Public Health Community Health Nursing

According to WHO According to Dr. Araceli Maglaya

Art of applying Science in the Context of Politics so as to
Reduce Inequalities in Health while ensuring the best
health for the greatest number.
According to Dr. Charles Edward Winslow, Father of
Public Health
The utilization of the Nursing Process in the Different
Levels of Clientele-Individuals, Families, Population
Groups and Communities, concerned with the
Promotion of Health, Prevention of Disease and
Disability and Rehabilitation.
Broader -includes CHNs in both public & private sectors.

Science and Art of Preventing Disease, Prolonging CHN Process: Assessment (diagnosis is embedded)
Life, Promoting Health and efficiency Planning
Implementation
Evaluation
Goal: Maglaya
1. Promotion of Health
Through: Organized 2. Preservation of Health
Community Effort for
Nisce, et. al
"To raise the level of health of the citizenry by
Environmental Medical & Nursing Standard of helping communities and families to cope with
Sanitation services for living the discontinuities in and threats to health in
1. Early Diagnosis adequate to such a way as to maximize their potential for
Communicable 2. Preventive maintain high-level wellness"
Disease Control Treatment health
Setting: Community -place where people under usual
or normal conditions are found (villages,
Goal: to Enable Every schools, workplaces, etc.)
Citizen to Realize His -must be outside the institutional setting
Birthright to Health and (hospitals, etc. are excluded)
Longevity Nature of Practice: Comprehensive, general, continual
Not limited to a particular specialization, not
episodic, and spans the entire life cycle.
Public Health Nursing Knowledge: Integration of nursing with public health as
well as sociology, psychology, anthropology,
According to WHO Expert Committee on Nursing economics and political science
Special Field of Nursing that Combines the Skills of Important concepts to note in answering questions:
Nursing, Public Health, and Some Phases of Social 1. “Greatest good for the greatest number”
Assistance and Functions as part of the Total Public 2. Health promotion & disease prevention
Health Program for the promotion of health, the are prioritized over curative care
improvement of the conditions in the social and 3. The primary responsibility of the nurse is to
physical environment, rehabilitation of illness and the population as a whole
disability. 4. Client is an active, equal partner of the
nurse, not a passive recipient of care
5. CHN is affected by its immediate context,
the healthcare delivery system, as well as
Nursing overall political, economic, socio-cultural, and
environmental factors
6. CHN is dynamic and flexible due to varying
objective and subjective realities in different
settings
Social Public 7. Community PARTICIPATION is key!!!
Assistance Health
Remember! CHN means “The philosophy of
Community  the client CHN is based on the
Health  the goal worth and dignity of
Includes nurses in the public sector or the government. man.” -Dr. Margaret
Nursing  the means Shetland
CHN is HUMANISTIC. It is guided by these beliefs:
Humanistic values of nursing are upheld
Unique and distinct component of healthcare
Multiple factors of heath considered
Active participation of clients encouraged
Nurse considers availability of resources
Interdependence among health team members practiced
Scientific and up-to-date
Tasks of CH nurse vary with time and place
Independence or self-reliance of the people is the end-goal
Connectedness of health and development is regarded
Roles of a Community Health Nurse
Clinician
Educator
Coordinator and
Collaborator
Supervisor
Manager
Leader and
Change Agent
Researcher
■ Clinician or Health Care Provider
utilizes the nursing process in the care of the
client in the home setting through home visits
and in public health care facilities; conducts
referral of patients to appropriate levels of care
when necessary
■ Health Educator
utilizes teaching skills to improve the health
knowledge, skills and attitude of the individual,
family and the community and conducts health
information campaigns to various groups for the
purpose of health promotion and disease
prevention
■ Coordinator and Collaborator
establishes linkages and collaborative
relationships with other health professionals,
government agencies, the private sector, non-
government organizations and people's
organizations to address health problems
■ Supervisor
monitors and supervises the performance of
midwives and other auxiliary health workers; also
initiates the formulation of staff development and
training programs for midwives and other auxiliary
health workers as part of their training function as
supervisors
■ Leader and Change Agent
influences people to participate in the overall
process of community development
■ Manager
organizes the nursing service component of the
local health agency or local government unit (ex.
Nursing service plan component of the overall
municipal health plan); also, as program manager,
the PHN is responsible for the delivery of the
package of services provided by the health
program to the target clientele (ex. The PHN is
almost always the program manager of the
National Tuberculosis Program)
■ Researcher
participates in the conduct of research and utilizes
research findings in practice (ex. disease
surveillance or the continuous collection and
analysis of data on diseases and causes of death)
In the event that the Municipal Health Officer
(MHO) is unavailable or is unable to perform his
duties, the Public Health Nurse will take charge.
Specialized Fields in CHN
■ Community Mental Health Nursing
A unique clinical process which includes an
integration of concepts from nursing, mental
health, social psychology, psychology, community
networks, and the basic sciences
■ Occupational Health Nursing
The application of nursing principles and
procedures in conserving the health of workers in
all occupations
■ School Health Nursing
The application of nursing theories and principles
in the care of the school population
Three Levels of Healthcare Services
Primary Level of Care - the first contact between the community people and the different levels of health facility; refers
to health care provided by the health center staff
Secondary Level of Care - rendered by physicians with basic health training in district hospitals, provincial hospitals and
city hospitals; these facilities are capable of basic surgical procedures and simple laboratory examinations; serves as the
referral center of primary health facilities
Tertiary Level of Care - rendered by specialists in medical centers, regional hospitals and specialized hospitals like the
Heart Center of the Philippines; serves as the referral center of secondary health facilities

PRIMARY

SECONDARY

TERTIARY

Health problems that are beyond the capability of the primary health care units are referred to an intermediate health
facility like the rural health unit (RHU). The RHU team usually consists of:
» Rural Health Physician or the Municipal Health Officer (MHO)
» Dentist
» Public Health Nurse (PHN)
» Rural Health Midwife (RHM)
» Sanitary Inspector
» Community Volunteer Health Workers (CVHW) or Barangay Health Workers (BHW)
Health problems that are beyond the capability of the RHU Team are referred to the District Hospital. Clients
manifesting more complicated conditions need referral to higher levels of care. Higher levels of health services at the
provincial, regional and national levels provide secondary or tertiary care to complete the health care given at the
district and peripheral levels. With this, the functionality and strengths of the health care delivery system lie on the
strength of the referral system. The two-way referral system creates and maintains the network of health services.

Two levels of Primary Healthcare Workers

1. Village or Barangay Health Workers (V/BHWs) - refers to trained community health workers or health auxiliary
volunteers 6r traditional birth attendants or healers
2. Intermediate Level Health Workers - refers to general medical practitioners or their assistants, public health nurses,
rural sanitary inspectors, and midwives
Midwife 1:5,000 MHO 1:20,000 Dentist: 1:50,000
Nurse 1:20,000 Sanitary Inspector 1:20,000
 Village/Grassroots Health Intermediate Level Health Personnel of First-Line
Workers Hospitals
E • Trained community health • General medical • Physicians with specialization
X
A worker practitioners • Nurses
M • Auxiliary health volunteer • Public health nurses • Dentists
P • Traditional birth attendant • Midwives
L
E
C • Initial link, 1st contact of the • 1st source of professional • Establish close contact with
H
A community health care the village and intermediate
R • Works in liaison with the • Attends to health problems level health workers to
A local health service workers beyond the competence of promote the continuity of care
C
T • Provides elementary curative village health workers from hospital to community to
E and preventive health care • Provides support to the home
R
I
measures frontline health workers in • Provides back-up health
S terms if supervision, training, services for cases requiring
T referral services and supplies hospital or diagnostic facilities
I
C thru linkages with other not available in health centers,
S sectors etc.
Adapted from CENE Nursing Board Exam Review Notes Volume 2

Four Levels of Clientele in the Community Healthcare Delivery System

Individual MAJOR PLAYERS
-sick or well individuals in homes and health centers
-considered as entry point in working with the family Public Sector - tax-based
- generally free at point of service
Family
-2 or more persons bound together by blood, marriage, National level - Department of Health as lead agency
or adoption (traditional meaning) Local health system - run by local government units
-2 or more persons who are joined by bonds of sharing
and emotional closeness and who identify themselves Private Sector – usually profit-oriented but some are
as being part of the family (contemporary meaning) also non-profit orgs e.g. NGO’s like Red Cross.
-2 major functions: reproduction and socialization
-basic unit of care in CHN THE PUBLIC SECTOR
-may contribute to wellness or illness
-locus of decision-making on health matters ■ Department of Health
-solid source of support to the young, elderly, disabled,
chronically ill Vision: Leader

Population group
Advocate in promoting health for all
-a group of people sharing the same characteristics, Model
developmental stage or common exposure to
particular environmental factors thus resulting in Mission: Equitable
common health problems Sustainable Health for all Filipinos

Community Quality especially the poor

-group of people sharing common geographic
boundaries and/or common values and interests
-no 2 communities are alike
-exerts a strong influence on health of individuals,
families, and communities
-most service provisions are in the community level
Roles and Functions (based on EO 102): LACE ■ Local Government Units

Leadership in health
-Leader in the formulation, monitoring, and
evaluation of national health policies, plans, and
programs
-Advocate adoption of health policies, plans,
programs
-National policy and regulatory institution
Administrator of specific services
-Manage selected health facilities e.g. national
centers like special or tertiary hospitals
-Administer service for emerging health concerns
the require complicated technologies
-Provide emergency health response for
catastrophic events, epidemics, and widespread
public danger upon authorization by the President
The Private Sector
and consultation with the local government.
Capacity builder and Enabler Commercial Non-Commercial
-Ensure highest achievable standards of quality • Profit-oriented • Oriented to social development, relief,
rehabilitation, and community
health care, health promotion and health
organizing
protection
• Manufacturing Socio-civic groups
-Innovate new strategies in health to improve the companies Religious organizations/foundations
effectiveness of health programs • Advertising NGO’s which assume the following roles
-Initiate public discussion on health issues and agencies -Policy and Legislative advocacies
disseminate policy research outputs to ensure • Private -Organizing, Human Rights advocacies
informed public participation in policy decision- practitioners -Research and Development
making • Private -Health Resource Development
-Oversee implementation, monitoring and institutions Personnel
evaluation of national health plans, programs and -Relief and Disaster Management
policies -Networking

Goal of the DOH: Implementation of the HSRA (Health

Sector Reform Agenda)
Framework for implemention of HSRA: FOURmula One
for Health
Elements of FOURmula One for Health
GOod GOvernance – enhance performance; key
player is PhilHealth
Health FInancing – health investments
Health REgulation – quality and affordable
health goods and services
Health Service Delivery – accessibility and
availability of health services
Primary Health Care
Essential health care made universally accessible to
individuals and families in the community by means
acceptable to them, through their full participation and
at a cost that the community and country can afford at
every stage of development. --WHO
Conceptual Framework:
a. Health is a fundamental human right
b. Health is both an individual and
collective responsibility
c. Health should be an equal opportunity
to all
d. Health is an essential element of
socio-economic development
TRANSLATED into ACTION, the PHC APPROACH Structure • Health is isolated • Intra and inter-
focuses on:
from other sectors sectoral linkages
Partnership with the community of society allow health to be
integrated with
Equitable distribution of health resources over-all socio-
Organized and appropriate health system economic
infrastructure development
Prevention of disease and promotion of efforts
health is the focus Process • Decision-making • Decision-making
Linked multisectorally from top to bottom from bottom to
top
Emphasis on appropriate technology
Technology  Curative case  Promotive and
5A’s of PHC based on modern preventive care
medicine and blend traditional
vailable
sophisticated and modern
ccessible
ffordable technology medicine
cceptable  Physician  Use of
ttainable dominated appropriate
technology
Outcome • Reliance on health • People
PHC GOAL (in 1978): Health for All by the year 2000 professionals empowerment or
self-reliance
PHC was declared in Alma-Ata (now Almati),
Kazakhstan, USSR during the First International
Conference on PHC held on September 6-12, 1978 Four Pillars of PHC
through the sponsorship of WHO and UNICEF.
Use of appropriate technology
LEGAL BASIS OF PHC IN THE PHILIPPINES: Letter of
Instruction (LOI) 949 signed in October 19, 1979 by Support mechanism made available
former President Ferdinand E. Marcos Active community participation
Intra and inter-sectoral linkages
NEW GOAL for the Philippine implementation of PHC:
Health in the Hands of the People by 2020

PHC as a service delivery policy of the DOH permeates Appropriate technology means…Super Capal
all strategies and thrusts of government health FACES (SC FACES)!!!
programs from the national to the community levels.
Scope of technology – serves a variety of purposes
Dimension Commercialized Primary Complexity – should be simple and easy to apply
under local conditions
Healthcare Healthcare
Goal • Absence of the • Prevention of
disease for the disease and Feasibility – compatible with local conditions
individual • Socio-economic Acceptability – measured in terms of the degree of
development utilization of the people
Focus of • Sick • Sick and well Cost – should be affordable
Care individuals
Effectiveness – should produce the desired effect
Setting for • Hospital-based • Satellite health
Services • Urban-centered centers Safety – effect of utilization should produce no harm
• Accessible only to • Community
a few people health centers PHC is a Multisectoral Approach – recognizes intra and
• Rural-based intersectoral linkages.
• Accessible to all
People • Passive recipients • Active Intrasectoral linkages means relationship within and
of healthcare participants in between different levels of healthcare services…
healthcare
 Primary HC ELEMENTs: Sectors most closely 6. LAGUNDI
Health education related to health: Indications: Cough, Asthma, Fever, Muscle Pain
LEAPPS Preparation: Decoction or syrup
Communicable disease
control Local Governments 7. ULASIMANG BATO
Education Indications: lowers serum uric acid in gouty arthritis
Preparation: Salad or decoction
Expanded program on Agriculture 8. BAYABAS
immunization
Public Works Indications: wound cleansing, as mouthwash in cases of
Locally endemic disease oral cavity infections & gingivitis (antiseptic properties)
treatment
Population Control
Preparation: Decoction
Environmental sanitation Social Welfare
9. BAWANG
Maternal and child health Indications: lowers serum cholesterol
and family planning Preparation: May be roasted, soaked in vinegar or used
Essential drugs provision for sauteing
10. YERBABUENA
Nutrition and adequate food Indications: for muscle pain
provision
Preparation: Decoction
Treatment of emergency
cases and provision and In "23 in '93", the utilization of the 10 Herbal Plants was
provision of medical care aggressively prescribed through community wide
implementation of projects such as herbal garden in
communities
DOH-Approved Medicinal Plants
RA 8423: utilization of medicinal plants as alternative
for high cost medications.
Sambong Lagundi Policies:
Ampalaya Ulasimang bato The indications/uses of plants
The part of the plant to be used
Niyog-niyogan Bawang
Preparation of herbal medicines
Tsaang gubat Bayabas
Akapulko Yerba Buena
Guidelines:
1. SAMBONG Properly labelled herbal medicine containers
Indications: edema and urolithiasis (diuretic effect) Appropriate herbal plant to specific symptom only
Preparation: Decoction Palayok or clay pots and a wooden spoon are used
2. AMPALAYA when cooking herbal medicines
Indications: Diabetes Mellitus
Preparation: Decoction or steamed CHemical pesticides or insecticides should not be
3. NIYUG-NIYOGAN used on herbal plants
Indications: Ascaris lumbricoides intestinal infestation
Preparation: Prepare dried, mature niyug-niyugan seeds
Use only the recommended plant part
Dosage: Consume by chewing the right amount of seeds Administer only at recommended dose
two hours after meals. Repeat same dose after 1 week. Remove the pot cover when the herbal
Side-effects: stomachache, diarrhea preparation starts to boil
4. TSAANG GUBAT If the symptoms persists despite using the herbal
Indications: Stomachache medicine 2-3 times, consult the nearest physician
Preparation: Decoction
5. AKAPULKO Watch out for allergic reactions ~ if observed, stop
Indications: Ringworm, Tinea Flava, Athlete's foot and using the herbal preparation
other types of fungal infection Always keep out of reach of children
Preparation: Poultice or ointment Prepare the herbal medicine as suggested
Community Health Nursing Process x1 Preventive potential  magnitude of future
problems that can be minimized by solving this
■ Assessment x1 Salience  family’s perception of the problem
-initiate contact x3 Magnitude of the problem severity:
-collect data proportion of population affected by problem
-identify health problems Total=10
-assess coping ability
-analyze and interpret data Why Undertake Community Dx?
1. To have a clear picture of the problems of the
2 Levels of Family Assessment community and to identify the resources available to
1. First level – determine actual and potential health the community people.
problems. Answers ‘what’ questions. 2. Community diagnosis enables the nurse/program
2. Second level – determine barriers to family’s coordinator to set priorities for planning and developing
performance of tasks. Answers ‘why’ questions. programs of health care for the community. The data
Categories of Health Problems (according to priority) gathered through the process serves as the material for
1. Wellness state – readiness to achieve higher level or analysis.
state of health
Health deficit – presence of illness; gap between Types of Community Dx
actual and ideal health 1. Comprehensive Community Dx — general view
*both are equally considered as priority #1 2. Problem-oriented Community Dx – specific problem
2. Health threat – condition that promote disease or
injury Components of Community Dx
3. Stress point/foreseeable crisis – anticipated periods 1. Demographic variables
of unusual demands 2. Socio-economic and cultural variables
3. Health and illness patterns
Initial Data Base 4. Health resources
1. Family structure and characteristics 5. Political and leadership patterns
2. Socio-economic and cultural factors
3. Environmental factors Components of Community Dx
4. Health assessment of each member 1. Primary Data - source would be the community
5. Value placed on prevention of disease people through survey, interview, focused group
discussions, observation and through the actual
Family Diagnosis minutes of community meetings
Point Component 2. Secondary Data - source would be organizational
given records of the program, health center records and other
x1 Nature  (1)Deficit/Wellness, (2)Threat, public records through review of records
(3)Stress Point
x2 Modifiability  possibility of success (highly, ■ Planning
partially, or non-modifiable) -goal setting
x1 Preventive potential  magnitude of future -constructing plan of action and operational plan
problems that can be minimized by solving this
x1 Salience  family’s perception of the problem ■ Implementation
Total=5 -put nursing plan to action
-coordinate care/services
Community Diagnosis -utilize community resources
Point Component -delegate and supervise
given -provide health education
x1 Nature  health status (illness, stats), health -document responses
resource (material, manpower), health-related
(social, economic, political, environmental) 2 Levels of Nursing Intervention in CHN
x4 Modifiability  possibility of success (highly, 1. Anticipatory – primary level of prevention
partially, or non-modifiable) 2. Participatory – secondary & tertiary levels
■ Evaluation
-nursing audit
-evaluate care outcomes
-performance appraisal for workers
-estimate cost-benefit ratio (determine efficiency)
-identify necessary alterations
-revise plans
Framework for Evaluation
1. Structural elements – physical: manpower,
equipment, infrastructure
2. Process elements – actions, procedures, protocols
3. Outcome elements – changes in clients’ health status
vis-à-vis objectives and goals of care outcomes
COPAR (Community Organizing
Participatory Action Research)
CO: A Manual of Experience; PCPD
A continuous and sustained process of educating the
people to understand and develop their critical
awareness of their existing conditions, working with
the people collectively & efficiently on their immediate
and long-term problems, and mobilizing the people to
develop their capability and readiness to respond &
take action on their immediate needs towards solving
their long-term problems
Principles of COPAR
People, especially the most oppressed, exploited and
deprived sectors are open to change, have the capacity
to change, and are able to bring about change.
■ COPAR should be based on the interests of the
poorest sectors of society
■ COPAR should lead to self-reliant community and
society
Processes/Methods Used
■ A Progressive Cycle of Action - Reflection - Action
-begins with the already existing practice,
experience, and concrete conditions of the
people, sums practice up into a body of theory,
puts theory to practice…and the cycle repeats,
constantly modifying for the better.
■ Consciousness-raising through learning by
experience. Related to A-R-A cycle.
■ COPAR is Participatory and Mass-based because
it is primarily directed towards and biased in favor
of the poor, the powerless and the oppressed and
seeks to empower the masses to participate in the
changing of their conditions.
■ COPAR is Group-centered and not Leader-
oriented. Leaders are identified, emerge and are
tested through action rather than appointed or
selected by some external force or entity.
Phases of the COPAR Process
1. Pre-entry Phase
• The initial phase of the organizing process where
the community organizer looks for communities to
serve/help
• Designing criteria for the selection of site
• Actually selecting the site for community care
2. Entry Phase
• Sometimes called the social preparation phase as
the activities done here include the sensitization
of the people on the critical events in their life,
motivating them to share their dreams and ideas
on how to manage their concerns and eventually
mobilizing them to take collective action on these.
• Signals the actual entry of the community
worker/organizer into the community with the
following guidelines:
» recognize the role of the local authorities by
paying them visits to inform them of their
presence and activities
» his/her appearance, speech, behavior & lifestyle
should be in keeping with those of the
community residents without disregard of their
being role model
» avoid raising the consciousness of the community
residents; adopt a low-key profile
3. Organization-Building Phase
• Entails the formation of more formal structures
and the inclusion of more formal procedures of
planning, implementing, and evaluating
community-wide activities
• Conduct of trainings for the organized leaders or
groups to develop their skills in managing their
own concerns/programs
4. Sustenance and Strengthening Phase
• Occurs when the community organization has
already been established and the community
members are already actively participating in
community-wide undertakings
• The different committees set-up in the
organization-building phase are already expected
to be functioning by way of planning,
implementing and evaluating their own programs,
with the overall guidance from the community-
wide organization
• Strategies:
» Education and training
» Networking and linkages
» Conduct of mobilization on health
and development concerns
» Developing secondary leaders