PUBLIC HEALTH
LECTURE / Mr. Diobert De Leon, RPh.
2nd Semester A.Y. 2023-2024
COMMUNITY HEALTH, EPIDEMIOLOGY, AND HUMAN BEHAVIOR (CHAPTER 3)
A number of local factors may affect health of communities.
According to the WHO, these factors may differ from one
community to the other. The following are the factors as cited
from WHO's Community Hea Needs Assessment (2001)
published by the WHO Regional Office for Europe:
1. the physical environment in which people live,
such as the quality of the air breathe and the water
they drink;
2. the social environment - the level of social and
emotional support people receive from friends
and/or family;
3. poverty a significant factor worldwide, which
shortens and reduces enjoyment of life
4. behaviour and lifestyle - for example, smoking
causes lung cancer and coronary heart disease so
a reduction in this behaviour will reduce the
disease;
5. family genetics and individual biology-if you
come from a healthy family you have better chance
of staying well
These factors remind us that Public Health or Community
Health is not just a matter of presence or absence of a
disease.
In collecting information about the community through a
community profiling certain data must be considered in
order to get a bigger picture about the community's health
status. In the same document from WHO, the following data
are recommended to be considered when one does
community profiling.
WORK AND LEVELS OF EMPLYMENT AND
UNEMPLOYMENT
in a community are fundamental to health for the following
three reasons:
OCCUPATIONAL DISEASES
All work affects health, both positively and negatively
However, some work is known to cause disease, such as
silicosis in mine and quarry workers and machinery
accidents among farm workers. New work. related illnesses
are also being recognized, such as repetitive strain injury for
keyboard operators.
INCOME LEVELS
The amount of income people earn has an important
influence on their health, affecting their ability to choose a
healthy lifestyle and to access health services. Levels of
income also have an impact on the local economy within a
community.
SELF WORTH
At the same time, the status of an occupation affects how
people feel about themselves. People's level of satisfaction
at work contributes their well-being Many define people by
their work or lack of it. The unemployed may feel excluded,
and lack of paid employment has been shown to contribute
to poor health.
POVERTY AND INCOME
Poverty can be absolute (Le. inadequate to sus health) or
relative (e. how poor one person is compared to another). In
health terms, it is not only the level of poverty that counts but
also the gap between richest and poorest. A large gap
results in a big difference in health and life expectancy
TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA
MIDTERM
03/24
between rich and poor. This is known as health inequality
tone of the most significant factors affecting health across
the world and therefore in formation on this issue will be
essential.
ENVIRONMENT
The surroundings where people live and work in directly
affect their health. A number of factors should be monitored
here
POLLUTION
of air and water causes disease and death and this is
throughout the world, whether it is lead in petrol or a
chemical spill from a factory, or drinking water contaminated
by sewage
GOOD STATION
eliminates some diseases such a cholera and dysentery
completely, and where it is absent, gastrointestinal illnesses
are quickly evident In communities lacking basic sanitation,
threats to health arise from the contamination of water
supplies by human excreta.
THE LACK OF A HOME
affects all aspects of health-shelter from the weather. an
environment to sustain a family, a place to feel safe. The
availability and type of housing reflect local history, culture,
the economy and political climate. The type, quality and
suitability of housing have an important affect on health.
Consider the distance of homes from work, pharmacies,
schools and shops.
TRANSPORT SYSTEMS
are important to record, as they can influence people's
access to services, social support networks and employment
Transport may al so have an impact on health through
accidents noise and air pollution.
SOCIAL SUPPORT
is essential for the well being of a community. There are a
number of elements that need to be taken into consideration
when describing the extent of social cohesion in a
community.
FAMILY AND FRIENSHIP NETWORKS
provide people with the emotional support that is
fundamental to well-being. Social networks can be hard to
describe and quantify. The best way is to ask local people. It
may be possible for them to describe social networks
through flow diagram, maps, drawings, stories and drama.
MIGRATION
causes disruption to a population, as large numbers of
people move location. It is often the younger working-age
population who emigrate. and this is a loss to the population
left behind while a gain to the community they move to.
Migration of workers may be daily, weekly or longer.
Population movements can be traumatic owing to the
upheaval caused, especially if forced by armed conflict,
threat of discrimination or severe economic necessity.
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MARGINAL GROUPS Himmelman (1992) developed a more collaborative
empowerment model emphasizing that communities should
are outside the dominant community, yet may form a dis- play a lead role in order to achieve "real empowerment" and
tinct population themselves. Some groups, such as religious not just "community betterment".
sects, travelers and gypsies may choose to remain outride
mainstream society. Others, such as the homeless, may be Generally, the following are the steps in Community
forced into that position Access to health care is often more Organizing
difficult for both these groups, who may have greater need
for services. 1. Problem Identification
2. Interface with Community
THE OPPORTUNITIES FOR NON-WORK SOCIAL ACTIVITIES 3. People Organization
4. Community Profile and Assessment
are signposts that can be used to indicate the extent of social 5. Goal-setting and Formulation of Strategies
cohesion and support in a community. Such activities 6. Implementation of Agreed Strategies or Solutions
reinforce a community's identity and the emotional wellbeing 7. Monitoring and Evaluation
of individuals. 8. Sustaining Gains, Addressing Emerging Problems

WHO identifies destabilizing factors that can affect the The process can loop back to the first step.
health status of a community. Factors such as "war,
economic recession and natural disasters such as In the process involved in maintaining Community
earthquakes, floods or drought affect health directly through Health, understanding population and community health
their impact on mortality disease patterns and lifestyle data is a necessity. Gathering and analyzing these types of
change. They also affect health indirectly by reducing the health data is part of any epidemiological study that can
resources available for health services, increasing poverty be conducted in a community. Epidemiology is "the study
and lowering the social and economic wellbeing of a of the distribution and determinants of diseases and injuries
population. They may radically lower population numbers in human populations" (Mausner and Kramer, 1985). The
and increase fear and mental health" goal of epidemiology is to limit disease, injury, and death
in a community by intervening to prevent or limit
In general, there are three broad factors that affect the health outbreaks or epidemics of disease and injury. This is
of a community; accomplished by describing out breaks and designing
studies to analyze them and to validate new approaches to
1. Physical Factors prevention, control, and treatment. Through these practices,
2. Social and Cultural Factors epidemiologists contribute to our knowledge of how diseases
3. Individual Factors begin and spread through populations, and how they can be
prevented, controlled, and treated' (McKenzie, Pinger and
Physical Factors Social and Individual
Kotecki, 2012).
Cultural Factors Factors
Geography Traditions Behavior
Environment Norms For an epidemiologist, the following data are essential:
Community Size Beliefs
Industrial Economy (micro
RATES
Development and Macro)
Politics A rate is the number of events in a given population
Income over a specific period or at a given point in time. An example
Livelihood of rate would be birth rate, mortality rate and morbidity
rate. The use of rates is more superior than just recording
These factors are very important in considering public health absolute counts especially in trying to determine the
or community hath interventions. Perhaps the fourth factor existence of an outbreak during a particular time at a
that can determine the health of a community as the process particular place.
of community organizing. Minkler and Wallerstein (1997)
de community organizing as "the process of by which Birth rate is the average annual number of births
community groups are helped to identify common problems during a year per 1,000 persons the population at the mid-
or goals, mobilize resources and in other ways develop and year. This is also known as crude birth rate. This is usually
implement strategies for reaching the goals they collectively the dominant factor in determining the rate of population
have set” growth.

Minkler and Wallerstein emphasize the importance of

community organizing especially in health education but also
in relation to the fact that social involvement and participation
are also significant psychosocial factors in "improving
perceived control individual coping capacity, health
behaviors and health status" (Cohen and Syme, 1985: Eng
and Cunningham, 1990).

There are various types of Community Organization.

According to Rothman an Tropman (1987), categories of
community organization consist of three distinct models of
practice:

1. Locality Development - process-oriented,

creating a consensus and sense of cooperation. Under morbidity, an epidemiologist would measure
2. Social Planning- task-oriented, emphasizing the incidence rate, prevalence rate and attack rate of a
rational-empirical problem-solving disease.
3. Social Action - both task and process-oriented.

TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA 2

 Rates Definition system must be able to monitor and report on time.
Incidence Rate the number of new cases of Depending on the type of diseases, reporting can be done
(new causes) a disease in a population- as frequent as weekly or immediately the case is
at-risk (those in the encountered in the field. The manner of reporting notifiable
population who are diseases in the Philippines is guided by the Department of
susceptible to the disease) Health Administrative Order No. 200 0009.
in a given time period
Prevalence Rate The total number of cases AD No. 2008-000
(old+ new) (old and new cases) of
disease existing in a Notifiable Diseases or Events Reported Immediately
population (must be reported within 24 hours)
Attack Rate The proportion of those Acute Flaccid Paralysis Paralytic Shellfish
who became ill after a Adverse Event Following Poisoning
specified exposure Immunization (AEFI) Rabies
Anthrax Severe Acute Respiratory
Human Avian Influenza Syndrome
The relationship between incidence and prevalence
Measles Outbreaks
depends greatly on the natural story od the disease state
Meningococcal Disease Clusters of Diseases
being reported. In the case of an influenza, epidemic, the
Neonatal Tetanus Unusual Diseases or
incidence may be high but not contribute to the growth of
threats
prevalence because of the high, spontaneous rate of
disease resolution. In the case of a disease that has a low Notifiable Diseases or Syndrome Reported Weekly
(or zero) cure rate, but where maintenance treatment Acute Bloody Diarrhea Diphtheria
permits sustained survival, then incidence contributes to Acute Encephalitis Influenza-like illness
continuous growth of prevalence. In such cases, the Syndrome Leptospirosis
limitation on prevalence growth is the mortality which occurs Acute Hemorrhagic Fever Malaria
in the population. Obviously, prevalence will continue to Acute Viral Hepatitis Non-neonatal
grow until mortality equals or exceeds the incidence rate. Bacterial Meningitis Tetanus
Cholera Pertussis
Dengue Typhoid and Para-Typhoid
Rates can be expressed as crude or specific. Crude rates
Fever
use total population as the denominator (eg, crude birth rate,
crude death rate).
The Department of Health adopts a "zero-case reporting"
Rate Numerator Denominator Multiplier policy which mean that even if a community has no reported
Crude Number of Estimate 1,000 case of any of the notifiable diseases of events, the health
Birth Rate live births mid-year workers still have to report it as "zero case".
population
Crude Number of Estimate 1,000 Other than reporting incidences of notifiable diseases in the
Death deaths from mid-year community, a health system (municipal, city, provincial)
Rate all causes population would also report a list of leading causes of morbidities and
mortalities over a specified time period.
An example of a specific rate is the cause-specific
Disease Number of Percentage
mortality rate. It measures the death rate for a specific
deaths
disease. This can be calculated by dividing the number of
deaths due to a particular disease by the total population. Diseases of the heart 100,908 21.0
Another example would be age-specific. Usually CSMRS or Cerebro-vascular 56,670 11.8
ASMRs are reported per 100,000 population. disease
Malignant neoplasm 47,732 9.9
Examples of a cause-specific-mortality rate are Infant Pneumonia 42,642 8.9
Mortality Rate and Neonatal Mortality Rate. They are both Tuberculosis 25,470 5.3
reported per 100,000 population. COPD 22,755 4.7
Diabetes 22,345 4.6
Rate Numerator Denominator Multiplier Nephritis, Nephrotic 13,799 2.9
Infant Number of Total live 100,000 syndrome
Mortality deaths births Assault 12,227 2.5
Rate under 1 Certain conditions 11,514 2.4
year of age arising from perinatal
Neonatal Number of Total live 100,000 period
Mortality deaths births Source National Stators Order. 300
Rate under 28 TOP LEADING CAUSES OF DEATHS IN THE
days of age PHILIPPINES

Case Fatality Rate is the percentage of cases that result in Among the mortalities being monitored for example by the
death. It measures the severity of the disease and is Philippine Department of Health is Infant Mortality Rate
proportionate to the virulence of a disease agent. It is (IMR). Together with Maternal mortality, these two indicators
calculated by dividing the number of deaths from a particular reflect the general condition of the health system.
disease in a specified period of time by the number of cases
of that same disease in the same time period. The resulting Time Neonatal Infant
fraction is multiplied by 100 and is reported as a percentage. mortality Mortality
1990 57.0 80.0
The prompt reporting of these numbers is vital to the 1993 17.7 33.6 54.2
maintenance of a community's health, especially since most 1998 17.8 35.1 48.4
of the time, public health leaders are confronted with acute 2003 17.0 29.0 40.0
types of diseases, infectious or communicable in nature. 2008 16.0 25.0 34.0
That is why, the Philippine Department of Health for example Source National Demographic and Health Servers NSO
would issue a list of notifiable disease that every health CHILD MORTALITY RATES IN THE PHILIPPINES

TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA 3

In the Philippine experience, while child mortality rates
appear to be decreasing through the years, disaggregating
the data, especially the IMR, would show disparities in
performance among socio-economic groups.
However, Mortality does not entirely express the burden of
disease (McKenzie, Pinger and Kotecki, 2012). WHO and
World Bank developed the indicator called Disability-
adjusted Life Years (DALYs). The DALY has emerged as
a measure of the burden of disease and it reflects the total
amount of healthy life lost, to all causes whether from
premature mortality or from some degree of disability during
a period of time. These disabilities can be physical or mental.
The intended use of the DALY is to assist
1. in setting health service priorities;
2. in identifying disadvantaged groups and targeting
of health interventions; and
3. in providing a comparable measure of output for
intervention, program and sector evaluation and
planning' (Homedes, 2000).
One DALY is equivalent to one lost year of healthy life.
Life Expectancy is usually interchanged with Life span
however, both are entirely different from each other. Life
span refers to the number of years a person lives. Life
expectancy refers to the number of years a person is
expected to live from a specified starting point. A person can
only have one life span but may have different life expec
tancies. Examples of a life expectancy would be Disability-
Adjusted Life Expectancy (DALE) and Health-Adjusted
Life Expectancy (HALE).
Mule
2000-2005 64.11 70.14 67.62
2005-2010 66.11 71.64 68.88
2010-2015 67.61 73.14 70.38
2015-2020 68.61 74.34 71.39
2020-2025 70.01 75.54 72.77
2025-2030 71.01 76.54 73.77
2030-2035 72.01 77.54 74.77
2035-2040 73.01 78.34 75.68
PROJECTED LIFE EXPECTANCY AT BIRTH,
PHILIPPINES
Collecting these data can involve various methodologies. It
can either be done through Surveillance Reporting.
Survey or Census.
SURVEILLANCE REPORTING
In the Philippine health care system, health facilities are
expected to submit monthly and annual reports pertaining to
identified health data being monitored by the National
Government. An example of a surveillance report would be
the Field Health Service Information System or FHSIS.
Municipal or City Health Offices would co late data from their
respective Barangay Health Stations/Units and consolidate
them in their FHSIS reports which are eventually submitted
to the Provincial Health Office an later to the Regional Office
of the Department of Health.
According to the National Epidemiologic Center of
Philippines, FHSIS was conceptualized in 1987 as a
response to the need for streamlining an existing reporting
system that, midwives complained, was burdensome, time-
consuming, and ultimately even pre- vented them from
discharging their service delivery functions fully. FHSIS was
then implemented na- tionwide by 1989 in a joint effort with
many sectors within and out. side the Department of Health
(DOH). The FHSIS is a facility-based system, and data
generated by the system comes from the Barangay Health
Stations (BHS) and Rural Health Units (RHU). This means
TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA
that, data from private or non-government units, clinics, and
institutions rendering the same services as the BHS and
RHU are missed.
In 1991, barely a year after the full implementation of FHSIS,
the Local Government Code (LGC) was implemented. With
this decentralization, the management and provision of
health services was transferred to the Local Government
Units (LGU). In order to make the FHSIS adapt to the
changes brought about by the LGC, the FHSIS technical
staff formed study teams and undertook activities aimed at
improving, simplifying, and making the system more
responsive and relevant to devolution. The team focused on
simplifying and shortening Summary Tables (ST) and
reducing over- dependence on computers in the production
of STs. These changes constituted the Modified FHSIS
(MFHSIS) which was implemented nationwide in 1996.
However, de- spite the innovations, the system continued to
experience problems in its operations including poor
utilization of data for decision making by leaders in various
levels of the health system, and the sub-optimal quality of
the data characterized by delayed submissions and
incomplete reports.
In 2001, another revision, the Decentralized FHSIS
(DFHSIS), was piloted in six areas nationwide (three
provinces and three cities) in an effort to address the short-
comings of the MFHSIS. However, this was not implemented
nationwide and was not sustained due to a very limited
information generation. An evaluation of DFHSIS was
undertaken in 2004 for which findings showed the same
problems of inaccuracy, in- completeness and delay from the
original FHSIS and MFHSIS. The recommendation showed
DFHSIS should not be implemented nationwide unless the
support systems are enhanced (policy and implementing
rules and regulations, skilled data managers, adequate
financing and efficient computerization of the system).
In 2005, The FHSIS started its program enhancement
through consultative work- shops. Program managers at the
national level were met to determine indicators that would
suit their needs. This was followed through in recent years
by series of consultations with National Center for Disease
Prevention and Control (NCDPC) Program
Managers and selected Rural Health Unit Physicians,
Nurses and Midwives, Provincial Health Officers to further
identify information needs and indicators in all health
management systems. FHSIS version 2008 was developed
as a result of these meetings with Program Managers and
Local Government Units (LGU). This version included the
updating of indicators needed at the rational level and the
FHSIS software developed the National Epidemiology
Center (NEC)"
SURVEYS
Survey is a method of gathering any type of information or
data from a sample of individuals. By sample it is meant that
the data is only taken from a portion of the to population
under study.
In the Philippine experience, an example of a survey is the
National Household Targeting System for Poverty
Reduction (NHTS) of the Philippine Department of Social
Welfare and Development. It is a data bank and an
information management system which identifies who and
where the poor are in the country. Through the survey.
around 3.8 million households identified to be very poor were
enrolled in a Condition Cash Transfer program and the
Philippine Health Insurance Company.
CENSUS
A Census is the opposite of a survey. It is the counting of
data gathered from the entire population. It is a regularly
4
occurring and official count of the human population of a
certain local administrative unit. In the Philippines, the
agency that conducti Census is the National Statistics
Office
At a local level municipalities or cities would maintain
Community-based Health (or Management) Information
System. It is a databank of information of all residents of a
municipality. Each household has a portfolio wherein all
profile data are stored and regularly updated. Data would
include number of members of the household, immunization
records, type of housing or dwelling place, access to sale
water and even pet ownership. It should be regularly
updated.
The process of census can be more expensive than doing
surveys. In the Philippine experience, a population census is
usually done every 5 years. Because it is a census data
generated especially the number of population segregated
according to localities would be used for local planning and
development.
More than collecting health data, a community health worker
or public health worker must also gather information on how
community members view their health situation.
It is important that people are able to describe health
problems and solutions in their own terms. This may involve
using less conventional methods such as photographs,
drawings or personal stories. The community view or
perspective is important to include, and involving local
people initiates their involvement and participation in
improving the health of their own community. There will
always be a great deal of expert expertise and knowledge to
draw on among the local population, in particular on what
assets exist, the factors that influence their health, what is
most important, local health belich and solutions to problems
(WHO, 2001)
BEHAVIOR CHANGE
How people view their health situation can influence how
they behave or act Knowing how behaviors are formed and
influenced therefore is a critical element in achieving
community health. There are various theories and
frameworks that can explain why certain behaviors are
manifested.
According to Bandura (1986), people's behaviors are driven
by external factors and not by inner forces. In his Social
Cognitive Theory. Bandura explains that human
functioning can be explained by a triadic interaction of
behavior, personal and environmental factors (reciprocal
determinism). Environmental factors represent situational
influences and environment in which behavior is preformed
while personal factors include instincts, drives, traits, and
other individual motivational forces.
Another theory that explains behavior is the Theory of
Planned Behavior. suggests that behavior is dependent on
one's intention to perform the behavior. Intention is
determined by an individual's attitude (beliefs and values
about the outcome of the behavior) and subjective norms
(beliefs about what other people think the person should do
or general social pressure). Behavior is also determined by
an individual's perceived behavioral control defined as an
individual's perceptions of their ability or feelings of self-
efficacy to perform behavior. This relationship is typically
dependent on the type of relationship and the nature of the
situation.
TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA
THEORY OF PLANNED BEHAVIOR MODEL
Another framework that can explain behavior is the
Transtheoretical Model or also known as the Stages of
Change Model". According to the theory, a person un-
dergoes at least six stages of change or transformation. The
practicality of this theory is in the aspect of matching
behavior change interventions with the person's current
stage of change. The six stages are:
Precontemplation is the stage in which people are not
intending to make a change in the near future (often defined
as the next 6 months).
Contemplation is the stage where people intend to change
(within the next 6 months). People in this stage are aware of
the pros of changing but also can identify the cons.
Preparation represents the stage where people have a plan
of action and intend to take action in the immediate future
(within a month).
Action is the stage in which people make the behavior
change.
Maintenance represents the stage where people work to
prevent relapse.
Termination represents that stage where individuals have
100 percent efficacy and will maintain their behavior. This
stage is the most difficult to maintain, so many people remain
a lifetime in maintenance.
Prochaska, Johnson, and Lee (1998) suggest a series of
activities that have received empirical support, which help
individuals progress through the stages:
1. Consciousness-Raising - increasing awareness
of the causes (providing educational materials,
confrontation, media campaigns, feedback, etc.) 2
2. Dramatic Relief-producing an emotional
experience which is followed by a reduced affect if
some action can be taken (personal testimonies,
media campaigns, drama)
3. Self-reevaluation-inviting individuals to make
cognitive and emotional assessments of their self
image (clarify values, provide healthy models,
using im agery)
4. Environmental reevaluation-assessments of how
the presence or absence of a behavior might
impact one's social environment (documentaries,
personal stories, family interventions)
Reviewing the various elements of Behavior Change, Witte
(1997) tabulated the various elements of different behavior
change frameworks."
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 Key Definition Strategies for regional and local information, providing a comparative
element Behavior picture.
Changes
Threat Definition A danger Raise awareness If it is not possible to obtain all the information required,
or a harmful event that the threat identify the gap and move on to collect what is available.
of which people exists, focusing on Local health and social care managers may keep information
may or may not be severity and for administrative purposes. However, this may be service-
aware. susceptibility. Be orientated rather than people-focused, providing information
Fear Emotional arousal Fear can on services rather than health. Nevertheless, proxy
caused by powerfully measures like these are useful in the absence of other data.
perceiving a influence behavior
significant and and, if it is Government departments are valuable sources of data
personally relevant channeled in the regarding social and eco- nomic structures in the local
threat. appropriate way, community. Wherever there is a tax collection system there
can motivate should be information about income distribution and wealth.
people to see Planning departments provide information about housing
information, but it and public amenities, industry and local hazards. Welfare
can also cause providers may collect information about the recipients of their
people to deny ser- vices and these are usually specific to a group of people.
they are at-risk This does not just apply to government agencies but also to
Response Perception that a Provide evidence charities and private agencies that provide services. When
Efficacy recommended of examples that looking at a small population, do not rely too much on
response will the recommended quantitative data as the numbers will be too small for
prevent the threat response will avert meaningful comparisons. When in doubt seek the advice of
from happening. the threat. experts in epidemiology.
Self- An individual's Raise individuals'
Efficacy perception of or confidence that
confidence in their they can perform
ability to perform a response and help
recommended ensure they can
response. avert the threat
Barriers Something that Be aware of
would prevent an physical or cultural
individuals from barriers that might
carrying out a exist, attempt to
recommended remove barriers
response.
Benefits Positive Communicate the
consequences of benefits of
performing performing the
recommended recommended
response. response.
Subjective What an individual Understand with
Norms thinks other people whom individuals
think they should do are likely to
comply.
Attitudes An individual's Measure existing
evaluation or beliefs attitudes before at
about a tempting to change
recommended them.
response.
Intentions An individual's plans Determine if
to carry out the intentions are
recommended genuine or proxies
response for actual behavior
Cues to External or internal Provide
Action factors that help communication
individuals make that might trig ger
decisions about a individuals to make
response decisions.
Reactance When an individual Ensure individuals
reacts against a do not feel they
recommended have been
response. manipulated or are
unable to avert the
threat.

Therefore, to obtain a full picture of health, information about

health should come may rom a variety of sources. A public
health department is a good place to begin. This be national
or local. Some have very detailed information covering
diseases, health ser vice use and inequality in service
provision, as well as mortality and morbidity rates This
information should also contain some analysis of national,

TRANSCRIBED BY: EMBERLYNN MARIE C. PETILLA 6