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FOAP Concept of Vicious Circle of Ill-Health: A basis for Resolving Unhealthy Environmental Practices in Liberian Communities

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International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
FOAP Concept of Vicious Circle of Ill-Health: A
basis for Resolving Unhealthy Environmental
Practices in Liberian Communities
Forkpah Pewee
Chairman, Public Health Department, University of Liberia
forkpahpewee91[at]gmail.com
Abstract: The FOAP Concept of Vicious Circle of Ill-health is an opinion or informative concept that is intended to change the
perspective of community dwellers in Liberia on health and prepare them to embrace the new ideas of adapting healthy environmental
practices to prevent and/or control the vicious circle of ill-health among them. Most Liberians have suffered untimely death from
preventable diseases acquired from the environment. The need to identify solutions to such undesirable events cannot be
overemphasized. Liberians, on many occasions, interact with the environment in an unhealthy manner. An observation has been done
over the years relative to understanding the behaviours of community dwellers in Liberia towards situations in the environment. The
mathematical method that was used to calculate the prevalence of vicious circle of ill-health was thoroughly brainstormed to fit the
existing health indicators used in the concept relative to the established formula for calculating prevalence rate. The concept serves as a
basis for further research initiatives to test the applicability of the concept in Liberian communities. A survey tool was developed to
collect data on vicious circle of ill-health. Constructs from Socio Ecological Model (SEM) and Health Belief Model (HBM) were
highlighted to provide solutions to vicious circle of ill-health by effectively utilizing their applications and concepts. FOAP Concept of
Vicious Circle of Ill-health has been developed to help citizens of Liberia improve their overall health and well-being by adapting its
ideas, concepts and practices. It is meant to assist them avoid unhealthy environmental practices both abstract and visible - for the
prevention and/or control of vicious circle of ill-health or preventable diseases.
Keywords: Vicious Circle of Ill-health, Unhealthy Environment, Prevalence of Vicious Circle of Ill-health, Health Indicator, and Ill-
health
1. Definitions of Key Terms
From the Merriam-Webster Dictionary, Vicious Circle is a
chain of events in which the response of one difficulty
creates a new problem that aggravates the original difficulty.
Ill-health is a condition that characterizes poor health.
With such existing knowledge on vicious circle, ‘Vicious
Circle of Ill-health’ could be defined as an undesirable
chain of events that successfully build on and reinforce one
another in an unhealthy environment to cause preventable
health issues/diseases.
An ‘Unhealthy environment’ is an environment that
threatens the health and safety of inhabitants, that
undermines social gatherings, and that is abusive, violent
and full of conflict.[6]
Preventable health issues/diseases are health problems that
can be prevented by optimizing the use of protective factors
of health indicators.
Health indicators are direct measurable variables that
reflect the health status of a population.[5]
Protective factors are factors that reduce the likelihood of
the occurrence of a disease or adverse health problem.[8]
2. Introduction
This opinion or informative paper focuses on detailing
factors responsible for the existence of vicious circle of ill-
health in Liberia while providing public health and
mathematical models that can be effectively utilized in
resolving the problem of vicious circle of ill-health. There
are many components both abstract and visible aspects of
the environment that are manipulated by human behaviors to
cause vicious circle of ill-health. This paper is providing a
basis for further extensive researches that would unearth
how each of those environmental components leads to
vicious circle of ill-health.
The environment humans live in nowadays is so complex in
form that the needs of one person or family cannot be
prioritized over the felt needs of another person or their
neighbor.[6] This might lead to disparity issues which could
nurture future unresolved hard feelings or conflicts that
could trigger the development of unintended health
complications. With that in mind, it remains the ultimate
duty and responsibility of public health professionals to find
possible solutions that would bridge such gaps for everyone,
regardless of color, political, economic, religious or cultural
backgrounds, to live healthy and well. It does not make
sense to me for people to get quality treatment for
preventable diseases and yet return to the same unhealthy
practices that gave them such diseases. It is an unacceptable
and reversible practice.
In reality, those who live in unhealthy environment in
Liberian communities are the greatest threats to individuals
living in healthy environment. Just as criminals are the
greatest threats to peaceful residents of a community, that is
the same way people experiencing vicious circle of ill-health
are major problems for people living in healthy
environment. It is not their wish to live in unhealthy
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
108
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
environment, anyways. Their current state of living might be
due to the lack of human capital to address their pressing
needs. However, taking good care of one‟s environment
does not require having millions of dollars; it is just a matter
of developing that cleanliness mindset to always do the
honorable thing of making your environment to look decent.
If everyone practiced to take good care of their environment
from intrapersonal to community level, it will be an
advantage for all community dwellers. Living in a clean and
protective environment is a matter of choice. But that choice
can become a matter of must when your uncleanliness
becomes a threat to your neighbors. The environment is a
natural protector for humans to take good care of. Why do
humans take good care of dogs? That is because they value
the protective services the dogs provide each day. That is
how humans must, at all times, value the protective
atmosphere the environment provides for us.
The unhealthy environment responds to humans by releasing
disease-causing microorganisms or substances that get them
sick. When they get sick from a disease the environment
feeds them with, they rush to clinics or hospitals for
treatment of a preventable disease. When they get quality
treatment from the clinics or hospital, they return to the
same unhealthy environment that got them sick from the
onset. This is a very bad practice by most communities in
Liberia, which has to be curtailed if the desire to improve
the health status of all citizens remains a priority.
3. Illustration of the Vicious Circle of Ill-
Health
I describe the patterns of health and disease in Liberia as
Vicious Circle of Ill-Health” as illustrated below:
Figure 1: Illustration of FOAP Concept of Vicious Circle of
Ill-health
The illustration of „FOAP Concept of Vicious Cycle of Ill-
Health‟ indicates that majority of the population in Liberia
believes that they are healthy, even with the presence of
their homes in filthy and unhealthy environment. How
pathetic that is. The concept illustrates that ill-health comes
about as a result of those four environmental related
components which engulf it. This concept further indicates
that most Liberians live in filthy environments with high
level of unhygienic, unhealthy, and improper sanitation
practices. They believe it is a normal thing since it has been
like that for years. They feel healthy in an unhealthy
environment. When they get a disease that makes them sick
from the unhealthy environment, they go to
hospital/clinic/community drug store to get treatment for a
preventable disease. After they receive the treatment, they
return home to the same conditions in the unhealthy
environment that made them ill in the first place. And no
one finds that disturbing?
Image 1: Dumpsite in Paynesville City Courtesy of
Intellectual Class of Paynesville
Image 2: Dumpsite in Paynesville City PC: Intellectual
Class of Paynesville
Image 3: Dumpsite in Paynesville City PC: Intellectual
Class of Paynesville
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
109
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Image 4: Dumpsite in Paynesville City PC: Intellectual
Class of Paynesville
Image 5: Dumpsite in Paynesville City PC: Intellectual
Class of Paynesville
The environment we live in plays an important role in
maintaining the health status of its inhabitants. It contributes
up to 20% towards our health status. On many occasions,
people tend to ignore environmental or lifestyle issues that
heavily contribute to the development of disease or
frequency of death.[1] They focus on quality hospital care
when the fundamental problem is not entirely the best
clinical care. It is outside the hospital and within the minds
of humans. That is one reason why it is a very good practice
to take good care of your environment. This gap can only be
bridged by the implementation of effective and efficient
health education/promotion programs or health fairs that are
geared towards enabling community dwellers to practice
high level personal/community hygiene and proper
sanitation.
We could further measure the vicious circle of ill-health by
considering the Prevalence of Vicious Circle of Ill-health
(PCVI). There are indicators of unhealthy environment that
can be used during health survey when studying health
status of a population.[7]
Health Indicators of Vicious Circle of Ill-health in an
unhealthy environment include but not limited to:
1) Unsafe drinking water (water pollution)
2) Polluted air (air pollution)
3) Poor personal hygiene
4) Poor community hygiene
5) Uncontrollable smoking areas (secondhand smoking)
6) Improper waste disposal (lack of separate trash cans)
7) Open defecation
8) Lack of sanitary toilet/latrine and bathroom
9) Neighborhood occupied with violent, abusive and
conflict-like neighbors,
10) Unhealthy eating patterns
11) Physical inactivity, and
12) Lack of social gatherings/Events
Causal Theory Illustration of Vicious Circle of Ill-Health
Figure 2: Causal Theory Illustration of Vicious Circle of Ill-
health
Prevalence of Vicious Circle of Ill-Health
The Prevalence of Vicious Circle of Ill-health can be
calculated using the mathematical method below:
This mathematical method for the calculation of the
Prevalence of Vicious Circle of Ill-health was brainstormed,
adopted and modified from the existing formula for
calculating prevalence rate. The Prevalence of Vicious
Circle of Ill-health is a determiner of the percentage of
individuals living in an unhealthy environment in a
community or region over a particular period of time.
Prevalence of Vicious Circle of Ill-health could therefore
be defined as the measure of the number of individuals
living in unhealthy environment divided by the total number
of population at risk times 100 percent.
The population at risk is the number of individuals who are
susceptible to (in proximity to) those who are living in
unhealthy environment or experiencing vicious circle of ill-
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
110
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
health. In this instance, at risk population for vicious circle
of ill-health includes both individuals in unhealthy
environment and their closest neighbors (totaling both to be
total population at risk).
It looks at the ratio of individuals living in unhealthy
environment to the total number of individuals susceptible to
those living in unhealthy environment (Ue : Tp) or (Ue / Tp).
As such, it mainly takes into account larger communities in
both rural and urban settings. In furtherance, it also focuses
mainly on two groups of individuals in the environment:
(i)individuals living in an unhealthy environment (ii)
individuals susceptible to (in proximity to) those living in
unhealthy environment.
Work Example 1:
Public health students at University of Liberia conducted a
health survey among residents of Red Light Community and
found that 23,000 persons live in unhealthy environment.
The total number of persons living in Red Light is 46,000.
Calculate the prevalence of vicious circle of ill-health.
Answer:
Data: Ue = 23,000; Tp = 46,000; Pvci= ?
Pvci = Ue / Tp X 100%
= 23,000 / 46,000 X 100%
= 0.5 X 100%
Pvci = 50%
Therefore, the prevalence of vicious circle of ill-health in
Red Light Community is 50%, which means approximately
50% or one-half of the population experiences vicious circle
of ill-health.
Work Example 2:
From a recent survey conducted on Whien Town Municipal
Landfill Site, it was observed that 10, 000 residents were
directly affected by polluted air due to their proximity to the
dumpsite, 8,000 residents drank unsafe drinking water,
15,000 residents practiced poor personal hygiene, and 4,000
residents practiced open defecation. With the total at risk
population of 100,000, calculate the prevalence of vicious
circle of ill-health.
Answer:
Data: Ue1 = 10,000; Ue2 = 8,000; Ue3 = 15,000; Ue4 = 4,000
Tp = 100,000; Pvci= ?
Pvci = Ue1 + Ue2 + Ue3 + Ue4 X 100%
Tp
= 10,000 + 8,000 + 15,000 + 4,000 / 100,000 X 100%
= 37,000 / 100,000 X 100%
=0.37 X 100%
Pvci = 37%
Therefore, the prevalence of vicious circle of ill-health in
Whein Town is 37%, which means approximately 37% of
the population experiences vicious circle of ill-health.
Practice Works
1) You were assigned in Ganta City as a Research Uptake
Coordinator. You and a team of researchers at Ganta
United Methodist Hospital conducted a health survey to
understand the number of persons experiencing vicious
circle of ill-health. Your team found out that 50, 000
residents practiced poor community hygiene, 10,000
residents do business in tobacco smoking areas, 30,000
residents lack sanitary bathroom/toilet, and 4,000
residents have violent and abusive neighbors. What is
the prevalence of the vicious circle of ill-health when
the total at risk population is 150,000?
2) You were hired by Eat Wise Network as Healthy
Lifestyle Consultant. Your duty on the first day of work
was to conduct a health survey on residents of Harbel,
Firestone. You carried out a survey and realized that
5,000 residents practiced unhealthy eating patterns and
6,000 residents do not exercise. Calculate the
prevalence of vicious circle of ill-health when the total
population at risk of vicious circle of ill-health is
20,000.
3) Liberia has fifteen political subdivisions or counties.
Each county has specified number of districts. You are
the Principal Investigator on the research team of a
health NGO situated in Monrovia that conducts
intervention programs on maintaining healthy
environment. The entity decided to expand its
operations to the remaining fourteen counties. You and
your team of researchers conducted a nationwide
survey. The essence of the survey was to be able to have
priority counties to begin the entity‟s sustainable
intervention programs. As a Principal Investigator,
calculate the prevalence of vicious circle of ill-health in
each county with understanding of the 2008 population
census considering the data in the table below and select
the priority counties to begin with orderly:
County Number of persons living in unhealthy
environment
Margibi 140,000
Montserrado 800,000
Sinoe 70,000
Lofa 180,000
Grand Bassa 210,000
Rivercess 60,000
Rivergee 58,000
Grand Gedeh 110,000
Bong 290,000
Nimba 300,000
Grand Cape Mount 100,000
Bomi 60,000
Gbarpolu 69,000
Maryland 125,000
Grand Kru 50,000
Remedy to Vicious Circle of Ill-Health
I am integrating key constructs from the Socio Ecological
Model (SEM) to be able to adequately resolve the issue of
ill-health in our communities. Resolving such requires
utilization of multi-sectorial and multi-level approaches and
maximizing health resources to achieve set goal and
objectives. This will further involve an annual conduct of
health fairs as a medium of health communication for
change of behavior using mass reach, limited reach and
folks media. Such will help in reducing the health disparities
for better health outcomes in diverse populations. The five
key pillars in SEM are being considered here.[3] That ranges
from tackling unhealthy health-seeking behaviors from the
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
111
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
intrapersonal level to the policy formulation and
implementation level.
Unhealthy environmental practices that lead to ill-health
must first be dealt with from the intrapersonal level. This
intrapersonal level incorporates constructs from the Health
Belief Model (HBM) [2] where there is increase in
knowledge on unhealthy environmental practices leading to
ill-health; acceptance of one‟s perceived susceptibility to
vicious circle of ill-health for doing unhealthy
environmental practices; understanding of the perceived
severity of contracting preventable diseases from practices
that lead to ill-health; one‟s perceived benefits of healthy
environmental practices; and increase in self-efficacy level
to begin practicing healthy environmental behaviors.
At the interpersonal level, we look at unhealthy
environmental practices at households among families,
friends and social networks and how they can be sufficiently
handled.
At the organizational/institutional level, we look at the level
of involvement of community-based organizations, schools,
churches, marketers, etc. in conducting health promotion
programs and awareness that would help to resolve the
issues of unhealthy environmental practices that lead to ill-
health.
At the community level, we look at the various existing
community norms concerning the unhealthy practices in the
environment that cause ill-health.
At the public policy level, we look into central and local
government regulations on unhealthy environmental
practices. We also look at how those existing regulations
have been enforced in dealing with unhealthy environmental
practices across various spectra of Liberian communities.
Vicious Circle of Ill-Health Survey Tool
PART I: Demography Profile
1) Age: ________
2) Gender: ( ) MALE ( ) FEMALE (Tick one)
3) Marital status: ( ) Married ( ) Single ( ) Divorced ( ) On
separation (Tick one)
4) Educational level: ( ) Dropped out of school ( ) High
school diploma ( ) Vocational/Technical
diploma/certificate ( ) Associate degree ( ) Bachelor
degree ( ) Master degree ( ) Doctoral degree (Tick one)
5) Monthly family income (LD): ( ) Below 10,000 ( )
10,005 30,000 ( ) 30,005 50,000 ( ) 50,005 70,000
( ) 70,005 90,000 ( ) Above 90,000 (Tick one)
6) Occupation: ( ) Student ( ) Teacher ( ) Politician ( )
Tailor ( ) Clinician ( ) Business person ( )
Driver/Mechanic ( ) Caretaker ( ) Farmer ( )
Carpenter/builder/plumber ( ) Fisherman ( ) Electrician
( ) Public health professional ( ) Accountant/Banker ( )
Police/Soldier/Immigration officer ( ) Other (Specify):
_______________________________
7) a) Do you know what vicious circle of ill-health means?
YES/NO
b) If you underlined YES, state the meaning of it:
_____________________________________________
__________
PART II: Health Indicators (Please put (X) to your best
answer (be honest).
No Statement
Yes
No
8 I drink water from purified or chlorinated hand
pump or reservoir.
9 I live in a tobacco/cigarette-free smoking area.
10 People most often smoke cigarette around me.
11 I drink liquor every day in a week.
12 I eat more than five servings (5 different) of
fruits every day.
13 I eat more than five servings (5 different) of
vegetables every day.
14 I like added salt on my food.
15 I drink sodas or sugary drinks (coke, fanta, sprite,
cool aid, ice cream, sour milk, juice, etc) every
day.
16 I eat junk foods (donuts, pepper kali, roasted
meat/sausage, fried/roasted chicken, pig-in-the-
blanket or meat pie) every day.
17 I eat breakfast, lunch and dinner every day.
18 I brush my teeth three times a day.
19 I take bath three times a day.
20 I do not keep long finger nails.
21 I wash all of my dirty clothes every week.
22 I clean my house surrounding every week.
23 I do house cleaning every day.
24 I join others to clean my community every week.
25 I do not pupu/defecate in clean toilet/pit latrine.
26 I pupu in the bush or open field.
27 I bath in outside bathroom where everyone
urinates/pepes and baths.
28 I exercise 150 minutes every week (25 minutes
every day).
29 I live in an area where there are violent, abusive
or conflict-like neighbors.
30 I live in an area where there are
recreational/entertainment sites or playgrounds
for social gatherings.
31 I waste my household dirt on a dumpsite in the
neighborhood authorized by city mayor.
32 I smoke cigarette or opium more than five times
a week.
4. Methods
A critical thinking outside the box was done for several
months to brainstorm ideas on making the concept to make
sense for the greater good. The mathematical method that
was used to calculate the prevalence of vicious circle of ill-
health was thoroughly brainstormed to fit the existing health
indicators used in the concept relative to the established
formula for calculating prevalence rate. An observation has
been done over the years relative to understanding the
behaviours of community dwellers in Liberia towards
situations in the environment.[4]
5. Result
The informative concept serves as a basis for further
research initiatives related to ill-health. Further studies will
be carried out to test the applicability of the concept in
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
112
International Journal of Science and Research (IJSR)
ISSN: 2319-7064
SJIF (2020): 7.803
Volume 10 Issue 8, August 2021
www.ijsr.net
Licensed Under Creative Commons Attribution CC BY
Liberian communities. A survey tool was also developed to
ably collect data on vicious circle of ill-health. Constructs
from Socio Ecological Model (SEM) and Health Belief
Model (HBM) were highlighted to provide solutions to
vicious circle of ill-health by effectively utilizing their
applications and concepts. This concept of vicious circle of
ill-health is deemed expedient for presentation,
demonstration and justification at international,
intracontinental and local public health conferences.
6. Conclusion
FOAP Concept of Vicious Circle of Ill-health has been
developed to help citizens of Liberia improve their overall
health and well-being by adapting its ideas, concepts and
practices. It is meant to assist them avoid unhealthy
environmental practices both abstract and visible - for the
prevention and/or control of vicious circle of ill-health or
preventable diseases.
7. Recommendation
I recommend that further studies be conducted to test the
application of the FOAP Concept of Vicious Circle of Ill-
health in communities in Liberia through pilot studies. This
process will begin with a team of undergraduate public
health students at University of Liberia and graduate public
health students at Cuttington University School of Graduate
and Professional Studies.
References
[1] Lalonde, M. (1974). A New Perspective on the Health
of Canadians. Ottawa, ON: Minister of Supply and
Services Canada. Retrieved from Public Health Agency
of Canada website: http://www.phac-aspc.gc.ca/ph-
sp/pdf/perspect-eng.pdf
[2] Louis J.P. (2016). Examining Constructs of the Health
Belief Model as Predictors of Haitian Men„s Intention
Regarding Prostate Cancer Screening. Barry University.
[3] McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K.
(1988). An ecological perspective on health promotion
programs. Health Education & Behavior, 15(4), 351
377.
[4] MRC Clinical Trials Unit, 2021- What is an
observational study? Retrieved from
https://www.ctu.mrc.ac.uk/patients-public/about-
clinical-trails/what-is-an-observational-study/
[5] Pan American Health Organization (2001). Health
Indicators: Building Blocks for Health Situation
Analysis. Epidemiological Bulletin; Vol. 22, No. 4.
https://www1.paho.org/english/sha/EB_v22n4.pdf
[6] Taylor, S.E. and Repetti, R.L. (1997). Health
Psychology: What is an Unhealthy Environment and
how does it get under the Skin? Annual Review of
Psychology; Vol. 48:411-447.
https://doi.org/10.1146/annurev.psych.48.1.411
[7] WHO Regional Office of Europe (2000).
Environmental Health Indicators: Development of a
Methodology for the WHO European Region. Retrieved
from
https://www.euro.who.int/_data/assets/pdf_file/0009/12
0231/E71437.pdf
[8] Youth.gov (n.d.). Risk and Protective Factors. Retrieved
from https://youth.gov/youth-topics/youth-mental-
health/risk-and-protective-factors-youth
Author Profile
Forkpah Pewee is a Health Promotion and Education Expert by
profession. He currently serves as Chairman of the Undergraduate
Public Health Department at University of Liberia. He worked as
Lecturer at Cuttington University and Harbel College respectively
before joining the University of Liberia Family. He is also an
Adjunct Faculty in the College of Health Sciences at the Cuttington
University Graduate School and Professional Studies. He has
authored two books with titles Health Benefits of Fruits and
Vegetables in Liberian Cuisine”, which was published in Book
Publisher International, India/United Kingdom in October 2019;
and ABCs of Healthy Living”, which was published on Amazon,
United States of America in July 2020. He is a 2017 graduate with
Master of Public Health in Health Promotion and Education from
the Adventist University of the Philippines, 2014 graduate from
Cuttington University, and 2010 graduate from Firestone Senior
High School. He was awarded HEALTH PERSONALITY OF
THE YEAR 2019” by the Firestone Liberia Debate Club. He was
also awarded a Certificate of Scholastic Recognition” from the
Administration of University of Liberia for having achieved
academic excellence in peer-reviewed publication at the Thomas
J.R. Faulkner College of Science and Technology in February
2021.
Paper ID: SR21728233819
DOI: 10.21275/SR21728233819
113
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Article
Full-text available
This review explores the role of environments in creating chronic and acute health disorders. A general framework for studying the nesting of social environments and the multiple pathways by which environmental factors may adversely affect health is offered. Treating socioeconomic status (SES) and race as contextual factors, we examine characteristics of the environments of community, work, family, and peer interaction for predictors of positive and adverse health outcomes across the lifespan. We consider chronic stress/allostatic load, mental distress, coping skills and resources, and health habits and behaviors as classes of mechanisms that address how unhealthy environments get "under the skin," to create health disorders. Across multiple environments, unhealthy environments are those that threaten safety, that undermine the creation of social ties, and that are conflictual, abusive, or violent. A healthy environment, in contrast, provides safety, opportunities for social integration, and the ability to predict and/or control aspects of that environment.
A New Perspective on the Health of Canadians. Ottawa, ON: Minister of Supply and Services Canada
  • M Lalonde
Lalonde, M. (1974). A New Perspective on the Health of Canadians. Ottawa, ON: Minister of Supply and Services Canada. Retrieved from Public Health Agency of Canada website: http://www.phac-aspc.gc.ca/phsp/pdf/perspect-eng.pdf
Health Indicators: Building Blocks for Health Situation Analysis
Pan American Health Organization (2001). Health Indicators: Building Blocks for Health Situation Analysis. Epidemiological Bulletin; Vol. 22, No. 4. https://www1.paho.org/english/sha/EB_v22n4.pdf
Risk and Protective Factors
  • Youth
  • Gov
Youth.gov (n.d.). Risk and Protective Factors. Retrieved from https://youth.gov/youth-topics/youth-mentalhealth/risk-and-protective-factors-youth