COMMUNITY HEALTH NURSING

FRANCIS C. CASTILLA, RN, Ll.B., MAN

COMMUNITY
A group determined by geographic boundaries and/or common values or interests. interests It functions within a particular sociocultural context, which means that no two communities are alike (Maglaya, 2003).

Characteristics of a Community
1. 2. 3. 4.

Has a population aggregate concept Defined geographic boundaries With common interest that binds the members together Made up of institutions & social system forming a complex network

Healthy Community: Characteristics

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Awareness that we r commty.; Conservation of natural resources; Recognition of and respect for the existence of subgroups (sg); Participation of sg in community affairs; Preparation to meet crises; Ability to solve problems Communication through open-channel Resources available to all; Settling of disputes through legitimate mechanisms; Participation by citizens in decision making; Wellness of a high degree among its members

Characteristics of Healthy Families

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

COMMUNICATE well and listen to all members Affirms and supports all of its members; Respect for others is valued Sense of trust Plays together and humor is present Balanced Interaction with each other Shares leisure time together Shared sense of responsibility Has traditions and rituals Shares a religious core Privacy of members is honored Family opens its boundaries to admit and seek help with problems

HEALTH
State of complete physical, mental, and social well-being not merely the absence of disease or infirmity (WHO).

Determinants of Health
(GPE)2+ICSH=DM)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Genetics Gender Personal Behavior and coping skills Physical envt Education Employment and working conditions Income and social status Culture Social support network Health Services

Ecosystem influences on OLOF: *Political Behavioral Hereditary HCDS Environmental influences *Socio-economic influences

Public Health (Winslow):

Science and art of : preventing disease, prolonging life, promoting health and efficiency through organized community effort for the sanitation of environment, control of CD, education of individual in personal hygiene, organization of medical and nsg services for the early dx and tx of disease and development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity (Winslow, C.E.).

Public Health (WHO):

Art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greater number. It points to the fact that PH is a core element of govts attempt to improve and promote the health and welfare of their citizens.

Public Health Nursing (WHO):

Special field of nursing that combines the skills of nsg, public health and some phases of social assistance and functions as part of the total public health program for the promotion of health, improvement of the conditions in the social and physical envt, rehabilitation of illness and disability.

PHN (NLPGN, 2005)

Refers to the practice of nursing in the local/national government health departments and public schools. It is CHN practiced in the public sector.

CHN (Jacobson):
Nursing practice in a wide variety of community services and consumer advocate areas and in a variety of roles, at times including independent practice

community nursing is certainly not confined to public health nursing agencies. agencies.

CHN (R. Freeman)

service rendered by a professional nurse with communities, groups, families, individuals at home, in health centers, in clinics, in schools, in places of work for the promotion of health, prevention of diseases, care of the sick at home, and rehabilitation.

CHN [ANA (1980)]

A synthesis of nsg practice and public health applied to promoting and preserving health of population. Practice is general and comprehensive Dominant responsibility is to the population as a whole. H. promotion and H maintenance, health education and mgt, coordination, & continuity of care are utilized in a holistic approach

Philosophy Basic ethical principles Focus Ultimate goal Objectives Concepts Principles Standards

CHN:

TYPES OF CLIENTELE IN CHN

Individuals Families Groups Communities

Roles of CHNurse
Case manager Advocate Teacher Partner & Collaborator Health planner/programmer Manager/Supervisor Community organizer Health educator/trainer Case finder Epidemiologist Recorder/Reporter/S tatistician Community leader

Overview of PHN/CHN in the Philippines

Significant events WHO & DOH Global and country health imperatives/trends The 8 MDGs HCDS

Do you know what they are? 1. Eradicate extreme poverty and hunger
2. Achieve universal primary education 3. Promote gender equality and empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, malaria, and other diseases 7. Ensure environmental sustainability 8. Develop a global partnership for development

PHCDS:
Significant events Major players DOH Local Health System Primary Health Care Levels of Health Care

HEALTH CARE DELIVERY SYSTEM (HCDS)

Totality of all policies, infrastructures, facilities, equipment, products, human resources, and services that address the health needs, problems and concerns of all people (Maglaya 2003). The network of health facilities and personnel which carries out the task of rendering health care to the people (Williams-tungpalan, 1981) (Williams-

Restructured HCDS
Combination of main health center and satellite BHS which is essentially the basis for the implementation of the new system Objectives: Strengthen the rural health services and to effect a more effective HCDS in the country

The DOH: Its Roles and Functions

1. Leadership in health
      National policy and regulatory institution In formulation, monitoring and evaluation of national health policies, plans and programs Advocacy Innovate new strategies in health Oversight functions and monitoring and evaluation of national health plans, programs and policies Ensure highest achievable standards of quality health care, health promotion and prevention Manage selected national health facilities Administer direct services for emergent health concerns that require new complicated technologies Administer health emergency response services

2. Enabler and capacity builder

3. Administrator of specific services

  

The DOH Vision DOH:

The Leader of Health for All in the Philippines.Health for All
Filipinos and Health in the Hands of the People by the year 2020.

The DOH: Mission

Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall lead the quest for excellence in health

MANDATE OF DOH:
Provide assistance to LGUs, Peoples organizations and other members of the society in effectively implementing programs, projects and services that will:
Promote health and W-B of every Filipino; W Prevent and control diseases among pop at risks; Protect IFCs exposed to hazards and risks that could affect their health; and Treat, manage and rehabilitate individuals affected by disease and disability (EO 102

DOH: DOH: Goal (HSRA)

1. 2. 3. 4. 5. Local Health Systems Devt. Hospital Reforms Public Health Programs Health Regulatory Reforms Social Health Insurance Reforms

Framework of Implementation of HSRA

FOURmula ONE for Health

FOURmula ONE for Health

Elements: 1. Health Financing 1. Better health outcomes 2. Health Regulation 2. More responsive 3. Health Service health systems Delivery 3. Equitable health 4. Good Governance care financing Goal

Roadmap for all stakeholders in Health: NOH 2005 to 2010

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Improve the general health status of the population Reduce mortality and morbidity from certain diseases Eliminate certain diseases as public health problems Promote HL and environmental health Protect vulnerable groups with special needs and nutrition needs Strengthen national and local health systems to ensure better HS delivery Pursue public health and hospital reforms Reduce the cost and ensure the quality of essential drugs Institute health regulatory reforms to ensure quality and and safety of health goods and services Strengthen health governance and management support systems Institute safety nets for the vulnerable and marginalized groups Expand the coverage of social health insurance Mobilize more resources for health Improve efficiency in the allocation, production and utilization of resources for health

 NOH 2005-2010 Targets: 20051.) Maintain the country free of polio and avian flu It is the target of NOH for 2005-2010 to 2.) Eliminate as major health ELIMINATE the ff major problems: b.) health problems: 3.) Intensified disease a.) Poliomyelitis, SARS prevention and control and Avian flu measures are the strategic b.) Leprosy, malaria, thrusts for TB, HIV/AIDS, filariasis, vaccine preventable schistosomiasis and diseases & other major CDs. rabies c.) Cancer, DM & other 4.) Strengthen health degenerative diseases promotion measures and HL d.) Leprosy, malaria, campaigns are the strategis filariasis, approaches for CVD, CA, DM schistosomiasis & other major degenerative diseases

BQ

Basic principles to Improve Health

1. Ensure universal access to basic
health services. 2. Prioritize the health and nutrition of vulnerable groups. 3. Manage the epidemiologic shift from infectious diseases to degenerative diseases. 4. Enhance the performance of health sector.

Local Health System (LHS)

Pre-devolution Devolution LHS

Objectives of LHS:
1. Effective and efficient delivery of health care services; 2. Upgrade the HC Mgt and service capabilities of local health facilities 3. Promote inter-LGU linkages and cost-sharing schemes intercostincluding local HC financing systems for better utilization of local health resources; 4. Foster participation of the private sector, NGOs and communities in local health systems devt. 5. Ensure the quality of health service delivery at the local level

What is Inter-Local Health System?

Is a system of health care similar to a district health system in which individuals, communities and all other health care providers in a well-defined geographical area wellparticipate together in providing quality equitable and accessible health care with ILGU partnership as the basic framework.

Over-all Concept of the ILHS

Creation of an inter LHS by clustering
municipalities into ILHZone. ILHZ has a defined population within a defined geographical area and comprises a central referral hospitals and a number of primary level facilities such as RHUs and BHS.

Composition of the ILHZ

1. People- WHO Standard per health district 100K to 500K 2. Boundaries 3. Health facilities 4. Health workers

Guiding Principles
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Financial and administrative autonomy Strong political Support Strategic synergies and partnerships Community participation Equity of access to health services, esp. the poor Affordability of HS Appropriateness of health program Decentralized mgt Sustainability of health initiatives Upholding of standards of QHS

Primary Health Care (WHO):

 Essential care based on scientifically sound and socially acceptable methods and technology made universally accessible to individuals, families and communities through their full participation, at a cost they can afford at any given stage of development, and with the goal of self-reliance and self-determination (WHO/UNICEF, 1978).

Facts about PHC:

 Declared during the 1st Intl Conference on PHC held in Alma Ata (now Almaty, Kazakhstan), USSR on September 6-12 1978 by WHO.  Goal: Health for all by the year 2000  Adopted in the Philippine through LOI __ dated 10-19-79 and has an underlying theme of Health in the hands of the people by 2020.  MOH Jesus Azurin, father of PHC in the Philippines.  The recent PHC summit was held on February 23-24, 2006.

 The conference strongly reaffirms WHOs definition of Health  Existing gross inequality in health status b/w developed and developing countries  Economic and social development is of basic importance to health for all  Right of the people to participate individually and collectively in planning and implementation of hc  Governments have responsibility for health of the people  PHC definition  All governments must formulate respective health policies, strategies and plan of action  All countries must cooperate in a spirit of partnership and services to ensure PHC for all people

Declaration of Alma Ata

Basic Concepts of PHC

 Health is related to social structures. Health problems are brought about by economic, political. Cultural problems and vice versa  Health & Development are interrelated  Genuine Peoples participation is essential  CO is the core in PHC  Use of appropriate technology. Making use of available resources is a step to self-reliance and making the community aware of its potential and resources bring about self-appreciation

Principles of PHC
 People as the center of development  Concern for equity-DDU are priorities of the DOH  Respect for area-based knowledge and capacities  Social accountability to community  Devolution as an opportunity for empowerment  Balancing promotive, preventive, curative and rehabilitative care  Continuing concern for strengthening the capacity for PHC  Paradigm shift as a requirement of PHC

HOME ELEMENTS ME of PHC (Essential Services)

E-ducation for health L-ocally endemic disease control

H-ospital as a center of welleness O-ral and dental health M-ental Health E-lderly care

E-xpanded program on immunization M-aternal & child health E-ssential drugs N-utrition T-reatment of communicable diseases S-afe water and sanitation M-edical care and E-mergency treatment

Strategies of PHC
 Reorientation and reorganization of the national health care system with establishment of functional support system (RA 7160);  Effective preparation and enabling process for health action at all levels  Mobilization of the people to know their communities and identifying their basic health needs with the end in view of providing appropriate solutions leading to self-reliance and self determination  Development and utilization of appropriate technology focusing on local indigenous resources available in and acceptable to the community

 Organization of communities arising from their expressed needs which they have decided to address and that this continually evolving in pursuit of their own development  Increase opportunities for community participation in local level planning, mgt, monitoring and evaluation within the context of regional and national objectives.  Development of inter-sectoral linkages with other government and private agencies so that the program of the health sector is closely linked with those of other socio-economic sectors at the national, intermediate and community levels  Emphasizing partnership so that the health workers and the community leaders/members view each other as partners rather than merely providers and receivers of health care

Four Cornerstones/Pillars in PHC

Active community participation Multi-sectoral linkages
 Intra and inter-sectoral linkages

Use of appropriate technology Support mechanism made available

Types of PHC Workers depends on:  Available health manpower resources  Local health needs and problems  Political and financial feasibility

2 Levels of PHC workers: 1. Village or BHWs (V/BHW) 2. Intermediate level health workers

Levels of health care and referral system

Primary level of care: Secondary level of care: Tertiary level of care:

Primary Level of HC
 Services offered are to individuals in fair health and to patients with disease in the early symptomatic stages.  Devolved to the cities and the municipalities  RHU/BHS  Private practitioners  Puericulture center  Given by center physician to BHWs;  usually the 1st contact b/w the community members and the other levels of health facility;

Secondary Health Care

 Services offered to patients with symptomatic stages of disease, which require moderately specialized knowledge and technical resources for adequate treatment  Given by physician with basic health training;  Given in health facilities (Private/public) such as:  Infirmaries and emergency hospitals  Municipal/City/District hospitals  Referral center for the primary health facilities  Capable of performing minor surgeries and some simple lab.exams.

Tertiary Level of Health Care

 Services rendered at this level are to clients afflicted with diseases which seriously threaten their health and which require highly technical and specialized knowledge, facilities and personnel to treat effectively  Rendered by specialists in health facilities (Medical centers, Regl and Specialized hosp);  Referral center for 2ndary care facility.

SUMMARY OF PHC
 WHAT
 An approach/partnership/concept  Community-based Community Knowledgeable response to the interrelated needs of the community

 WHY
 Making health care accessible, affordable, sustainable for all  Towards self-reliance self Towards devt and social transformation

 HOW
    Partnership and Community participation Linkages Provision of community services Use of appropriate technoogy and organizing

Various Health Services

(made 4As)

High Level Of Health

SelfReliance

Public Health Nursing

National League of Philippine Government Nurses Inc. Standards of Public health Nursing in the Philippines RA 7160, RA 7305, RA 9173, PD 807

PUBLIC HEALTH NURSES

QUALIFICATIONS FUNCTIONS

CHIEF NURSE: QUALIFICATIONS

BSN, RN, @ LEAST 5 YRS EXP. IN GENERAL NGS SERVICE ADMINISTRATION MASTERS DEGREE IN NSG PREFERABLY IN PUBLIC HEALTH/CHN MEMBER OF GOOD STANDING IN APO

SUPERVISING PHN (HEAD OF NSG UNIT):

BSN RN 5 YEARS SUPERVISORY EXPERIENCE IN PUBLIC HEALTH MASTERS DEGREE IN PH/NSG (MAJOR IN NSG ADMINISTRATION) MEMBER OF GOOD STANDING OF APO

PHNS QUALIFICATIONS
BSN, RN Has the ff personal and professional qualifications: Good physical and mental health Leadership potential Active membership to professional nursing organizations Resourcefulness and creativity Honesty and integrity Capacity and ability to: Relate the practice with on going CH and health related activities Work cooperatively with other disciplines and other members of the community Accept and take actions needed to improve self and and service Analyze combination of factors and conditions that influence health of populations Apply nsg process in meeting the health and nsg needs of the community Mobilize resources in the community

PHNS FUNCTIONS:
Management Process; Nsg service; Program mgt Supervisory Supervisory plan and visit, eg. SSM Nursing Care Inherent fxn, Process, HV, Referral Collaborating and Coordinating Linkages, communication Health Promotion and Education Role in HL, Demo KS on advocacy, creating supportive envt, Mobilize community, CO Training Staff devt, support students affiliates Research Conducts and make use of research findings; Disease surveillance Demonstrating Professional responsibility and accountability

COMPETENCIES(SK) OF PHNs
CHN process Nursing procedures during clinic and home visits Community Organizing Health Promotion and Education Surveillance Records and reports

NURSING PROCESS
FAMILY
Types of family structure Stages
Beginning Childbearing Family with preschooler Family with school aged children Family with teenagers Launching center family Middle aged-family Aging family

COMMUNITY

FAMILY NURSING PROCESS

ASSESSMENT Data collection Data Analysis Diagnosis PLANNING Prioritization Definition of outcomes Selection of appropriate nursing intervention Developing evaluation tools IMPLEMENTATION Expert caring, nsg int., continuous data collection EVALUATION Effectiveness, efficiency, appropriateness, Adequacy Quantitative and Qualitative (S, P O),

COMMUNITY NURSING PROCESS

Assessment CDx (Compre./Problem-oriented) Data:
Demo. profile,S-economic & cultural values, H-Illness patterns,H.resources,Political/leadership patterns

Process: 1. Det. the objectives 2. Def. and study population 3. Det. Data to be collected 4. Collecting the data (thru RSIP) 5. Developing instrument (survey q., Int. guide, Obs. Chcklst) 6. Actual Data gathering 7. Data collation (categories for classification & Summarizing) 8. Data presentation 9. Data analysis: to establish trends and patterns 10.Id. the CHN problems (HS, HRes, HRel:SEEP) 11.Priority settings (NMMPS, 34332, 13411)

Planning
Situational analysis Goal and Objective Setting Strategy/Activity Setting Evaluation

Intervention
CO Partnership and Collaboration Advocacy Supervision

Evaluation
Structure, Process and Outcome Appropriateness, Efficiency and Effectiveness Quantitative and Qualitative Program Evaluation
Decide what to evaluate(Relevance, progress, effectiveness, impact and efficiency) Design the evaluation plan Collect relevant data Analyze data Make decision Report or give feedback (eg. Executive summary)

Community Organizing
is a process whereby the community members develop the capability to assess their health needs and problems, plan and implement actions to solve these problems, put up and sustain organizational structures which will support and monitor implementation of health initiative by the people.

Phases of CO
I.

(Manalili 1985, Andamo 1986, Maglaya 2003)

II. 1. 2. 3. 4. III. 1. 2. 3. 4. IV. V.

Preparatory Phase 1. Area selection 2. Community profiling 3. Entry in the community and integration with the people Organizational Phase Social preparation (Nurse will be introduced in the community) Spotting and developing potential leaders Core group formation Setting up community organization Education and Training Phase Conducting CDx Training of CHWorkers Health Services and mobilization Leadership formation activities Intersectoral Collaboration Phase (For sourcing of additional resources) Phase Out

COPAR PROCESS
A collective, participatory, transformative, liberalized, sustained, and systematic process of building peoples organization by mobilizing and enhancing the capabilities and resources of the people for the resolution of the issues and concerns towards effecting change in the existing oppressive and exploitative condition

Phases of COPAR
Pre-entry phase
Looking for a community to be served

Entry Phase
or social preparation phase
Sensitization of the people on the critical events in their life, motivating them to share their dreams and ideas on its mgt and eventually mobilizing them to take action

Organization-Building Phase Sustenance and Strengthening Phase

Education and training Networking and linkaging Implementation of livelihood program Developing secondary leaders

CO: A Community Health Promotion Model 5 Stages of Organizing

I. II. III. IV. V.

Community Analysis Design and Initiative Implementation Program MaintenanceConsolidation Dissemination and Reassessment

I.Community Analysis:
AKA: CDx, Cmmty needs assessment, HE Planning, and Mapping

Process of assessing and defining needs, opportunities and resources involved in initiating CH action program 5 Components: Demographic, and socio-economic profile Health Risk profile (social, Behavioral & Envtl) Health/wellness outcomes profile (Mort/Morb) Survey of current health promotion program Studies conducted in certain target groups Steps: Define the Community Collect data Assess Community capacity Assess Community barriers Assess readiness for change Synthesis data and set priorities

II. Design and Initiation

Estab a core planning group and select local organizer Choose an organizational structure
Board/Council, Coalition, Lead or Official agency, Grass-roots, Citizen panels (part with the Govt)

Identify, select and recruit org members Define the org mission and goals Clarify roles and responsibilities of people involved Provide training and recognition

III. Implementation
Generate broad citizen participation Develop a sequential work plan Use comprehensive integrated strategies Integrate community values into the programs, materials and messages

IV. Program Maintenance-Consolidation

Integrate intervention activities into community networks Establish a positive organizational culture Establish an ongoing recruitment plan Disseminate results

V. Dissemination-Reassessment
Update the community analysis Assess effectiveness of interventions and programs Chart future directories and modifications Summarize and disseminate the results

Health Promotion (HP)

In 1986, WHO, Health and Welfare Canada and the Canadian Public Health Association organized an international Conference on HP. The Ottawa Charter for Health Promotion defines HP as the process of enabling people to increase control over and to improve their health.

The Ottawa Charter for HP

Prerequisites for health
Peace, Shelter, Education, Food, Income, Stable eco-system, Sustainable resources, Social Justice and equity (PEF 4S)

Action Areas Recommended by the Charter

Build Healthy Public policy Create Supportive Environment Strengthen Community Action Develop Personal Skills Reorient Health Services

WHO Cites 5 HP Principles

HP involves the population as a whole in the context of their everyday life, rather that focusing on people at risk from specific disease HP is directed towards action on determinants of health HP combines diverse, but complementary methods of approaches including communication, education, legislation, fiscal development and spontaneous local activities against health hazards HP aims particularly at effective and concrete public participation HP is primarily a societal and political venture and not a medical service although health professionals service, have an important role in advocating and enabling HP

Health Education
Any combination of learning experience designed to facilitate voluntary adoptions of behaviors conducive to health (Green et al, 1980) Covers all levels of prevention

Levels of Prevention
A. Primary Prevention  Directed to healthy pop. focusing on prevention of emergence of risk factors(Primordial) and removal of the risk factors or reduction of their levels (specific). B. Secondary Prevention  Aims to id. and treat existing health problems at the earliest possible time, eg.screening, case finding, disease surveillance. C. Tertiary Prevention  Limits disability progression. Nurse attempts to reduce the magnitude or severity of the residual effects of disease.

Levels of Prevention
1. Primary
Health promotion Specific protection

2. Secondary
Early Diagnosis & prompt treatment
Prevent spread to others Cure the disease process to prevent sequalae

3. Tertiary
Disability limitation Rehabilitation

Epidemiology
Study of the occurrences and distribution of diseases as well as the distribution and determinants of health states or events in specified population and population, the application of this study to the control of health problems

Epidemiological Process (EP)

Systematic course of action taken to identify:
1. 2. 3. 4. Who is affected(persons) Where the affected persons reside(place) When the persons are affected(time) Causal factors of health and disease occurrence (host-agent envt determinants) 5. Prevalence of and incidence of health and diseases (frequencies) & 6. Prevention and control measures (levels of prevention) in relation to the natural life history of a disease or a condition.

Steps of EP
1. Determine the nature, extent and scope of the problem A. Natural life hx of dis B. Determinants influencing condition 1. Primary data (essential agent) e.g parasite, nutritional, psychosocial 2. Contributory data (agent-host-envt) C. Distribution patterns 1. Person 2. Place 3. Time. Place D. Condition frequencies 1. Prevalence 2. Incidence 3. Other biostatistical measures Formulate develop tentative hypotheses Collect and analyze further data to test hypotheses Plan for control Implement control plan Evaluate control plan Make appropriate report Conduct Research

2. 3. 4. 5. 6. 7. 8.

Uses of Epidemiology
1. 2. 3. 4. 5. 6. 7. Study hx of health population and the rise and fall of diseases and changes in their character Dx the health of the community and the condition of the people Study the work of health services with a view of improving them Estimate the risk of the disease, accident, defects and disease the chances of avoiding them Identify syndromes by describing the distribution and association of clinical phenomena in the population Complete the clinical picture of chronic disease and describe their natural history Search for causes of health and disease by comparing the experience of groups that are clearly defined by their composition, inheritance, exp, behavior and environment

Epidemiologic Triangle
Host
Any organism that harbors and provides nourishment for another organism

Agent
Intrinsic property of microorganism to survive and multiply in the environment to produce the disease

Environment
Sum total of external condition and influences that affects the development of an organism which can be biological, social and physical

Disease Distribution
Epidemiology Variables: Variables: Time: 1. Time Refers to both the period during which the cases of the disease being studied were exposed to the source of infection and the period during which the illness occurred. Persons:Refers to the character of 2. Persons individuals who were exposed and who contacted the infection or the disease in question 3. Place Refers to the feature, factor or Place: conditions which existed in or described the envt in which disease occurred.

Patterns of Occurrence and Distribution Sporadic Occurrence Endemic Occurrence Epidemic Occurrence Pandemic

Epidemiology and Surveillance Unit (ESU)

Established in regional and some local office Responsibilities:
Surveillance of infectious diseases with outbreak Assisting LGUs in investigation of outbreak and their control Developing information package on public health Providing technical assistance related to epidemiology

Public Health Surveillance

An on-going systematic collection, analysis, interpretation and dissemination of health data Surveillance system is often considered information loops or cycles involving health care providers, public health agencies and the public Objectives of surveillance surveillance:
To measure magnitude of the problem To measure the effect of the control program

National Epidemic Sentinel Surveillance System and its roles

NESSS is a hospital based information system that monitors the occurrence of infectious diseases with outbreak potential. OBJECTIVES OBJECTIVES:
To provide early warning on occurrence of outbreaks To provide program managers, policy makers and public administrators, rapid, accurate and timely information so that inventive and control measures can be instituted.

What are included in NESS DATA?

Trends of cases across time Demographic characteristics of cases Estimates of case fatality ratio Clustering of cases in a geographical area Information to formulate hypotheses of disease causation

Diseases under Surveillance

Laboratory Dxed: Cholera Hepatitis A Hepatitis B Malaria Typhoid fever Clinically Dxed: Dengue Hemorrhagic fever Diptheria Measles Meninggococcal disease Neonatal tetanus Non-neonatal tetanus Pertussis Rabies Leptospirosis Accute Flaccid Paralysis Under Surveillance System: System AFP Measles Maternal & Neonatal Tetanus Paralytic Shellfish Poisoning Fireworks and related injury HIV/AIDS

Importance of Outbreak Investigation

Control and prevention measure Severity and risk to others Research opportunities Public, political or legal concerns 5. Program consideration 6. Training 1. 2. 3. 4.

Specific Roles During Epi. Inv

Maintains surveillance of occurrence of notifiable diseases Coordinate with other members of the HT during the disease outbreak Participates in case findings and collection of laboratory specimens Isolates cases of CD Renders nsg care teaches and supervises giving of care care, Performs and teaches household members method, concurrent and terminal disinfection Gives health teachings to prevent further spreads of disease to ind and families FollowFollow-up cases and contacts Organize, coordinates and conducts CH education campaign/meetings Refers cases when necessary Coordinates with other concerned community agencies Accomplishes and keeps records and reports and submits to proper office

Vital Statistics (VS)

Statistics refers to a systematic approach of obtaining, organizing and analyzing numerical facts so that conclusion may be drawn. Vital Statistics refers to the systematic study of vital events such as births, illnesses, marriages, divorce, separation and deaths. Statistics of disease (morbidity) and death (mortality) indicate the state of health of a community and the success or failure of health work.

Uses of VS & Sources of VS Data

USES OF VS Indices of the health and illness status of community Serves as bases for planning, implementing, monitoring and evaluating CHN programs and services SOURCES OF DATA DATA: 1. Population census 2. Registration of vital data 3. Health Survey 4. Studies and researches

STATISTICAL TERMS
Rate Rel. b/w a vital event and persons exposed Rate: to the occurrence of said event w/in a given area and during a specified unit of time. Ratio: Rel. b/w 2 numerical quantities or measures Ratio of events without taking particular considerations to the time and place. Crude/General Rate Refers to the total living Rate: population. It must be presumed that the total population was exposed to the risk of occurrence of the event. Specific rate: Rel is for a specific population class or group. It limits the occurrence of the event to the portion of population definitely exposed to it.

Crude Birth/Death Rates & Infant/Maternal Mortality Rates:

CBR is a measure of one characteristic of the natural growth or increase of population Tot # of LB registered in a given cal. yr./ Estimated pop as of / July 1 of same yr.X1,000 X CDR is a measure of one mortality from all causes which may result in a decrease population. / Tot # of Deaths reg in a given cal yr./ Estimated pop as of July 1 of same yr.X 1,000 X IMR measures the risk of dying during the 1st yr of life. It is a good index of the general health condition of a community since it reflects changes in the env and medical condition of a community. Tot # of Deaths under 1 yr of age reg in a given cal yr./ Tot # of / reg LB of same calendar yr X 1,000 MMR measures the risk of dying from causes related to pregnancy, childbirth and puerperium. It is an index of the obstetrical care needed and received by women in a community.
Tot # of Deaths from maternal causes reg for a given yr./ Tot # of LB / reg of same yr.X 1,000 X

Fetal Death Rate & Neonatal Death Rate

FDR measures pregnancy wastage. Death of the product of conception occurs prior to its complete expulsion, irrespective of duration of pregnancy.
/ Tot # of FDs reg in a given calendar yr./ Tot # of LB reg on same year.X 1,000 X

NDR measures the risk of dying during the 1st month of life. It serves as an index of the effects of prenatal care and obstetrical mgt of the NB
# of Ds under 28 days of age reg in a given cal yr./ No. of LB reg of the same yr.X 1,000 X

Specific Death Rate & Incidence Rate

SDR describes more accurately the risk of exposure of certain classes or groups to particular diseases.
Cause SDR= # of Ds in specific class/group reg in a given cal yr./ Est pop as of July 1 in same / specified class/group of said yr. X 100,000

IR measures the frequency of occurrence of the phenomenon during a given period of time.
# of new cases of a particular disease reg during a specified period of time / population at risk X 100,000

Prevalence Rate and Attack Rate

PR measures the proportion of the population which exhibits a particular disease at a particular time.
# of new and old of a certain disease reg at a given time / Tot # of persons examined at same given time X 100

AR is a more accurate measure of the risk of exposure

# of persons acquiring a disease reg in a given yr / # of exposed to same disease in the same year X 100

Proportionate Mortality (Death Ratio) & Case Fatality Ratio

PM shows the numerical rel b/w deaths from all cases (or group of cases), age, (or group of age), etc.. And the total # of deaths from all causes in all ages taken together.
# of reg deaths from specific cause or age for a given cal yr. / # of reg deaths from all causes, all ages in same yr. X 100

CFR index of a killing power of a disease and is influenced by incomplete reporting and poor morbidity data.
# of reg deaths from a specific disease for a given yr. / # of reg cases from specific disease in same yr. X 100

Functions of the Nurse in VS

Collects data Tabulates data Analyzes and interprets data Evaluates data Recommends redirection and/or strengthening of specific areas of health programs

BQs
The estimate of the past and present occurrence of disease in a given locality is referred to as: a.) Prevalence rate b.) Incidence rate c.) Case fatality ratio d.) Swaroops index
The habitual occurrence of a disease is referred which indicates low number of both immune and susceptible is referred to as: a.) Endemic b.) Pandemic c.) Herd immunity d.) Epidemic

FIELD HEALTH SERVICES AND INFORMATION SYSTEM (FHSIS) OBJECTIVES:

1. To provide summary of data on health services delivery and selected programs accomplished indicators 2. To provide data which when combined with data from other sources, can be used for program monitoring and evaluation purposes purposes; 3. To provide a standardized, facility level data base which can be accessed for a more indepth studies; 4. To ensure that the data reported to the FHSIS are useful and accurate and are disseminated in a timely and easy to use fashion fashion; 5. To minimize the recording and reporting burden

Components of FHSIS:
Family Treatment Record Target Client List Its Purposes: List:
To plan and carry out patient care and service delivery. To facilitate the monitoring and supervision for services To report services delivered To provide a clinic-level data base which can be accessed for further studies.

Tally/Reporting Forms Output Reports

PHN
in

Schools and Work Settings

School Nursing (SN)

 SN is a type of PHN that focuses on the promotion of health and wellness of the pupils/students, teaching and non-teaching personnel of the schools.  The Health and Nutrition Center (HNC) of the DepED is mandated to safeguard the health and nutritional well-being of the total school population  2 Divisions of HNC Health and Nutrition HNC: The Health Division has 4 sections: Medical, Dental, Nursing and Health education sections

Redirected Approach in School Health Nursing (RASHN)-Utilizing PHC Concept (RASHN)I. Activities of the program:
 School health survey  Functional school clinic  Comprehensive pupil health assessment  Referral of cases  School plant inspection  Attending to emergency cases  Organize and reactivating school community health council  Intensify health education activities  Establishing data in school health activities

Objectives of School Nursing

1. Provide quality nursing service to the school population 2. Create awareness on the importance of the promotive and preventive aspects of health through health education; education 3. Encourage the provision of standard functional facilities facilities; 4. Provide nursing personnel with opportunities for continuing education and training training; 5. Conduct and participate in researches related to nursing care; care; and 6. Establish/strengthen Linkages with government and nonnongovernment organization/agencies for school community health work

Four (4) Phases of SN

Health Instruction Health Services Healthy School Living School and community coordination

SKILLS NEEDED BY SN
Assessment and screening skills Health counseling skills Social mobilization skills Good oral and written communication skills Basic management skills

Functions of SN
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. School health and nutrition survey Putting up a functional school clinic Health assessment Standard vision testing for school children Ear examination Height and weight measurement and nutritional status determination Medical referrals Attendance to emergency cases; Student health counseling Health and nutrition education activities Organization of school-CH and nutrition councils schoolCD control Establishment of data bank on school Health and nutrition activities; School plant inspection for healthy envt; Rapid classroom inspection Home visitation

CLINIC TEACHER IN THE CLASSROOM

 @ least 1 clinic teacher (CT) in each school  CT must have undergone training by the school nurse  CTs duties are as follows: Administers simple remedies and first aid; Keeps records of treatments given Responsible for the cleanliness and care of the medicine cabinet and the school clinic; and Reports to the principal cases of emergencies and when supplies need replenishing Recommends suggestion for the improvement of service

BQ: BQ SHN caters to the health

needs of the: a.) School children only b.) School children and teaching personnel c.) School children, teaching and non-teaching personnel d.) School children, teaching and non-teaching personnel, individuals in the community where the school is found

BQ: A school nurse has to perform

health assessment of every pupil of the school at least: a.) Once a year b.) Twice a year c.) Every month d.) Whenever a pupil is sent to the clinic by a teacher

BQs
During physical assessment of school children, Nurse Dyosa found three children having visual acuity of 20/50, 20/30 and 20/40. The appropriate next action of Nurse Dyosa is: a.) Do anything as these are normal findings in children below 12 y/o b.) Refer all children for further examination c.) Refer children with visual acuity of 20/40 or poorer for further examination d.) Tell the teacher of the students to make the student sit on the 1st row

 Nurse Dyesebel is to assess the nutritional status of grade 2 pupils. Her initial assessment will include: a.) BMI b.) Ht and Wt measurement c.) CBC d.) Measurement of arm circumference

OCCUPATIONAL HEALTH NURSING

It is the specialty practice that provides for and delivers health care services to workers and worker population.

Functions of OHNurses
1. Work with the occupational health team to lead the sanitary and industrial hygiene accdg to the sanitation code and its IRR 2. Recommends to local health authority the issuance/suspension or revocation of license/business permit 3. Coordinates with other government agencies relative to the implementation of the IRR 4. Attends to complaints of all establishments related to industrial hygiene and recommends appropriate measures for immediate compliance 5. Participates to provide, install and maintain in good condition all control facilities and protective barriers for potential and actual hazards.

6. Informs all affected workers regarding the nature of hazards and the reasons for the control measures and protective equipment 7. Makes a periodic testing for phy.examination of the workers and other health examinations related to workers exposure to potential and actual hazards in the workplace 8. Provides control measures to reduce noise, dust, health and other hazards 9. Ensure strict compliance with the regular use and proper maintenance of Personal Protective Equipment (PPE) 10. Provides employees/workers an occupational health services and facilities 11. Refers or elevates to higher authority all unsolved issues in relation to occupational and environmental health problems 12. Prepares and submits yearly reports to the local and national government

Application of PH Principles to OHN

Community assessment Workers Assessment Application of Epidemiology principles Team approach Program planning and implementation:Levels of prevention 6. Referral to community resources 7. Program evaluation 1. 2. 3. 4. 5.

OHNs Primary Focus

The mission of OH and Safety (OHS)is to assure so far as possible every working man and woman in the country is safe and in healthful working conditions .

OHNs Professional Goals

A. Its central mission is to promote and maintain the health and safety of workers through nsg process. B. Occupational physicians focus on on the prevention, detection and tx of work-related diseases and injuries workC. Industrial hygienists recognize, evaluate and control toxic exposures and hazards in the work envt D. Safety engineers and and other safety professional focus on the prevention of occupational injuries and the maintenance or creation of safe workplaces and safe work practices E. Other professional include: Toxicologists; Industrial engineers; Ergonomists; Health educators and Environmental engineers

The Practice of OHN

A. B. C. D. E. F. G. OHNurses focus on the promotion, protection and restoration of worker s health Autonomy and independent nursing judgments characterized the practice of OHN With a research-based foundation, OHN s theoretical, conceptual, and factual framework is multidisciplinary OHNurses are advocates for workers and encourage and enable individuals to make informed decisions about health care concerns OHNurses are key to the coordination of a holistic approach to the delivery of quality, comprehensive OH services OHNurses have professional accountability The essential element of OHS services are defined by the standards of OHN practice

Essential Components of OHN Practice

 Health promotion and prevention principles  Workers and workplace health hazards surveillance  Injury and illness investigation, analysis and prevention, examination of trends or work-related illnesses and injuries to develop preventive strategies  Primary care  Case management  Counseling  Management and administration  Legal/ethical monitoring  Research  Community orientation

THE FAMILY HEALTH

The DOH uses the life span approach to design programs and assist in the delivery of health services to specific age groups. It views health care of individuals in the context of the family.

Aims of the Family Health Office (FHO):

1. 2. 3. 4. 5. Improve the survival, health and well being of mothers and the unborn through a package of services for the pre-pregnancy, prenatal, natal and postnatal stages; Reduce morbidity and mortality rates for children 0-9 years; Reduce mortality from preventable causes among adolescents and young people; Reduce morbidity and mortality among Filipino adults and improve their quality of life life; Reduce morbidity and mortality of older persons and improve their quality of life

Statistics on MH
1. 2. 3. Reduce the MMR by 3/4 by 2015 to achieve the MDG (112/100,000 LB in 2010; 80/100,000 LB by 2015) Pregnant women w/ at least 4 prenatal visits decreased from 77% in 1998 to 70.4 in 2003; Pregnant women who receive at least 2 doses of TT decreased from 38% in 1998 to 37.3% in 2003; Percentage of women with at least one prenatal visit increased from 43% in 1998 to 51% in 2003 Births attended by health professionals increased from 56% in 1998 to 59.8% in 2003

4.

5.

6. Only 76.8% of pregnant women received iron supplementation 7. Only 44.6% of postpartum women received a dose of Vitamin A 8. Proportion of births occurring at home declined from 66% in 1998 to 61% in 2003 9. of home deliveries, 61% were deliveries, assisted by hilots or traditional birth attendant; only 34% were midwife-assisted midwife-

 DELAYS IN TAKING CRITICAL ACTIONS

DELAY IN SEEKING CARE DELAY IN MAKING REFERRAL DELAY IN PROVIDING APPROPRIATE MED.MGT

OTHER FACTORS:
Closely spaced births Frequent pregnancies Poor detection and mgt of of high-risk pregnancies Poor access to health facilities Health care and health staff who lack competence in handling obstetrical emergencies

HU r deemed High Risk Women?

1. Less than 18 and more than 35 y/o 2. With low educational and financial resources 3. With unmanaged chronic illness 4. Had just given birth for the last 18 months

The Strategic Thrusts of MHP for 200520052010

1. Launch and implement the Basic Emergency Obstetric Care (BEMOC) strategy in coordination with the DOH. Emergency obstetric care for every 125K population Improve the quality of prenatal and postnatal care Reduce womens exposure to health risks through the institutionalization of responsible parenthood and provision of appropriate health care package to all women of reproductive age LGUs , NGOs and other stakeholders must advocate for health through resource generation and allocation for health services to be provided for the mother and the unborn

2. 3.

4.

Essential Health Service Packages Available in the Health care Facilities

I. II. III. IV. V. VI. VII. Antenatal registration TT Immunization Micronutrient Supplementation Tx of Diseases and other conditions Clean and safe Delivery Support to breastfeeding Family planning counseling

I. Antenatal Registration
Prenatal Visits
1st Visit

Period of Pregnancy
As early in pregnancy as possible before 4 mos. or during the 1st trimester During the 2nd trimester During 3rd trimester After 8th month of pregnancy til delivery

2nd Visit 3rd Visit Every 2 weeks

II. TT Immunization for Women

Vaccine Minimum Age/Interval % Protected Duration of Protection

TT1

As early as possible during pregnancy At least 4 wks later At least 6 mos later At least 1 yr later 80 Infant born protected from NT: 3 yrs protection for mother Infant born protected from NT; 5 yrs protection for mother Infant born protected from NT; 10 yrs protection for mother Infants born protected from NT; all childbearing years protection for mother (Lifetime Protection)

TT2

TT3

95

TT4

99

TT5

At least 1 yr later

99

III. Micronutrient Supplementation

Vitamins Vitamin A Dose 10,000 IU Schedule 2x a week starting on the 4th month of pregnancy Daily Remarks Giving of Vit. A before the 4th month may cause congenital problems

Iron

60mg/ 400ug

IV. Tx of Diseases and other Conditions

Conditions/Diseases Difficulty of breathing/Obstruction of airway What to do: Clear airway Place in her best position Refer to hospital with Em 2& FDSDELOLWLHV Keep on her back arms at the side Tilt head backward Lift chin to open airway Clear secretions from throat Give IVF to prevent/correct shock Monitor BP, pulse and shortness of breath q 15 mins Monitor fluid given. If difficulty of breathing and puffiness develops, stop infusion. Monitor urine output Do not give

Unconscious

Postpartum bleeding

Massage uterus and expel clots If bleeding persists: Massage fundus in a circular motion Apply bimanual uterine compression if ergometrine tx done and postpartum bleeding still persists Give ergometrine 0.2 mg IM and another dose after 15 mins Mebendazole 500mg single dose anytime from 4-9 mos of pregnancy if none was given in the past 6 mos. Sulfadoxin-pyrimethamine to women from malaria endemic areas who are in 1st or 2nd pregnancy, 500mg-25mg, 3 tabs at the beginning of 2nd and 3rd trimester not less than 1 month interval; OR Chloroquine 150 mg 2 tabs per week as prophylaxis for the whole duration of pregnancy

Do not give ergometrine if woman has eclampsia, pre-eclampsia or hypertension

Intestinal parasite

Mebendazole, if given during 1st trimester, may cause cong.prob

Malaria

In goiter endemic areas, 1 iodized oil capsule 200 mg iodine may given annually

V. Clean and Safe Delivery

Do a quick check upon admission for emergency signs Unconcious/convulsion Make the woman comfortable Vaginal bleeding Assess the woman in labor Severe abd pain Looks very ill Determine the stage labor Severe headache with visual Decide if woman can safely deliver dist. Breathing difficulty Give supportive care throughout the labor Fever Monitor and manage labor Severe vomiting Monitor closely within one hour after delivery and give supportive care 9. Continue care after one hour postpartum 10. Educate and counsel on FP and provide FP method if available and decision was made by a woman 11. Inform, teach and counsel the woman on important MCH messages 1. 2. 3. 4. 5. 6. 7. 8.

All of the following should be observed in home deliveries, except: a.) Clean hands b.) Clean delivery surface c.) Clean cord cutting and care d.) Clean sheets

When rendering prenatal care, the CHNurse uses this as guide in the identification of risk factors and danger signs and in doing appropriate measures. This is known as: a.) Treatment record b.) HBMR c.) Target Client List d.) Nutrition Record

Stages of Labor FIRST STAGE: Not yet in active labor, cervix is dilated 0-3cm and contractions are weak, less than 2 to 10 min.

What to do
Check qhr for emergency signs, frequency and duration of contractions, FHR Check q4hrs for fever, pulse, BP and cervical dilation Record time of rupture and color of amniotic fluid

Not to do Do not do vaginal examination more frequently than q4hrs

Assess progress of labor:

Refer woman immediately to hosp facility with comprehensive emergency obstetrical care capabilities if after 8hrs, contractions are stronger and more frequent but no progress in cervical dilatation, with or w/o membrane ruptured. It is false labor if after 8hrs there is no increase in contractions, membranes are not ruptured and no progress in cervical dilatation

Stages of Labor labor, 1st Stage In active labor 4cm or Stage: more cervical dilatation

What to do Check q30min for emergency signs Check q4hrs for fever, pulse, BP and cer.dilatation Record time or rupture of membranes and color of amniotic fluid Record findings in partograph/patients record

Not to do Do not allow woman to push unless delivery is imminent. It will just exhaust the woman Do not give medications to speed up the labor. It may endanger and cause trauma to mother and baby

2nd STAGE: Cervix dilated 10 cm or bulging thin perineum and head visible

Check q5min for perineum thinning and bulging, visible descent of the head during contraction, emergency signs, FHR, and mood and behavior

Do not apply fundal pressure to help deliver the baby

3rd STAGE: B/w birth of the baby and delivery of the placenta

Do not squeeze or massage the Deliver the placenta Check the completeness of placenta abdomen to deliver the placenta and membranes

1. When attending a home delivery, it is important to monitor the condition of the parturient. During the first stage of labor, which is the correct method of monitoring? a.) Check pulse and BP every 4 hrs b.) Check perineum every 5 mins for bulging c.) Check every hour for emergency signs d.) Check cervical dilation every 30 mins

2. The first post partum visit should be done when? a.) after 48 hrs b.) After 3 days c.) After 24 hrs d.) Within 24 hrs
DOH Protocol for Home deliveries deliveries: 1.) 1st postpartum visit-within 24 hrs 2.) 2nd visit-1 wk after delivery 3.) 3rd visit -2-4 wks after deliver 4.) Mother is advised to visit clinic within 46wks after delivery

FAMILY PLANNING PROGRAM

In 2oo3, 84M population and expected to grow by 2.36% annually 44% of women got pregnant with their 1st child at ages 20-24 20and 6.1% at ages 15-19 15 The FP unmet need had declined from 26.2% in 1993 to 17.3% in 2003 with 8% wanting to limit and the other 9% wanting to space. TFR remains at 3.5 children per woman, much higher than the desired FR of 2.5 3 to 4 M are getting pregnant every year Low contraceptive prevalence rate of 47.3% (15-49y/o) (15 Among married women in 2003, 48.8% use any form of contraceptive method and 51.1% do not use at all. 33.4% of them use any modern method of contraception and 15.5% use any traditional method

Goal/Objectives/Strategies of FP
Overall Goal of FP Reduce infant, neonatal, under-five and maternal deaths Objective of FP Address the need to help couples and individual achieve their desired family size within the context of responsible parenthood and Improve their RH to attain sustainable development Ensure that quality FP services are

Strategies of FP
Focus service delivery to the urban and rural poor Reestablish FP outreach program Strengthen FP provision in regions with high unmet needs Promote frontline participation of hospitals Mainstream modern natural FP Promote and implement CSR strategy

The Family Planning Methods

Female Sterilization/Bilateral Tubal Ligation

Advantages: Permanent method Single procedure method. leads to lifelong, safe and very effective contraception Nothing to remember, no supplies needed and no repeated clinic visit required Does not interfere with sex Results in increased sexual enjoyment No effect on breastfeeding No known long term SE or health risks Minilaparotomy can be performed after a woman gives birth
Disadvantages: Uncommon complications of sx In rare cases, when pregnancy occurs, it is more likely to be ectopic than in woman who has not undergone the procedure Requires physical exams and minor sx by trained service provider Requires an operating set up Permanent. Reversal sx is difficult, expensive and not available in most areas Do not protect against STD including HIV/AIDS Clients may have limitation in physical activities such as heavy work and lifting heavy objects immediately after sx.

% of effectiveness: 99.5% Perfect or Typical use

Advantages Very effective 3 mos after the procedure Permanent, safe, simple and easy to perform Can be performed in a clinic, office or at a primary care center No resupplies or repeated clinic visits No apparent long term health risks An option for couples whose female partner could not undergo permanent contraception A man who had vasectomy will not lose his sexual ability and ejaculation Not affect hormonal function, erection and ejaculation Not lessen but may actually increase the couples sexual drive and enjoyment Man can have better sex since he does not fear that his partner will get pregnant

Male Sterilization/Vasectomy

Disadvantages: It may be uncomfortable due to slight pain and swelling 2-3 days after the procedure Man needs to wear condom up to 15-20 ejaculation Reversibility is difficult and expensive Bleeding may result in hematoma in the scrotum

% of effectiveness: effectiveness: Perfect use: 99.9% Typical Use: 99.8%

Pills
Advantages Safe as proven through extensive studies Convenient and easy to use Makes menstrual cycle occur regularly and predictable Reduces gynecologic symptoms Reversible, rapid return to fertility Reduces the risk of ovarian and endometrial CA Does not interfere with sexual intercourse
Disadvantages: Often not used correctly and consistently, lowering its effectiveness Has SE such as nausea, dizziness, breast tenderness which are not generally harmful but which some women may find difficult to tolerate Offers no protection against STI Effectiveness may be lowered when taken with certain drugs such as rifampicin and most anti-convulsants Can suppress lactation Requires regular resupply

% of effectiveness: 99.7% Perfect use; 97% Typical use

Male Condom
Advantages Safe and has no hormonal effect Protects against microorganisms causing STIs/HIV Encourages male participation in FP Easily accessible Used in managing premature Disadvantages: May cause allergy May decrease sensation, making sex less enjoyable for other partner Interrupts the sexual act Requires a mans cooperation for use

% of effectiveness: 98% perfect use and 85% Typical use

Injectables
Advantages Reversible No need for daily intake Does not interfere with sexual intercourse Perceived as culturally acceptable by some women Private since it is not coitally dependent No estrogen related SE nor serious complications such as thrombophlebitis or pulmonary embolism Not affect breast-feeding-quality and quantity of milk Has beneficial non-contraceptive effects

How it is used: Drug containing progestin is injected into the body to suppress ovulation making sperm difficult to pass through the uterine lining It thickens cervical mucus and changes uterine lining

% of effectiveness Perfect Use: 99.7% Typical Use: 97%

Lactating Amenorrhea Method (LAM)

Advantages:

LAM is universally available to all postpartum breastfeeding women Using LAM, protection from an unplanned pregnancy begins immediately postpartum No other FP commodities are required Contributes to improve maternal and child health and nutrition

Disadvantages: Considered as an introductory, short term FP method which is effective only for a maximum of 6 mos. Postpartum Effectiveness of LAM may decrease if a mother and child are separated for extended periods of time Fully or nearly full BF may be difficult to maintain for up to 6 mos due to a variety of social circumstances Disadvantage to women who do not pass any three criteria to practice lactation amenorrhea

How it is used: 1).Amenorrhea; 2). Fully or 1). nearly fully BF her infant; 3). Infant is < 6mos.

% of Effectiveness: Perfect use: 99.5% Typical use: 98%

Mucus/Billing/Ovulation
Abstaining from sexual intercourse during fertile(wet) days prevents pregnancy

Advantages Can be used by any woman or reproductive health provided she is not suffering from an unusual disease or condition that results in extraordinary vaginal discharge that makes observation difficult

Disadvantages: Cannot be used by woman with medical conditions that would make pregnancy especially dangerous

How it is used used: Recording of menstruation and dry days Inspecting underwear regularly for presence of mucus Recording the most fertile observation at the end of the day

% of Effectiveness: Perfect use: 97% Typical Use: 80%

Basal Body Temperature

Advantage: Requires to take the BBT qday and time to record temperature. Couples may practice abstinence during fertile periods
How it is used: Take the temp (axillary/orally) at least 3 hrs of undisturbed rest during(upon waking up and before any activity) throughout the menstrual cycle. Cover line is being determined to identify the highest temp from day 6-10 of the menstrual cycle to identify thermal shift (the 3 consecutive temp above the cover line labeled as days 1,2,3) Intercourse is allowed only from the 4th day of thermal shift until the end of the cycle. These are known as the absolute infertile phase days.

% of effectiveness: Perfect Use: BBT 99% Typical Use: BBT 80%

Sympto-Thermal Method
STH method is identifying the fertile and infertile days of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temp recording and other signs of ovulation

% of Effectiveness: 99% Perfect use 80% Typical use

Standard Days Method/Beads Method

Advantages Disadvantages: No health related SE Cannot be used by women who Increases self awareness and knowledge of human usually have menstrual cycle reproduction and can lead to diagnosis of some between 26 and 32 days long gynecologic problems No need for counting or charting since the standard days method makes use of beads for tracking the cycle days How it is used: Can be used either to avoid or achieve pregnancy Very little cost and promotes male partner Abstain from sexual intercourse involvement in FP during fertile period Enhances self-discipline and mutual respect Provides opportunities for enhancing couples sexual Use color coded beads to mark the life fertile and infertile periods Acceptable to couples regardless of culture, religion, socio-economic status and education Not dependent on medically qualified personnel Once learned, may require no further help from % of Effectiveness: health care providers 95% Perfect use 88% Typical use

Misconceptions about FP Methods

1. Some FPM cause abortion: Not true. Abortion is the termination of abortion pregnancy, while, FP prevents pregnancy through the use of contraceptives, abstinence during fertile periods, blocking of tubes to prevent meeting of egg and sperm; It prevents induced abortion by preventing unplanned pregnancy Using contraceptive will render couples sterile: Cessation of temporary methods, couples can have children again. Vasectomy and tubal ligation however are permanent methods and are chosen only by couples who have completed their desired family size. Using contraceptive methods will result to loss of sexual desire. Sex drive or desire varies from person to person. In fact its use, frees the couple from the fear of unwanted pregnancies, thus, enhancing the couples sexual relationship

2.

3.

1.

2.

3.

Provide counseling on FP methods and its advantages, disadvantages, SE, what to do if problems develop and effectiveness. Provide packages of health services among reproductive age group in all health facilities (FP, MCHN, Mgt of RTI, STIs, HIV, Violence against WC, Mgt of breast and reproductive Cancers) Ensure availability of FP supplies and logistics for the clients

Roles of PHN on FP Program

RH Strategic Frameworks
1. The countrys development is reflected in the quality of life of its citizens. Its effective pursuit is premised on: a. The achievement of individual goals and aspirations towards the pursuit of societal objectives that also ensure the well being of future generations; b. Shared aspirations, where people empowerment is a major objective and a necessary means; c. The empowerment of women and the improvement of their political, social, economic and health status that is essential to its fulfillment 2. Individual development can best be achieved by more sustainable patterns of production and consumption; managed population; poverty alleviation; social and economic equality; and gender equity and equality;

3.

4.

5.

We must focus on the individual as the center of development since past population policies, which were primarily macro-level and demographically driven, achieved only moderate success; Gender equity and equality are essential for individual empowerment. empowerment Current gender roles and status in the Philippines are adversely affecting womens health and her contribution and participation in our countrys growth; Reproductive wellbeing is a major component of womens health. health In turn, RH is an integral aspect of this well being. Womens health and RH is a multi-sectoral effort;

6.

7.

RH also recognizes the right and responsibility of men for their own sexual and reproductive behavior as well as their social and family roles particularly in the promotion of the RH of their partners; Recognizing all the above, a RH Policy is necessary to promote womens health and development as a goal in itself. Achieving this will lead to a sustainable development of the Philippines;

Basic RH Rights
R to RH information and health care service for safe pregnancy and child birth R to know different means of regulating fertility Freedom to decide on the number and timing of birth of children R to exercise satisfying sex life

The 10 Elements of RH
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Family Planning Maternal and Child Health and Nutrition Prevention and Treatment of Reproductive Tract Infections Prevention and Management of Abortion and its Complications Breast and Reproductive Tract Cancers Education and Counseling on Sexuality and Sexual Health Adolescent Health Violence against Women and Children Mens Reproductive Health Infertility Prevention and Treatment

The Child Health Programs

Infant and young child Feeding Newborn screening EPI Management of childhood illnesses Micronutrient supplementation Dental Health Early Child Development Child health injuries

Strategic Thrusts for 2005-2010

1. 2. 3. 4. 5. 6. Develop capacity to deliver the whole range of essential health packages for children. children Pursue SS initiative to ensure quality of health services at the peripheral levels and identify priority areas for health systems devt. Implement programs and projects that favor disadvantaged populations. Apply the reaching every barangay strategy for immunization to reach every child Intensify HE and Information campaigns at the ground level to increase the proportion of mothers practicing behaviors that promote childrens health Enhance medical, nursing and midwifery education with cost effective life-saving lifestrategies such as the IMCI and the BEmOC Pursue the implementation of laws and policies for the protection of NB, infants and children

1. Infant and Young Child Feeding

The strategy calls for the promotion of
breast milk as the ideal food for the healthy growth and devt of infants; exclusive breastfeeding for the 1st 6 mos of life as the means to achieve optimal growth, devt and health of newborns. complementary food while breastfeeding continues for up to 2 yrs of age or beyond.

Overall Objective/Natl Plan of Action for IYCF

Overall Objective- To improve the survival of infants and young children by improving their nutritional status, growth and devt through optimal feeding; National Plan of Action for 2005-2010- for IYCF
Goal: reduce Child Mortality Rate by 2/3 by 2015 Objective: Improve health and nutritional status of IYC Outcome: Improve exclusive and extended breastfeeding and complementary feeding Specific objectives objectives:
70% of NB are initiated to BF within 1 hr after birth 60% of infants are exclusively bfed up to 6 mos 90% of infants are started on complementary feeding by 6 mos of age Median duration of breastfeeding is 18 mos

Benefits of BF
To Infants Nutritionally complete food Strengthens infants immune system, preventing many infections Safely rehydrates and provides essential nutrients to a sick child, esp. to those suffering from diarrheal diseases Reduces infants exposure to infection Increase IQ points To mother Reduces womans risk of excessive blood loss after birth Provides natural methods of delaying pregnancies Reduces the risk of ovarian and breast cancers and osteoporosis To household and community Conserve funds Saves medical cost of families and govt by preventing illnesses and by providing immediate postpartum and contraception

Laws that Protect IYCF

RA 7600 EO 51 RA 8976

Polio

Diphtheria

Measles

Tetanus

Pertussis

Hepatitis B

EPI: 4 Major Strategies

1. Sustaining high routine FIC coverage of at least 90% in all provinces and cities; 2. Sustaining the polio free country for global certification 3. Eliminating measles by 2008 4. Eliminating neonatal tetanus by 2008

1. 2.

3.

4.

It is safe and immunological effective to administer EPI vaccines on the same day at different sites of the body; Measles should be given as soon as the child is 9 mos old, regardless of whether other vaccines will be given on that day. MV if given at 9 month provide 85% protection and if given at 1 year and older provides 95% protection; The vaccination sched should not be restarted from the beginning even if the interval b/w doses exceeded the recommended interval by mos or years years; Moderate fever, malnutrition, mild resp infection, cough, diarrhea and vomiting are not contraindications to vaccination. Generally, one should immunize unless the child is so sick that he needs to be hospitalized;

General Principles in Vaccination

5.

The absolute contraindications to immunization are: DPT2 or DPT3 to a child who has had convulsions or shock w/in 3 days the previous dose. Vaccines containing the whole cell pertussis should not be given to children with an evolving neurological disease;

6.

7. 8.

9.

Giving of a vaccine at less than the recommended 4 weeks interval may lessen the antibody response. Lengthening the interval b/w doses of vaccines leads to higher antibody levels levels; Strictly follow the principle of never ever reconstitute the freeze dried vaccines with anything other than the diluents supplied with them them; No extra doses must be given to children/mother who missed dose of DPT/HB/OPV/TT. The vaccination must be continued as if no time had elapsed b/w doses. Use one syringe one needle per child during vaccination

Other facts:
BCG if given at earliest possible age protects the possibility of TB meningitis & other TB infections in which infants are prone Early start with DPT reduces the chance of severe pertussis The earlier OPV is given, the increased extent of protection against polio is. Keeps the Philippine polio free free. An early HepB reduces the chance of being infected and becoming a carrier. Prevent liver cirrhosis & liver cancer. About 9000 die of complications of HB. 10% of Filipinos have chronic HB infection. Eliminate HB b4 2012 (a western regional goal). At least 85% of measles can be prevented by immunization at this age. Prevents deaths (2% die), malnutrition, pneumonia, diarrhea (at least 20%) get theses complications from measles) etc Eliminates measles by 2008

New Immunization Schedule

AGE Birth 6 weeks 10 weeks 14 weeks 9 months VACCINES BCG, HepB OPV, DPT, HepB OPV, DPT OPV, DPT, HepB Measles

Maintain polio free Phil., Eliminate HepB b4 2012 and Measles by 2008

Who are deemed fully immunized child?

Giving of 1 dose of BCG, 3 doses of OPV, 3 doses of DPT, 1 dose of MV + 3 doses of Hepatitis B vaccine before reaching 1 year of age

= FULLY IMMUNIZED CHILD (FIC)

The EPI Vaccines and its Characteristics

Type/Form of Vaccines Most sensitive to heat Oral Polio (Live attenuated) Measles (Freeze dried) Least sensitive to heat DPT/HepB D-Toxoid w/c is a weakened toxin P-Killed bacteria T-Toxoid w/c is a weakened toxin Storage Temp -15C to -25C -15C to -25C +2C to 8C ( in the body of the refrigerator)

HepB BCG (freeze dried) Tetanus toxoid

+2C to 8C ( in the body of the refrigerator) +2C to 8C ( in the body of the refrigerator)

To maintain potency of vaccines:

A first expiry and first out (FEFO) vaccine is practiced to assure that all vaccines are utilized b4 its expiry date Temperature monitoring of vaccines is done in all levels of health facilities to monitor vaccine temperature. This is done twice a day in the morning and in the afternoon before going home. Each level of health facilities have cold chain equipment for use in the storage of vaccines. These are: cold room, freezer, refrigerator, transport box, vaccine carrier. Other cold chain logistics supplies includes: thermometers, cold chain monitor, ice packs, temperature monitoring chart, safety collector box, etc

Administration of Vaccines
Vaccine BCG DPT OPV Dose Infants .05ml 0.5ml 2 gtts or depending on manufacturers instruction 0.5ml 0.5ml 0.5ml Route of Administration Intradermal Intramuscular Oral Site of Administration R deltoid region of the arm Outer upper portion of the arm Mouth

Measles HepB TT

Subcutaneous Intramuscular Intramuscular

Outer part of the upper arm Upper outer portion of the thigh Deltoid region of the upper arm

Management of Childhood Illnesses

Facts on MCI
About 10M children aged 0-4 y/o and another 10M among five to ten years of age. The top cause of death among NB is pneumonia at the rate of 2/1,000 LB closely followed by bacterial sepsis at 1.8/1,000LB Among children 0-4 y/o, the number one cause of death is pneumonia (37.76/100,000) followed by accidents at the rate of 17.63/100,000. Accidents are identified s the top cause of mortality among older children 5 to 9 y/o followed by pneumonia and malignant neoplasm

IMCI
Assess the patient: check for the danger signs, main symptoms and other problems Classify the disease Treat the patient Counsel the patient Color Presentation Green Yellow Pink Class of Dis. Mild Moderate Severe Level of Mgt Home care Manage at the RHU Urgent referral to hospital

Common nutritional deficiencies (Vitamin A.,Iron, Iodine) Goal of Nutrition Program To improve quality of life of Filipinos through better nutrition, Program: improved health and increased productivity Objectives: 1. Reduction in the proportion of Filipino households with intake below 100% of the dietary energy requirement from 53.2% to 44%. 2. Reduction in: Underwt among pre-school children Stunting among pre school children Chronic energy deficiency among pregnant women Iron def. among children 6 mos to 5 y/o, pregnant and lactating mothers Prevalence of overwt, obesity and non-CD Reduction in the prevalence of iron def. disorder among lactating mothers Elimination of moderate and sever IDD among school children & pregnat women Reduction in the prevalence of LBW

Nutrition Program

Strategies of Nutrition Program

1. Food based interventions for sustained improvements in nutritional status 2. Life-cycle approach with strategic attention to 0-3 years old children, adolescent females and pregnant/lactating women 3. Effective complementation of nutrition interventions with other services 4. Geographical focus to needier areas

NP: Programs and Projects:

Micronutrient supplementation Food fortification Essential Maternal and Child Health Package Nutrition information, communication and education Home, school and community food production Food assistance includes center-based complementary feeding for wasted/stunted children and pregnant with delivering LBW Livelihood assistance

The ABC of Promoting Healthy Nutrition

Aim for ideal body weight Build Healthy Nutrition-related practices Choose foods wisely

Nutritional Guidelines
Eat a variety of foods everyday Exclusive breastfeeding from birth to 6 mos, and complementary feeding up to 2 yrs or beyond. 3. Maintains childrens normal growth through proper diet and monitoring their growth regularly 4. Consume fish, lean meat, poultry or dried beans 5. Eat more vegetables, fruits and root crops 6. Eat food cooked in edible/cooking oil daily 7. Consume milk, milk products and other calcim-rich foods such as small fish and dark green leafy vegetables 8. Use iodized salt but avoid excessive salty foods 9. Eat clean and safe food 10. For a healthy lifestyle and good nutrition, exercise regularly, do not smoke and avoid drinking alcoholic beverages 1. 2.

Universal Supplementation of Vitamin A

Target Infants 611 mos Preparation 100,000IU Dose/ Duration 1 dose only Remarks 1 cap is given anytime during the 6-11 mos but usually given at 9 mos during the measles immunization

Children 200,000 IU 12-71 mos

1 cap q 6 mos

Vitamin A Supplementation for High Risk Children

Target/Illness Measles Infants (6-11mos) Pre-school child (12-71mos) Severe Pneumonia Persistent Diarrhea Malnutrition Infants (6-11mos) (12-71mos) Malnutrition (6yrs-12yrs/o) Preparations 100,000IU 200,000IU 1 cap given upon dx, except when the child was given VAC less than 4 weeks before dx 100,000IU 200,000IU 200,000IU - same Dose/Duration 1 cap given upon dx, regardless of when the last dose of VAC was given

Vitamin A Supplementation for Pregnant and Post Partum Women

Targets Pregnant women Preparation 10,000 IU Dose Duration Remarks Vit A 10,000 IU should NOT be given to those who are already taking pre-natal vitamins of multiple micronutrient tables that also contain Vitamin A

Start from the 4th 1cap/tab of 10,000 IU twice a month of week pregnancy til delivery

PostPost-partum women

200,000 IU

1 cap 200,000 IU

1 dose only within 4 weeks after delivery

Vit A of 200,000IU should NOT be given to pregnant women

Vitamin A Tx for Xeropthalmia for all age groups & Pregnant Women
Targets
6-11 months 12-59 months

Preparation
100,000 IU 200,000 IU

Dose/ Duration
Should be given immediately upon dx, 1 cap given the next day & 1 cap 2 weeks after

Remarks

Pregnant women w/ xeropthalmia

10,000 IU

One cap/tab once a day for 4 weeks upon dx

Do NOT give Vit A 10,000 IU if prenatal vitamins or multiple micronutrients tablets containing Vit A. are to be given. Vit A can be given regardless of age of gestation if pregnant women has night blindness.

Iron Supplementation for Pregnant and lactating Women

Targets
Pregnant women

Preparations
Tab (preferably coated) containing 60mg elemental iron(EI) w/ 400 mcg Folic Acid

Dose/Duration
1 tab once a day for 6 mos or 180 days during the pregnancy period Or 2 tablets per day (120 mg.EI) if prenatal consultations are done during the 2nd and 3rd trimester

Remarks
A dose of 800 mcg of folic acid is still safe to the pregnant woman

Lactating women

Tab (preferably coated) containing 60mg elemental iron(EI) w/ 400 mcgFolic Acid

1 tablet once a day for 3 mos or 90 days

Iron Supplementation for LBW Infant & 6-11 mos of Age 6Target LBW Preparation Drops: 15 mg EI/0.6ml Dose/Duration 0.3 ml once a day to start at 2 mos of age until 6 mos when complementary foods are given

Infants 6-11 mos

Drops containing 15 mg EI/.0.6ml

0.6ml once a day for 3 months

Iron Supplementation for Preschool and School Children

Target Children 1-5 y/o Preparation Syrup containing 30 mg EI/5ml Dose/Duration 1 tbsp. once a day for 3 mos or 30mg once a week for 6 mos with supervised administration 2 tbsp once a day for 6 mos

Children 6-11 y/o anemic and underwt

Syrup containing 30 mg EI/5ml

Iron Supplementation for Adolescent girls & Older persons

Targets Adolescent Girls (10-19 y/o) Preparation Tab. Containing 60 mg EI with 400 mcg folic acid (coated) Dose/Duration 1 tab once a day

Older persons

Tab. Containing 60 mg EI with 400 mcg folic acid (coated)

1 tab once a day

Iodine Supplementation for Specific Population Groups

Targets Women 15-45 y/o Preparation Iodized oil cap with 200 mg. iodine Iodized oil cap with 200 mg. iodine 1 cap for 1 yr Iodized oil cap with 200 mg. iodine Adult males 1 cap for 1 yr Dose/Duration 1 cap for 1 yr

Children of school age

Oral Health Program

92% and 78%of Filipinos are suffering from dental caries and gum diseases, respectively. In terms of decayed, missing, filled teeth (DMFT) index, Philippines is ranked 2nd worst among 21 WHO western pacific countries countries. PGA in 1998 survey resulted that 88.4% of respondentdentist claimed that their practice were based in urban areas, 10.9% in sub-urban centers and 0.7% in rural. Dental caries and peridontal diseases are more prevalent in rural than in urban areas.

OHP: Goal and Objectives

Goal: Reduce the prevalence rate of dental caries and peridontal diseases from 92% in 1998 to 85% and from 78% to 60% by end of 2010 among general population. Objectives: 1. To increase the proportion of orally fit children under 6 y/o to 80% by 2010; 2. To control oral health risks among the young people 3. To improve the oral health conditions of pregnant women by 20% and older persons by 10% q yr until 2010.

Classification of Oral Interventions

I. 1. 2. 3. 4. II. 1. 2. 3. 4. 5. 6. 7. III. 1. Preventive services Oral exams Oral Hygiene Pit and fissures sealant program Flouride utilization program Curative or TX Services Permanent filling Gum tx Atraumatic restorative tx Temporary filling Extraction Tx post extraction complication Drainage of localized oral abscesses-incision and drainage Promotive Services Health education

The Adolescent Health Program

Young people account for a little over 30% of the population (26M) Among adolescent age 19, 12% of young people are already sexually active, and by age 24, 45% of women are already mothers Women aged 15-24 yrs are the age group with the highest unmet need for FP services at 26% Smoking prevalence among adolescent is 21% and 41% admit to social drinking Random drug testing yields screening positivity of 3 to 10% Accidents and injuries are the most common causes of death at the rate of 30.68/100,000 aged 10-24y/o 22.52% among all those who died od accidents and injuries are adolescent and youth

Adolescent Health Programs ST for 2005-2010

Come up with models for adolescent-friendly health services and adolescentadolescentadolescent- friendly environments Organize and build the capability of young people to promote HL HL, including sound RH practices, accident prevention and the promotion of sound policies on work to improve their health and quality of life Continue fertility awareness activities among high school teachers and students to reduce the proportion of unwanted pregnancies and unmet need for family planning among young people

Essential Health Package for the Adolescent and Youth

1. 2. 3. 4. 5. 6. Management of illness Counseling on substance abuse, sexuality and reproductive tract infections Nutrition and diet counseling Mental health FP and responsible sexual behavior Dental care

The Adult Men

Filipino males aged 25-59 is about 19% (16M) of the entire population and about 38% of them are males Have poor health status, with the highest level of health risk behavior and lowest use of health services. This age group accounted for 22% of total deaths in 2000.; 68% of the total deaths are men aged 25-59 y/o. A significantly larger proportion of males than females succumbed to accidents and injuries (86.85%), chronic liver diseases (86.39%), digestive diseases (75.19%), TB (71.25%), COPD (64.79%) and cardiovascular diseases (64.67%) Mortality for females is 3.9/100,000and 5.71/100,000 for males Occurrence of benign hyperplasia and prostatic malignancies 92.68% of those who died of acute pancreatitis were males 85% of HIV cases tested positive were males from 18-49

Adult Men ST for 2005-2010

Improve the overall participation of men in the health care system. Develop male-focused information system and strategic communication plans Develop and implement a health package for the Filipino adults Improve the health seeking behavior of the Filipino adults Intensify the implementation of policies and laws that protect and improve the quality of life of adult Filipinos

Essential Health Care Package for the Adult male and Female
1. 2. Management of illness Counseling on substance abuse, sexuality and reproductive tract infections Nutrition and diet counseling Mental health FP and responsible sexual behavior Dental care Screening and mgt of lifestyle related and other degenerative diseases

3. 4. 5. 6. 7.

The Adult Women

In 2000, CVD is the leading cause of death among adult women at 85.67/100,000 followed by malignant neoplasm at 54.62/100,000. Leading causes of death among women are mostly degenerative and lifestyle-related, lifestyle-related except for TB and pneumonia. Goiter is high in females And 55.62% of those who died of females. Hypothyroidism, endocrine and other metabolic disorders were females More Filipino women died of DM and thyroid problems than men at 52% and 58%, respectively. Among adult women, it is breast CA which has a death rate of 13.64/100,000, uterine malignancies at 4.09/100,000 and cervical CA at 3.88/100,000.

The Older Persons

Estimated 5M older Filipinos aged 60 y/o and above (6% of the pop) Non-CD or degenerative diseases are the leading causes of mortality: Diseases of the heart, vascular system and CA. The leading causes of morbidity are infectious in nature (influenza, pneumonia and TB) 10 leading causes for all ages, significantly most of this is COPD, fall on older persons at 70% among all age groups. The diseases which show greater % of the elderly population from dying are: CVD (66.13%), pneumonia (64%), peptic ulcer and GI disorders (56.34%) DM (52%), and TB (51%)

Goal and Objectives of Health Programs for Older Persons

Goal: Reduce morbidity and mortality of older persons and improve their quality of life Objectives: Redefine the minimum health care package for older persons Build the capacity of human health resources toward the preventive, medical and supportive care for older persons Integrate into current licensing and accreditation requirements, building facilities, equipment and personnel standards appropriate for care of older persons Develop community-based and institution-based models of health care for older persons Pursue implementation of laws and policies for the protection and improvement of the quality of life of the older persons such as the RA 9257 or the Expanded Senior Citizens Act of 2003

1. 2. 3. 4. 5. 6. 7. 8. 9.

Essential Health Care Package for the Older Persons

Management of illness Counseling on substance abuse, sexuality and reproductive tract infections Nutrition and diet counseling Mental health FP and responsible sexual behavior Dental care Screening and mgt of lifestyle related and other degenerative diseases Screening and management of chronic debilitating and infectious diseases Post-productive care

NON-COMMUNICABLE DISEASES PREVENTION AND CONTROL

Ten Leading Causes Of Mortality, Philippines

90

5 Year Average (1991-1995) & 1998 Rate Per 100,000 Population

R a t e o f D e a t h

80 70 60 50 40 30 20 10 0
Diseases of Diseases of Pneumonias Malignant Tuberculosis, Accidents neoplasms all forms the heart the vascular /cancers system
LEGEND: 5 YEAR AVERAGE (1991-1995) 1998

COPD and Allied conditions

Diabetes Mellitus

Nephritis, Other diseaNephrotic ses of respirasyndrome tory system

Causes of Death

I. INTEGRATED COMMUNITY-BASED NON-CD PREVENTION AND COMMUNITYNONCONTROL PROGRAM: Facts

It aims to prevent the 4 major non-cd diseases or the lifestyle related diseases: CVD, CA, COPD and DM. In 2002, 7 of 10 leading causes of deaths are lifestyle related. In related addition to the 4 are: accidents, kidney problems and diseases of the heart. 4, In 2005, estimated 35M deaths occurred due to these 4 contributing 60% of deaths worldwide. Based on the current trends, by the year 2020 these diseases are expected to account for 73% of death and 60% of the disease burden Globalization and social change influenced the spread of non-cd by increasing exposure to health LE of Filipinos has gone up to 69.6 yrs. The afore-cited diseases are linked by 3 major factors: tobacco smoking, physical inactivity and unhealthy diet

Goal: Reduce the morbidity, disability and premature deaths due to chronic non-cd lifestylerelated diseases Objectives: 1. Analyze the social, economic, political and behavioral determinants of NCD that will serve as bases for a. developing policy guidelines; b. setting legislative and political directions c. providing directions; financial measures to support NCDPC programs 2. Reduce exposure of individuals and population to major determinants of NCD while preventing emergence of preventable common diseases 3. Strengthen health care for people with NCD through HSR and cost effective intervention

Goal and Objectives of Non-CD NonPrevention and Control Programs

Approaches in NCDPC Programs

1. Comprehensive Approach Focused on Primary Prevention Prevention of emergence of risk factors referred to as primordial prevention Specific protection from NCD by removal of the risk factors Community2. Community-based Approach Active community participation, Involvement of community leaders, Strong support and guidance from LGU and multi-sectoral collaboration 3. Integrated Approach Considerations :
NCD and its risk factors are not to be regarded solely as health issues AND, Interventions for NCD and its major risk factors encompasses 3 levels of prevention

Key Intervention Strategies

1. Program direction and infrastructure 2. Changing environments/living
conditions

3. Changing lifestyle 4. Reorienting health services

Framework on NCD Prevention and Control

Healthy Public Policy Infrastructures for HP Investment in Health

Policy, Planning & Direction

Changing Living Conditions Environmental Audit, Intervention, & Health-Promoting Settings

Changing Lifestyles
Developing Personal Skills: Information, Education, Communication

Reorienting Health Services High-risk vs Population Approaches. Secondary and Tertiary Prevention

Roles of PHN in NCDPC

Health advocate Health educator Health care provider Community organizer Health trainer Researcher

II. Causes and Risk Factors of Major NCDS

A. Diseases of the Heart and Blood

vessels (CVD)
 Hypertension  Coronary artery diseases  Cerebrovascular Disease or Stroke

B. C. D. E.

CA DM COPD Bronchial Asthma

A. Cardiovascular Diseases
1. HPN:
Risk factors:
Family hx, advancing age, race high salt intake, obesity and excessive alcohol intake (FARSOA FARSOA)

Key areas of prevention

Encourage proper nutrition Prevent becoming obese Smoking cessation Identify people with risk factors and encourage regular check ups for possible HPN and modification of risk

2. Coronary Artery Disease/Ischemic Heart Disease

Etiology: Atherosclerosis- thickening of the walls of arteries due to fat deposits. Atherosclerosis usually occurs when there is high levels of cholesterol Risk Factors:
HPN, DM, Obesity, physical inactivity Elevated blood lipids (LDL) Smoking or tobacco use

Key areas of prevention

Promote physical activity and regular exercise Encourage proper nutrition by limiting intake of saturated fats, salt intake and increase dietary fiber, fruits and unrefined cereals Maintain body wt and prevent obesity Advise smoking cessation. Promote smoke-free envt Early dx and prompt tx of DM and HPN

3. Cerebrovascular Accident/Stroke

Etiology:
Atherosclerosis(thrombi/emboli)/HPN, aneurysms, trauma, erosion of bv due to tumors

Risk factors:
Increasing age, Sex, Family Hx, HPN, Cigarette smoking, DM, Heart disease, Socio-economic factor, Season and climate, IV drug abuse, alcohol

Key Area of Prevention

Tx and control of HPN Smoking cessation Prevent thrombus formation Limit alcohol consumption Avoid IV drug abuse and cocaine Prevent all other risk factors of atherosclerosis

B. Cancer
Causes of CA.
Heredity Normal cells transform into CA cells because of damage to DNA (inherited). Carcinogens: Polycyclic hydrocarbons, Aflatoxin, Benzoprene, Nitrosamines, Radiation and Viruses

Key areas of Prevention

Smoking cessation Encourage proper nutrition Drink alcoholic beverages in moderation Control obesity Early dx and tx

C. DM
Type II: Risk factors:
Heredity, Over wt, HDL cholesterol < 35mg/dl; Hx of GDM, previously identified to have IGT,

Key Areas of Prevention

Maintain body wt and prevent obesity Encourage proper nutrition Promote regular physical activity and exercise Advise smoking cessation RA 8191: National Diabetes Act National Diabetes Prevention and Control Program

D. COPD
Characterized by airflow limitation

Causes and risk factors:

Due to chronic bronchitis and emphysema, both are due to cigarette smoking. Cigarette smoking is the primary cause of COPD.

Complications:
Peripheral airway obstruction, parenchymal destruction, CVD (Pulmonary hypertension)

E. Bronchial Asthma
Causes and Risk Factors:
Host Factor:
Genetic predisposition, Allergy, airway hyper responsiveness, gender, race.

Envtal factors:
Indoor/outdoor allergens, Occupational sensitizers, Tobacco smoke, air pollution, Respiratory infection, parasitic infections, socioeconomic, family size, diet and drugs, obesity

Key area of Preventions

Recognize triggers that exacerbate asthma Avoid the triggers Promote exclusive breastfeeding; early introduction to cows milk may predispose baby

Risk Factors
Smoking Nutrion/Diet Phy.Inact Obesity Alcohol Elev.BP Bld.Glucose Bld. Lipids

Condition
CVD/CVA/HPN /CHD DM CA COPD/Asthma/other Respiratory Conditions

/ / / / / / / /

/ / / / / / / /

/ / / / / / / /

/ / / / / / / /

Risk Assessment Exercises

1. CAUTIONUS 2. BMI 3. WC 4. WHR 5. Interview 6. BP 7. Blood sugar A. Smoking B. Obesity C. DM D. HPN E. Nutrition F. Drinking G. Cancer

BMI= Wt in kgs/Ht in meters

N 18.6-22.9 @ risk 23-24.9; Obese I: 25-29.9 18.6-22.9; Obese II: >30

WC= M:<90cm (35in), F:<80cm(31.5in) WHR= WC in cm/HC in cm

M- less than 1; F-less than 0.85

BP= 120/80 Cholesterol level

N: <200 mg/100ml

FBS
N= 109mg/dl, Possible DM:126mg/dl

CAUTIONUS-

Roles of PHN in Risk Assessment

Educate as many people and in every opportunity on the warning signs of the NCDs Educate on how to prevent NCD RFs through a healthier diet, engaging in moderate activity and not smoking Every client should be assessed for the presence of RFs and early signs of NCDs Train other HW on performing risk factor assessment

PROMOTING PHYSICAL ACTIVITY

Minimum amount pf PA required for health Benefits: At least 30mins, cumulative, of moderate intensity most days of the week OR At least 30min, cumulative, of vigorous intensity, 3 or more days of the week

Promoting Proper Nutrition

Strategy is ABC Nutritional Guidelines
Variety of foods EBF and CF Proper diet and monitor growth regularly of children Consume fish, lean meat, poultry of dried beans More vegetables, fruits and root crops Food cooked in edible oil daily Milk, milk products and other calcium-rich foods Iodized salt but avoid excessive salty food Clean and safe food For a healthy LS and good nutrition, exercise regulaly, do not smoke and avoid drinking alcoholic beverages

Roles of PHN
Nutrition assessment Nutrition education and counseling Promoting supportive envt for healthy nutrition Encourage food gardens Campaign for nutrition friendly envt Advocate for healthy policies

Promoting a smoke free envt

Smoking: a serious problem
Associated w/ 40 diseases and 20 types of cancer

How smoking causes Harm

The more, longer, younger and deeper smoking, THE GREATER THE RISK

Harmful substances/Chemicals in tobacco

Acetone, acetic acid, ammonia, arsenic, butane, cadmium, C.Monoxide, Formaldehyde, Hydrogen cyanide, Naphthalene, Nicotine, Ethanol, Stearic acid, Vinyl chloride, etc..TAR

The good news on quitting smoking

Roles of PHN (smoking)

Assisting smokers to quit
4As
Ask (Assess, Id all tobacco users) Advise to stop coz it can cause disease and even death (Motivate, Enc. Complete cessation, Discuss alternatives Assist (Dev. Quit plan, Set Quit Date, Supplementary materials, Dev. Plan to prevent relapse) Arrange follow up( Set ff-up )

Promoting a smoke-free envt

Education and legislation (taxation) Building anti-tobacco coalition

Promoting Stress Mgt

Spirituality Self-awareness Scheduling/Time mgt Siesta Stretching Sensation Techniques Sports Socials Sound and songs Speak to me Stress debriefing Smile

Program for the Prevention and Control of Other Non-CD

NATIONAL PREVENTION OF BLINDNESS PROGRAM

Vision 2020: The Right to Sight as global partnership b/w WHO and Intl Agency for prevention of Blindness Vision: All Filipinos enjoy the right to sight by 2020 Mission:
Strengthen partnerships to eliminate avoidable blindness Empowerment of communities to take proactive roles Provide access to quality eye care Work towards poverty alleviation through preservation and restoration of sight to indigent Filipinos

General Objectives
1. Increase cataract surgical rate from 730 to 2,500 by the year 2010 2. Reduce Visual impairment due to refractive errors by 10% by the 2010 3. Reduce the prevalence of visual disability in children from 0.43% to 0.20% in 2010

Renal Disease Control Program (REDCOP)

History:
June 1994: Preventive Nephrology project with the NKTI as the implementing agency Jan. 2000: PNP was renamed through Memo No. 67-D from the DOH Kidney diseases ranks as no. 10 killer in the Philippines, causing death to 7,000 Filipinos every year

Vision: Healthy and empowered Filipinos by the year 2010- with reduced mortality and morbidity from kidney diseases and their sequelae

 Common Kidney Diseases:

Chronic glomerulonephritis Diabetic Kidney Disease Hypertensive kidney Disease Pyelonephritis ESRD

Community-Based Rehabilitation Program

Is a creative application of the PHC approach in rehabilitation for persons with disabilities Facts:
WHO: 10% of the population of developing and under developed countries is physically disabled There are 96 rehabilitation centers concentrated in major cities/urban areas Persons with disabilities are found in rural areas In 1997, there were 549,062 PWDs

 Goal: Improvement of quality of life and productivity of PWDs Objective: Reduce the prevalence of disability through prevention, early detection, and provision of rehabilitation Program Components:
Social preparation Services preparation Training Information, Education and Communication Monitoring, supervision and Evaluation Laws: RA 7277 and RA 9442

Mental Health and Mental Disorders

SubSub-programs Wellness of daily living Extreme life experiences Mental Disorder Substance abuse & other forms of addiction 4 facets of MHProblems Defined burden Undefined burden Hidden burden Future burden WH Report showed that Mental, Neurologic and substance abuse cause a large burden of disorder/disease

ENVIRONMENTAL HEALTH & SANITATION

ENVIRONMENTAL HEALTH

PI=ME + CPB Man-Disease AgentManAgentEnvironment triad

Preventive Strategies Based on the Triad

1. Change the peoples behavior to manipulate the environment and reduce their exposure to disease agents 2. Manipulate the environment to prevent production or presence of disease agents 3. Increase mans resistance or immunity to disease agents

 Is the study of all factors in mans physical environment, which may have deleterious effect on his health or wellbeing and survival Factors:
H2O sanitation Food sanitation Refuse and garbage disposal Insect vector and rodent control Housing Air pollution Noise pollution Radiological protection Institutional sanitation

Environmental Sanitation

Major Environmental Health and Sanitation Program

Health and Sanitation Water supply Sanitation program
Level I or Point Source 15-25 hh; Level II or the Communal faucet ave. of 100; Level III or the Waterworks system or Individual House connections

Proper Excreta and Sewage Disposal Program

Level I
: Non-H2O carriage facility: : Requiring small amount of h2o to flush the waste into a receiving space

Level II: on site facilities of the h2o carriage type with h2o sealed and flush type Level III: connected to septic tank and/or sewerage system to tx plant

Food Sanitation Program Hospital Waste Management Program

BOTIKA SA BARANGAY
Legal Basis: DOH Adm. Cir # 23A dtd July 5, 1996 In 2001: GMA 50

NATIONAL VOLUNTARY BLOOD DONATION PRGRAM

LEGAL BASIS Vision: Envision a network of modernized national and regional blood centers operating on a voluntary and non remunerated blood donation system Objectives:
To promote and encourage voluntary blood donation by the citizenry and to instill public consciousness of the principle is a humanitarian act. To provide adequate, safe, affordable supply of blood and blood products To mobilize all sectors to participate

Agencies in charged: DOH, PNRC, PBCC Qualifications of Donors Steps on how to donate in BCU Storage of blood donated: 4-5 wks (whole blood and red cell concentrates) and Plasma can be stored frozen for 1 yr. After donating blood
Keep on eye on the dressing Avoid carrying heavy objects Do not smoke Eat meals and increase fluid intake

List of walking blood donors in the RHU

SENTRONG SIGLA MOVEMENT

4 Pillars
1. 2. 3. 4. Quality Assurance Grants and technical assistance Health promotion Award

Programs
EPI, Disease surveillance, CARI, CDD, FP, STD/AIDS, EHS, CA control, Micronutrient supplementation, HL

HERBAL MEDICINE
10 DOH ADVOCATED HERBAL PLANTS SANTALUBBY RA 8423

HEALTH EMERGENCY PREPAREDNESS AND RESPONSE PROGRAM

PD 1566 (1978)
Creation of the NDCC, Multi-level Organizations, funding of 2% reserve for calamites

RA 7160 DOH ADM. ORDER NO. 6 S. 1999

Definition of terms:
Disaster: is a serious disruption of the functioning of a society, causing wide spread losses(human, material or environmental) which exceed the ability to cope using only its own resources Emergency: Occurrence requiring immediate response Hazards: Phenomenon which has potential to cause disruption Risk: level of loss/damage that could be predicted ( Susceptibility&Vulnerability)

RA 9482: Anti Rabies Act

(1) Pet Owners who fail or refuse to have their Dog registered and immunized against Rabies shall be punished by a fine of Two thousand pesos (P2,000.00). (2) Pet Owners who refuse to have their Dog vaccinated against Rabies shall be liable to pay for the vaccination of both the Dog and the individuals Bitten by their Dog. (3) Pet Owners who refuse to have their Dog put under observation after said Dog has Bitten an individual shall be meted a fine of Ten thousand pesos (P10,000.00). (4) Pet Owners who refuse to have their Dog put under observation and do not shoulder the medical expenses of the person Bitten by their Dog shall be meted a fine of Twenty-five thousand pesos (P25,000.00). (5) Pet Owners who refuse to put leash on their Dogs when they are brought outside the house shall be meted a fine of Five hundred pesos (P500.00) for each incident. (6) An impounded Dog shall be released to its Owner upon payment of a fine of not less than Five hundred pesos (P500.00) but not more than One thousand pesos (P1,000.00). (7) Any person found guilty of trading Dog for meat shall be fined not less than Five thousand pesos,(P5,000.00) per Dog and subjected to imprisonment for one to four years. (8) Any person found guilty of using electrocution as a method of euthanasia shall be fined not less than Five thousand pesos (P5,000.00) per act and subject to imprisonment for one to four years. (9) If the violation is committed by an alien, he or she shall be immediately deported after service of sentence without any further proceedings.