Community Health Nursing:

Definitions:

1) World Health Organization:

a. Special field of nursing that combines skills of nursing public health…
b. Function as part of total public health program for:
i. Promotion of health
ii. Improvement of condition
iii.Rehabilitation of illness and disability
2) Jacobsen
a. Learned practice discipline with ultimate goal of contributing as individuals to
promote client’s optimum level of functioning through teaching and delivery of care
3) Dr. Ruth B. Freeman
a. CHN is a unique blend of nursing and public health practice aimed at developing and
enhancing health capabilities of people. It is involved in entire spectrum of health
services for the community
4) Tinkham and Voorhies, 1972
a. CHN is a field of nursing in which family and communities are patients
b. Unique blend of nursing and public health practice woven into human service
c. “The hallmark of CHN is that it is population or aggregate-focused.”

Philosophy of CHN

Dr. Margaret Shetland:

“Philosophy is based on the worth and dignity of man.”

Ultimate Goal

“To raise level of health of the citizenry.”

Objectives of CHN

1) participate…
2) conduct researches…
3) coordinate…

Concepts of CHN

• emphasis on importance of “greatest good for the greatest number”

• assessing health needs, planning, implementing and evaluating impact of health services on
population group
• priority of health promotive and disease preventive strategies over curative interventions
• tools for measuring and analyzing community health problems
• application of principles of management and organization of the delivery of health services to
the community

Basic Principles of Community Health Nursing

• family is the unit of care, community is the patient and the four levels of clientele of CHN
are:
○ individual
○ family
○ group
○ community
• goal of improving community health involves multidisciplinary effort
• CHN works not for individual patient, family, group or community. The latter are active
partners, not passive-recipients of care
• Practice of CHN is affected by changes in society in general and by developments in health
field in particular
• CHN is part of community health system, which in turn is part of the larger human services
system

Barangay Health Centers

1 doctor, 1 nurse, midwives, 2 barangay health workers. 1 nurse= 5000 people

Wednesday: check-up and free immunizations

Roles and Functions

• Planner: e.g. IMCI = Integrated management of childhood illnesses

• Provider of Nsg Services: direct nursing care of sick; provides patient continuity of care
• Manager/Supervisor: formulates individual, family, group and community centered care of
plan; organize work force
• Coordinator of Services: coordinates with individuals, family, group for health related services
provided by GO’s and NGO’s
• Trainer/health educator/counselor: identifies and interprets training needs of RHM’s, BHW’s
and hilots; resource speaker; IEC materials
• Health Monitor: detects deviation from health of individual, family, group and community
through contact visits with them; use of systematic and objective assessment
• Role model: provides good example/ model of healthful living to public
• Change agent: motivates changes in health behavior of individual, family, group and
community including lifestyle to promote and maintain health. “most difficult role.”
• Recorder/reporter/statisticiain: prepares and submits records and reports
• Researcher: participates/assists in conduct of surveys

Community Health Nursing:

History:

• Early Christian era: virgins, noblewomen and plebeians took care of sick
• Phoebe: 1st visiting nurse
• Mr. William Rathbone:
○ Philanthropist who first thought of public health nursing
○ District nursing service in Liverpool in 1859
○ More emphasis on midwifery
○ Forerunner of public health nursing system
• In the USA:
○ Public HN developed from visiting nursing service under missionary societies and
visiting nursing associations
○ 1877: women’s board of NY mission established 1st visiting nurses
History of Public Health

• Babylonians
○ Understood need for hygiene
○ Developed medical skills
• Egyptians
○ Developed variety of pharmaceutical preparations
○ Constructed earth privies and public drainage system
• Hebrew Mosaic Law
○ Maternal health, communicable disease control, protection of food, water, waste and
sanitary disposal
• Greeks
○ Linked health to environment
○ Wealthy people value personal cleanliness, exercise, diet and sanitation
• Romans
○ Viewed medicine from a community health and social medicine perspective
○ Emphasized regulation of medical practice
○ Provision of pure water
○ Sewage systems, public food preparation
○ Women visited and cared for the sick
• Christianity
○ Brought idea of personal responsibility
○ Started the care for the sick
• Middle Ages
○ Poor sanitary conditions
○ Increase in communicable diseases (cholera, bubonic plague, smallpox)
○ Religious convents and monasteries established hospitals
○ Started movement of health education and personal hygiene
 • Renaissance
○ Health practices were influenced by recognition of human dignity and worth
○ Elizabeth Poor Law: established 1601, guaranteed medical services to poor and lame
individuals
• Industrial Revolution
○ Advances in transportation
○ Religious women started to provide nursing care in institutions and homes

Milestones in history of public health

• 1601- Elizabeth Poor Law

• 1617- Sisterhood of Dames de Charite organized by St. Vincent de Paul
• 1789- Baltimore Health Department
• 1798- Marine Hospital Service, nuns visited poor
• 1813- Ladies Benevolent Society of Charleston, South Carolina founded
• 1836- Lutheran deaconesses provided home visits in Germany
• 1851- Nightingale visited Kaiserwerth, 3 months of nursing training
• 1855- Quarantine Board, established in New Orleans; beginning of tuberculosis campaign in
US
• 1859- district nursing established by William Rathbone
• 1860- Florence Nightingale Training School for Nurses established in St. Thomas Hospital in
London
• 1864- Beginning of Red Cross

Community Health Nursing Historical Background in Philippines

• 1901- Act 157, est. Board of Health of Philippines

• 1905- Act 1407, est. Bureau of Health, under Department of Interior
• 1912- Fajardo Act (Act 2156) – Sanitary Division, forerunner of present Municipal Health
Offices; President of Sanitary division took charge of 2 to 3 municipalities. Philippine General
Hospital sent 4 nurses to Cebu
• 1914- School of Nursing rendered by Filipino Nurse employed by Bureau of Health in
Tacloban, Leyte
• 1915- Philippine Health Service; Reorganization Act 2462 created. Office of Inspector General
and Office of District Nursing headed by Dr. Rosario Pastor, a nurse and physician
• 1915-1918- Ms. Perlita Clark took charge of Public Health Nursing Works
• 1919- 1st Filipino Nurse Supervisor was appointed, 84 PHN’s assigned in 5 health stations
• 1927- Office of District Nursing abolished and changed to Section of Public Health Nursing
• 1930- Section for Nursing
• 1941- Outbreak of war, PHN’s were assisted to take care of sick and wounded
• 1942- 31 nurses as POW’s at Bilibid Prison, released to Director of Bureau and Health, Dr.
Eusebio Aguilar
• 1948- 1st training center of Bureau of Health organized in cooperation with Pasay City Health
Department
• 1950- Rural Health Demonstration and Training Center by DOH
• 1958-1965- RA 977 abolished Division of Nursing
○ Annie Sand= nursing consultant, Office of Secretary of Health
 Founded DOH National League of Nurses Inc.
○ RA 977created 8 regional offices in country increased to 11 then to 16

Primary Health Care (Basic Health Care)

Definition

1) World Health Organization: “essential health care made universally accessible to

individuals and families by means acceptable to them, through full participation and
at cost that the community and country can afford at every stage of development.”

Conceptual Framework

• Goal: Health for all Filipinos and Health in the hands of th epoeple by the year 2020
• Mission: to strengthen the health care system by increasing opportunities and supporting
conditions wherein people will manage their own health care.
 • Concept: Primary Health Care (PHC) characterized by partnership and empowerment of
people shall permeate as core strategy in effective provision of essential health services

Legal Basis

• Letter of Instruction (LOI) 949: signed on Oct. 19, 1979 by then Pres. Ferdinand E. Marcos
• Historical Background
○ 1974- WHO and UNICEF conducted a joint study
○ 1975- World Health Assembly passed a resolution giving priority to the development
of PHC
○ 1977- World Health Assembly decided that main target of government and WHO is
the attainment of the level of health that would allow or permit them to lead a
socially and economically productive life by year 2000
○ September 6-12, 1978- 1st International Conference on Primary Health Care in Alma
Ata, USSR
○ 1979- WHA launched global strategy to attain health for all
○ 1980- PHC endorsed for implementation by respective regional community

Why Philippines Adopted PHC

1) magnitude of health problems

2) inadequate and unequal distribution of health resources
3) increased cost of medical care
4) isolation of health care activities from other developmental activities

Principles of PHC

1) Accessibility, acceptability, availability, and affordability of health services

a. Health services are delivered where people live and work
b. Development of indigenous or resident volunteer health workers to provide health
care with an ideal ration of 1:10-20 households
c. Use of low cost, appropriate technology sustainable by community
d. Combined utilization of traditional medicines and essential drugs
2) Partnership between community and health agencies in provision of quality, basic and
essential health services
a. Community needs and priorities are basic for planning health services and activities
b. Training curriculum of community health workers I based on community health
problems and task analysis of community health workers
c. Regular supervision and periodic evaluation of community health workers’
performance by health staff to community
d. Development of promotive, preventive, curative and rehabilitative care
e. Recognition of role and traditional healers in delivery of health services
3) Community Participation
a. Awareness building and consciousness raising on health and developmental issues
b. Community building and organizing
c. Planning, implementation, monitoring and evaluation done by community
d. Community discussions done through small group discussions
e. Selection of community health workers by community
f. Foundation of health committees
g. Establishment of community health organizations
h. Mass health campaigns and community mobilization
4) Self-reliance
a. Community generates support for health care
b. Mobilization of health resources
c. Training of community leaders on leadership and managerial skills
d. Income-generating projects
5) Recognition of interrelation of health and development
a. Convergence of health, food, nutrition, water, sanitation and population services
b. Integration of PHC into national, provincial, municipal and barangay development
plan
6) Social Mobilization
a. Establishment of effective health referral system
b. Multi-sectoral and inter-disciplinary linkages
c. Integration, Education, Communication (IEC) support using multimedia channels
d. Collaboration among government agencies, non-government organizations and
community groups
7) Decentralization
a. Reallocation of budgetary resources
 b. Advocacy for political will and support
c. Re-orientation of health profession

Strategies of PHC

1) reorientation and reorganization by local government code of 1991 or RA 7160

2) effective preparation and enabling process for health action at all levels
3) mobilization of people to know their communities and identify basic health needs
4) development of utilization of technology
5) organization of communities arising from needs
6) increase opportunities

Essential Components of Primary Health Care

1) Multi-Sectoral Approach
a. Intrasectoral linkages
b. Intersectoral linkages
2) Community participation
a. Identify problem
b. Identify solution
c. Mobilizing resources
d. Barriers
i. Lack of motivation
ii. Indifference on part of community
iii.Resistant to change
iv.Bureaucracy of government
v. Lack of managerial skills
vi.Dependence on part of community
3) Appropriate Technology
a. 6 criteria:
i. effectiveness and safety
ii. less complex
iii.less costly
iv.broader scope of technology
v. acceptability to local culture
vi.feasibility
4) Community involvement
a. Involvement level:
i. Individual
ii. Family-monitor growth and development of child and able to address to
problems in government
iii.Community- organizations formed to promote health development

Concepts of Primary Health Care

1) PHC represents supplementary health system

2) Equip community with capability to solve its own problems by conducting trainings
3) Come into being only when community recognizes and accepts problems
4) Government officials don’t work in place of community and vice versa
5) Community involvement is the heart and soul of PHC
6) Good health is related to living conditions and lifestyle
7) Provide opportunity to underprivileged majority to develop to an acceptable level
a. Basic minimalistic needs:
i. Food
ii. Clothing
iii.Shelter and clean environment
iv.Health
v. Education and information
vi.Security of life
vii.Means of livelihood
8) Community must take its role and responsibility to develop basic needs
9) PHC activities must be in harmony with existing institution
10) PHC activities must be flexible in its application
11) Must be related to public health services and technical support levels of public…

Elements of Primary Health Care

1) Education
2) Locally Endemic Diseases
 a. Filariasis
b. Schistosomiasis
3) Essential basic drugs
a. Cotrimoxazole
b. Amoxicillin
c. Rifampicin
d. Isoniazid
e. Ethambutol
f. Paracetamol
g. Pyrazinamide
h. Oresol
i. Nifedipine
4) Maternal and Child Health Care
5) Expanded program of immunization
a. BCG- bacillus calmette guerin
b. OPV- oral polio vaccine
c. AMV- anti-measles vaccine
d. DPT- dyptheria pertussis tetanus
e. Anti-Hep B
6) Nutrition
a. IDD- iodine deficiency disorder
b. IDA- iron deficiency anemia
c. PEM- protein energy malnutrition
7) Treatment of common diseases
8) Safe water supply and sanitation
9) Prevention and control of leading communicable diseases
10) Promotion of dental health
11) Elderly and disabled’s physical and mental health

The Philippine Healthcare Delivery System

• Health Care System- organized plan of health services

• Health Care Delivery- rendering services to people
• Health Care Delivery System- network of health facilities and personnel which carries out task
of rendering health care to people
• Philippine Health Care System- complex set of organizations interacting to provide an array
of health services
• RA 7160
○ Local Gov’t Code of 1991
○ Provides for decentralization
○ Places in local gov’ts to manage health care system

Levels of Health Care Facilities

1) Primary level
a. Composed of barangay, municipal and medicare health facilities
b. 1st contact emergency care
c. rural health units, chest clinics, malaria eradication units, schistosomiasis control
units, puericulture units, private clinics, company clincis
d. early symptomatic stage
2) Secondary level
a. Consists of district health care institutions with capabilities and facilities for cases
with hospitalization
b. Smaller non-departmentalized hospitals including emergency and regional hospitals
3) Tertiary level
a. Highly technological and sophisticated services
b. Specialized centers, regional health care institutions and provincial health care
centers

Multi-Sectoral Approach to Health

• Intersectoral
○ Sectors most closely related to health
○ Agriculture, education, public works, local governments, social welfare, population
control, private sectors
• Intrasectoral

Restructured Healthcare Delivery System

 Rationale

• healthcare system serves only small portion of rural population

• diseases do not require sohphistication
• some problems can be handled by other postiions besides MHO (Municipal Health Officer)

Solutions

• 3 levels of health care provided by RHU (rural health unit) staff, with referral and supervisory
system support
• redefinition of roles and relationships among RHU staff
• establishment of satellite health centers in selected barangays

Features of DOH reorganization

• 1958- RA 1082
○ 1st Rural Health Act
○ employment of more physicians, dentists, nurses, midwives and sanitary inspectors
assigned to RHU’s
○ 1st 81 rural health units
• 1972- RA 5435
○ defined authorities of regional directors for more meaningful decentralization
○ 13 regional health offices
• 1974
○ IBRD- RHCDS implemented RHM were sent to BHS to man BHS
○ Midwives were trained and roles expanded
• 1982- EO 851
○ integrated public health and hospital systems with emphasis on importance of
putting together promotive, preventive, curative and rehabilitative components of
health care
○ utilization of BHW
○ implementation of DOH impact programs

Role of Society in RHCDS

• participation in information drive of HCDS

• identifying problems
• identify sources

Local Health Board

• propose annual budget

• identify problems
• identify what programs
• Chairman, vice-chairman, chairman of committee on health, DOH representative, NGO
representative

Two-way referral system

Referral- intervention to direct client to another healthcare facility to continue his/her treatment

Population

BHS Midwife BHS BHW

Sanitary Inspectors RHU Midwife

PHN

Physician

Secondary Health Care Facility

Tertiary Health Care Facility

Types of Health Care Systems

1) Traditional
a. E.g. client provider
2) Non-Traditional
a. Holistic Health Centers
i. Believes that time, space and encouragement can help people find strength to
deal with problems confronting them
ii. Spiritual, physical and psychological care
iii.Acts:
1. Pastoral counseling
2. Stress reduction
3. Parenting
4. Dietary conditioning
b. Faith Healing
i. Believes that disease is a state of mind so one can alter his state of mind so he
will be healed
c. Chiropractic
i. System of manipulation treatment which teaches that all diseases are caused
by impringement on spinal column and corrected by spinal adjustment
ii. Daniel Palmer- founder
d. Acupuncture
i. Insertion of needles into selected body parts to control pain
e. Acupressure
i. Finger pressure to control pain in body parts
f. Kinesiology
i. Study of movement which applies principles of anatomy to movement
g. Reflexology
i. Systematic massage of soles of feet
ii. Applies same principles as applied in acupressure
h. Massage
i. Relieves tension, enhances flexibility and creates coordination between mind
and body
i. Homeopathy
i. Use of variety of herbs, drugs and chemicals that when used in small quantities
can cure or prevent disease caused by same substance in larger doses

Health Promotion, Health Maintenance, and Disease Prevention

Health Promotion

• Defintion
○ WHO- “Health promotion includes encouraging healthy lifestyles, creating supportive
environments for health, strengthening community action, reorienting health
services to place primary focus on promoting health and preventing disease, and
building healthy public policy.”
○ Pender, 1996- “Health promotion is a behavior motivated by the desire to increase
well being and actualize human health potential.”
• Health promotion includes any activity that helps people to change or maintain lifestyles that
support a state of optimal health or balance of physical, emotional, social, spiritual and
intellectual health.
• Prominence of health promotion came about as a result of changing patterns of health and
corresponding emphasis on “lifestyle” as a factor.
• PHE (Public Health Education) can only have impact on PH only if joined other sectors and
brought multiples social forces to bear.
• Green- “Behavioral changes that health education is able to effect can only be maintained if
supportive environment were provided via: political, economic, social, biological and other
sectors.”
• 1st use of term, health promotion- 1945, Henry E. Sigerist
○ Defined 4 major tasks of medicine
 Promotion of health
 Prevention of illness
 Restoration of the sick
 Rehabilitation
 ○ Sigerist: “Health is promoted by providing a good labor condition, education,
physical culture and means of rest and recreation.”
 Concepts used and found in Ottawa Charter for Health Promotion which
occurred 40 years later
• 1986, WHO, Health and Welfare Canada and Canadian Public Health Association organized an
International Conference on Health Promotion
○ later known as Ottawa Charter
○ Guiding principle in health promotion efforts currently

Ottawa Charter for Health Promotion

• “Process of enabling people to increase control over and to improve their health”
• To reach a state of complete physical, mental and social well-being , an individual or group
must be able to identify and to realized aspiration; to satisfy needs and to change and cope
with environment
• Health promotion is not just a responsibility of the health sector, but goes beyond healthy
lifestyles to well-being.
• Prerequesite for Health
○ Peace
○ Shelter
○ Education
○ Food
○ Income
○ A stable eco-system
○ Sustainable resources
○ Social Justice
○ Equity
• In order to operationalize the concept of Health Promotion, the Charter recommended the
following areas.
○ Build Health Public Policy
 Coordinated action that leads to health, income and social policies that
foster greater equity
○ Create Supportive Environment
 Societies are complex and interrelated
 Overall guiding principle is the need to encourage reciprocal maintenance
to take care of each other, our communities and our natural environment
 Conservation of natural resources throughout world should be emphasized
as a global responsibility
 Changing patterns of life; work and leisure leave a significant impact on
health
 Systematic assessment of health impact of rapidly changing environment,
especially in areas of technology, works, energy production and
urbanization
○ Strengthen Community Action
 Setting priorities, making decisions, planning strategies and implementing
 Heart of this process is Empowerment of communities
 Community development helps to enhance self-help and social support, to
develop flexible system for strengthening public participation in and
direction of health matters
○ Develop Personal Skills
 Through providing information, education for health and enhancing life
skills
 Enabling people to learn throughout life, to prepare themselves for all of its
stages and to cope with chronic illnesses and injuries
○ Reorient Health Services
 Health services are shared among individuals; community groups, health
service institutions and government