who identify themselves as being part of the family. Unlike those of other social systems, family relationships are characterized by intimacy, emotional intensity, and persistence over time. ‘ Santrock (2006:216) states: â€Å"[The family is] a social system, a constellation of subsystems defined in terms of generation, gender and role. Divisions of labour among family members define particular sub-units, and attachments define others. Each family member is a participant in several subsystems. Some are dyadic (involving two people) some polyadic (involving more than two people). † Stanhope and Lancaster (2006:322) refer to the following definition: â€Å"A family refers to two or more individuals who depend on one another for emotional, physical, and/or financial support.The members of the family are self-defined. † 15 Activity Ask different members of the multi-disciplinary health team to define family. Analyse the responses for similarities and differences. 2. 3 Structure of the family Family structure is the organised pattern or hierarchy of members that determines how they interact. Components of a family structure include the role of each family member and how they complement each other, the family's value system, communication patterns and power hierarchy. The family structure influences the way that a family functions. Allender & Spradley 2005:526) The genogram shows family information graphically in order to view complex family patterns over a period of time, usually three generations or more. d. 1956 Heart Peg 71 Housewife Al 72 Grocer Sue Housewife John Steelworker d. 1982 Cancer Mark 37 Engineer Jan 36 Housewife Jim 9 Jack 46 Mechanic Mary 16 Pat 41 Waitress Married 1979 Steve 18 Clerk Earl 17 Student Detroit Fig 2. 1 Genogram Source: Allender & Spradley (2005:528) Nan 4 Married 1977 Divorced 1979 Joe 45 Teacher Sam 20 Student Lou 13 Los Ang eles Married 1983 Ann 39 Nurse Pam 11 16 ActivityDraw a genogram of your own family. 2. 4 Types of families There are many family types and a family type may change over time as it is affected by birth, work, death, divorce and the growth of family members. * * * * * * * The nuclear conjugal family. The traditional nuclear family structure consists of a husband, wife and children. Most young people move away from their parents when they marry and form nuclear families (no grandparents, aunts or uncles live in the home). The nuclear family is found in all ethnic and socio-economic groups, and is accepted by most religions.Today the number of nuclear families is declining as a result of the increase in divorce, single parenthood and remarriage, the acceptance of alternative lifestyles, and greater disparity. The extended (multi-generational) family. The extended family includes the nuclear family as well as other family members such as grandmothers, grandfathers, aunts, uncles, cousin s and grandchildren. The advantage of such a family is that it means more people may serve as resources during crises and also provides more role models for behaviour and learning values. The single parent family.Single parent families consist of an adult woman or man and a child or children. Single parent families result from divorce, out-of-wedlock pregnancies, absence or death of a spouse, or adoption by a single person. A health problem in a single parent family is almost always a serious matter, because there is no backup person for childcare when the parent is ill. The blended family. The term blended family refers to a remarriage or a reconstituted family, where a divorced or widowed person with children marries someone who also has children of his or her own.Children of blended families are exposed to different ways of living and also have increased security and resources. They may become more adaptable to new situations. However, rivalry may arise among the children for the attention of a parent or there may be competition with the step-parent for the love of the biological parent. The communal family. The communal family is made up of groups of people who have chosen to live together as an extended family group. Their relationships with each other are motivated by social values or interests rather than by kinship.Because of the number of people present, members may have few set traditional family roles. The values of commune members are often religiously or spiritually based and may be more oriented to freedom and free choice than those of a traditional family structure. The cohabitation family. The cohabiting family consists of two persons who are living together, but remain unmarried. They may be heterosexual or homosexual. Some such relationships are temporary but others are long-lasting. Reasons for cohabitation include the desire for a trial marriage, the increased safety that results from living together and financial factors.The single allianc e family. Many single young adults live together in shared apartments, dormitories or homes for companionship and financial security. Although these relationships are often temporary, they have the same characteristics as cohabitation families. 17 * * The homosexual family. The homosexual family is a form of cohabitation where a same sex couple live together and share a sexual relationship. Such a relationship offers support in times of crisis that is comparable with that offered by a traditional nuclear or cohabitation family. The foster family. Children whose parents are unable to care for them are laced in a foster home by a child protection agency. Foster parents usually receive remuneration for their care. Foster families may also include the parents' own biological or adopted children. Foster care is theoretically temporary until children can be returned to their own parents (Clark 2008:318). Prescribed reading Read Clark (2008, or later edition), types of families. 2. 5 Stage s of family development Stage 1: Beginning family During this first stage of family development, members work to accomplish three specific tasks: * * * to establish a mutually satisfying relationship to learn to relate well to their families of origin f applicable, to engage in reproductive life planning The first stage of family life is a tenuous one, as evidenced by the high rate of divorce or separation of partners at this stage. The time frame for this stage extends from marriage to the birth of the first child. Stage 2: The early child-bearing family The birth or adoption of a first child is usually an exciting yet stressful event in a family. It requires economic and social role changes. The duration of this stage is from the birth or adoption of the first child to 30 months after this date. The following developmental tasks are usually accomplished during this stage: * * * he establishment of a stable family unit the reconciliation of conflict regarding developmental tasks fa cilitating developmental tasks of family members Stage 3: The family with pre-school children A family with pre-school children is a busy family as children at this age demand a great deal of time related to growth and developmental needs and safety: accidents are a major health concern at this stage. The time frame for this stage is when the oldest child is two to five years of age. Developmental tasks during this stage include: * * * integration of second or third child socialisation of children beginning of separation from children 18Stage 4: The family with school-age children Parents of school-age children have the major responsibility of preparing their children to be able to function in a complex world. At the same time they have to maintain their own satisfying marriage relationship ? this can be a difficult time for a family. Many families need the support of tertiary services such as friends, church organisations or counselling. The time frame for the family with school-ag e children is when the oldest child is 6 to 13 years old. Developmental tasks during this stage include: * * * separation from children to a greater degree fostering education and socialisation aintenance of marriage Stage 5: The family with teenage/adolescent children The primary goal for parents with teenagers differs considerably from that of the previous developmental stages. Family ties must now be loosened to allow adolescents more freedom and prepare them for life on their own. Rapid technological advances have increased the gap between generations ? this can make stage 5 a trying time for both parents and children. Violence, accidents, homicide and suicide are the major causes of death in adolescents ? and death rates from HIV are growing. This places a still greater responsibility on the family.The time frame for this stage is when the eldest child is 13 to 20 years of age. Developmental tasks of this stage include the following: * * * maintenance of marriage development of new communication channels maintenance of standards Stage 6: The launching centre family For many parents this stage when children leave to establish their own households is the most difficult. It appears as though the family is breaking up and parental roles change from those of mother and father to guideposts. The parents may experience a loss of self-esteem as they feel themselves replaced by other people.For the first time they may start feeling old and less able to cope with responsibilities. The time frame for this stage is from the time the first child leaves home to the time the last child leaves home. The following developmental tasks should be accomplished during stage 6: * * * * * promotion of independence integration of in-law children restoring of marital relationship developing of outside interests assisting own aging parents Stage 7: The family of middle years At this stage a family returns to a two-partner nuclear family, as before childbearing.Some partners see thi s stage as the prime time of their lives with the opportunity to do things they never had time or finances for, such as travelling and hobbies. Others may experience this time as a period of gradual decline without the constant activity and stimulation of children in the home and may experience the â€Å"empty nest† syndrome. Support people may 19 also not be as plentiful as earlier in the parents' lives. The time frame for this stage is from the time the last child leaves to retirement. Developmental tasks for this stage include: * * * developing leisure activities provision of a healthy environment ustaining a satisfying relationship with children and grandchildren Stage 8: The family in retirement or older age The number of families of retirement age is increasing rapidly, with people living longer as a result of advanced technology, medical research and increasing health consciousness. Family members of this group are, however, more apt to suffer from chronic and disablin g conditions than people in the younger age groups. The time frame for this stage lasts from retirement to death. Developmental tasks include the following (Clark 2008:323): * * * maintaining satisfying living arrangements adjusting to reduced income djusting to loss of spouse Prescribed reading Study Duvall's and Carter and McGoldrick's stages of family development in Clark (2008, or later editions). 2. 6 The family as social system All families share certain characteristics. Every family is a social system with its own cultural values, specific roles, functions and structure and each family moves through recognisable developmental stages. A social system consists of a group of people who share common characteristics and who are mutually dependent. What affects one member affects the whole family, and vice versa. Families have certain features that differ from other social systems: * * * Families last longer than many other social systems. Families are inter-generational social sys tems consisting of three or sometimes four generations. Family systems include both biological and affinal relationships (relationships created by law or interest). Biological aspects of family relationships create links to a larger kin group that are not found in other social systems. A social network support map gives a detailed display of the quality and quantity of social connections. The community nurse can use this to help the family understand its support systems and to form a basis for nursing interventions. 20 Fig 2. Social network support map Source: Allender & Spradley (2005:528) 2. 7 Cultural values in the family The cultural values in a family can have a major influence on how a family views health and health care systems. Each new generation takes on the values of the previous generation, passing traditions and cultures from generation to generation. A family's cultural values and behaviours can either facilitate or impede the promotion of health and prevention of dise ase. Prescribed reading Read Clark (2008, or later editions), the chapter on the cultural context. Activity (1) Apply the four principles of cultural assessment to the family. 2) Discuss culturally competent care. h Feedback Note the following points: 21 (1) You needed to view the culture in the context in which it developed, examine the underlying premise of culturally determined behaviour and the meaning of behaviour in the cultural context. There is a need to recognise intercultural variation. (2) You needed to define cultural competence, consider the characteristics and challenges of cultural competence and the modes of culturally competent care. 2. 8 Family functions Family functions are the activities that a family performs to meet the needs of its members.These needs include basic needs such as food, clothes, housing, emotional support and guidance. All families ? regardless of the type of family ? have in common these basic needs that require a family to function in certain ways to ensure family survival. As the social system changes, the family system has to adapt if it is to meet individual needs and equip its members to participate in the social system. The family is a hierarchical system which is usually built on kinship, power, status and privileged relationships that may be related to age, gender, personality and health. All family functions can be reduced to two basic ones: * *