Lesson 1 Over view of Community Health Nursing in Ghana Introduction Mothers and children form about 70%of the

nations population,motality and mobidity rates were high meanwhile conditions causing them are preventable,hence the implimentation of Community health Nursing in Ghana

Objectives By the end of the lesson, the students should be able to: Identify the root of Community Health Nursing Identify supportive organizations Differentiate between Public Health Nurse and Community Health Nurse Explain Community Health Nursing Describe the qualities of the Community Health Nurse. History of Community Health Nursing The history of health visiting is bound up with the history of Maternity and Child Welfare Movement because the health visitors took care of both mother and children. MCH services started in Britain in 1782 by the MATERNITY AND Child Welfare Movement. They educated mothers on hygiene and diet of children. In 1863, another group also made up of ladies was formed because the previous group was not making much impact. They distributed tracts, pamphlets and leaflets, however this approach was still not successful. This initiated a systematic house to house visiting irrespective of creed or circumstance to educate mothers especially the poorer ones. This was effective and a lot more were added on. The aim of the Ladies groups was to popularize sanitary knowledge and devote the people physically, socially, morally and religiously. They performed by duty by dividing the area into districts where a lady superintendent, a voluntary worker and a health visitor were made responsible. In addition to home visiting, meetings were organized at which simple talks were given followed by discussion. Topics were based on personal and environmental hygiene, prevention of infection, care of children, demonstration of food and sick nursing. The health visitors were appointed by the voluntary society in the early years, but later around 1890 the Manchester and Salford Corporation paid their salaries. The corporation charged the Medical Officer of Health to become responsible for the supervision and direction of the work of the health visitors. Miss Florence Nightingale suggested a proper training programme for the health visitors which she called Health Missioners. By her efforts the first course for health visitors was started by the North Buckinghamshire Technical Committee by the Buckinghamshire Country Council from 1891-1892. Their syllabus are similar to current course content of health visitors. Sixteen women attended the lecturers, twelve entered for the examination but only six obtained the certificate. Visiting in the early years was difficult because tracing homes of new born was very difficult this gave way to the need for Birth and Death Registration Act to be passed in 1874. Again, the London Country Council, which is the local supervising authority under the Midwives Act, 1902 arranged for notification of births by the midwives, and forwarded this information weekly to the medical officer for health. This was embraced by other countries which led to the Notification of Births Act in 1907 and in 1915 notification of birth was made compulsory to all. In 1909, the London Country Council Act on Health Visitors was passed. This order required that a candidate should be qualified for appointment as a health visitor if she possessed one of the following qualifications: a medical degree, three years training as a nurse, the certificate of the Central Midwives Board not less than six months training which included childrens nursing as well as nursing of adults and the Health Visitors Certificate must possess these certificates: Nurses Training Certificate of the Central Midwives Board and Health Visitors. In 1919, the Ministry of Health was formed and the Board of Education (Health Visitors Training) Regulations were passed, it came out with two types of courses: a full course of two years duration for ordinary people who had not knowledge or experience of a special nature likely to be of value in the work of a health visitor. a shortened course of one year for trained nurses and others already possessing substantial knowledge or experience. In 1925, the training of health visitors became the responsibility of the Ministry of Health, and has been till now.The syllabus was revised in 1950. Public Health Nursing started in Ghana in about 1928. Nurses of the Princess Marie Louis Hospital (PML) in Accra were used in rendering these services. They were not trained PHN. Their duties were as follows:- Visit the children who were receiving treatment at the hospital in their homes. Assist the health sisters in running Child Welfare Clinic at the hospital.. Give talk on hygiene in the homes. In 1929, two assistant health visitors with no proper training accompanied the health inspectors in their daily house to house inspection. Cadbury and Fry Trading Company paid their salaries. In 1932, the British Red Cross Society built clinics at Koforidua and Cape Coast. They also ran mobile clinics in the surrounding villages. During this period child welfare clinic was organized in Kumasi, Osu and Kpando. They took carte of minor ailments, well babies and antenatal. The common ailments treated at that time were yaws, scabies and malnutrition.

In 1936, Health Visiting was published in the gazette. Nurses educated mothers on the importance of growth monitoring and immunization. Initially clinics were held in churches, schools, market places and cinema halls. These effort yielded positive results, mothers enjoyed food demonstration and attendance kept increasing. The health visitors distributed Tab Quinine and skimmed milk to clients. In 1950, a trained Public Health Nursing Tutor from UK was appointed for the training of Public Health Nurses in Ghana. In 1951 one of the pioneers in the person of the late Mrs. Samara Signge was sent for the tutorship course at the Royal College in London. She returned in 1952 and started the one year Public Health programme at the P.H.N.T.S. Korle Bu. The syllabus was the same as that of the royal college of nursing. Both QRNS AND SRNS with midwifery certificate were recruited for the training. The course did not attract many and the average intake was 10 even though 20 30 was expected. There is only one Public Health Nurses Training School in Ghana, however, two CHNTS. Winneba and Oda are piloting the training of Diploma in C.H.N. History of Community Health Nursing in Ghana In other to reduce infant and maternal mortality rate, control communicable diseases, promote and maintain the health of mothers and children. There was the need to train more public health nurses (PHNS) to work at the various health facilities.The training of PHNs to a long period about 7 to 8 years. They were in great demand, there was therefore the need to train assistants for a short period 2 years to assist in working in the remote areas and also to assist PHNs in the urban areas.

In 1960, the training of females with Middle School Leaving Certificate for two years for the position of C.H.N was established in Tamale. This was followed by Akim Oda in 1962, then Ho in 1965, Winneba 1980, Esiama 2001.It is the plan of the government to get Community Health Nursing institutions in the 10 regions of Ghana.The government had achieved something, we have CHNTS at Jirapa (Upper West) and Navrongo in 2001, Tanoso 2002 and finally Fomina 2004. The CHN is trained to assist the PHN in using human and material resources in the community to: promote and maintain health prevent and control communicable diseases aid rehabilitation prolong the lives of individuals and families. She is in contact with people in the community and achieve the above through health education. The Public Health Nurse (P.H.N) A PHN is a qualified state registered nurse with a certificate in midwifery and has had an additional one year training in Public Health Nursing. Currently midwifery is not a criteria since males without midwifery background are recruited for the training. Qualities of a P.H.N She in depth the knowledge in both curative and preventive She is a health educator She is a medical social worker She is a family counsellor She had a good interpreting health services that are available in relation to health problems. The C.H.N (Community Health Nurse) Is a male or female between the ages of 18 to 34 years, has an aggregate of 30 or better for 6 courses. She is an assistant to the PHN and works under his supervision.

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Community Health Nurses on the field,Image provided of FLICKr.wwwflick.com Qualities of a Community Health Nurse The CHN is in direct contact with people of different ideas, beliefs, superstition, customs and culture about health.She meets people with (different classes in the society). Meet people with different attitudes. She must therefore possess special qualities which will enable her work successfully. She must be sympathetic, empathetic and understanding She must be respectful, tolerant and patient. She must tactful, observant and co-operative She must be able to adjust and work freely with different people and different situations in the community. She must appreciate the effort of all people and correct their mistakes tactfully and not condemn. She must create good interpersonal relationship with colleagues and other health workers and clients She must be trustworthy, punctual and serious with his/her work.

Definition Health: It is a state of complete physical, mental, and social well being of an individual and not merely the absence of disease or infirmity (W.H.O). Public Health: Is the science and acts of preventing disease, prolonging life and promoting mental and physical health and efficiency through organized community efforts. Public Health: can also be defined as the science and act of preventing disease and prolonging life by using available resources in the community and involving the community members in efficiency. Public Health Nursing: Is the branch of professional nursing that utilizes human and material resources in the community for the promotion and maintenance of health, prevention and control of communicable diseases and not merely the care and rehabilitation of the sick. Nursing Virginia Henderson: Is to assist the individual, sick or well in the performance of those activities contributing to health or its recovery or to a peaceful death which he would have performed unaided if he has the necessary strength and will or knowledge and to do this in such a way as to gain independence as rapidly as possible. Community Health Nursing: Is defined as a field of nursing practice that blends knowledge ands skills from both the nursing and the public health sciences and applies them to the promotion of optimal health for the total population. (Turner and Chavigny). Community Health Nursing: Is a combination of nursing and public health practice that is, knowledge, skills and attitudes used to: o Promote and maintain good health o Prevent and control illness o Treat minor common illness o Aid rehabilitation (to help people live full normal lives after an illness or disability). The CHN provides care which is: Comprehensive: embraces all ages, all types of persons, and all conditions. Continuous: care is not just for a limited period as in hospital, but it embraces all ages and aspects of care in any community ie antenatal care, maternity, under fives clinics, school health, occupational health, care for the handicapped and elderly. Personalized: care is adapted to the particular health needs of individuals, families and communities according to needs. Areas of Work of the CHN o Homes o Villages

Schools Work places Clinics Maternity Homes, Health Centres. Who is the Registered Community Health Nurse He or she is an SSS graduate with aggregate 24 or better, who has gone through a three year diploma programme and has satisfied the examining body and been registered as a professional nurse to practice. This makes her well matured in skills to work in the community. She is therefore a health teacher, social worker, family adviser. With his background, he is able to give technical assistance in matters of nursing care, control of community diseases and on nutrition, maternal and child care (Reproductive and Child Care), School health services and environmental health. As a social worker, she is able top carry social investigation in the homes, assess the health needs of the family and interpret the services which are available to the families and the country as a whole. She knows the existing social organization and voluntary groups in her area and works though them when necessary. Objectives of Community Health Nursing Include the following,To: Provide antenatal, maternity and postnatal care to ensure safe pregnancy, delivery and puerperium for the mother and child. Provide Under Fives Clinics for: o immunization o developmental assessment o advice on nutrition and child care o treatment of minor ailments o providing encouragement and support to mothers. Provide clinics for treating adults and children for: o minor ailments o referral of major illness health education Provide facilities for family planning. Teach the correct use of common medicines and drugs and the dangers of buying medicines at the chemist and market. Explain and promote the use of local health services in the community, advising people to seek health care from safe, qualified heath personnel. Promote projects in the community that will improve life for the people there eg. Womens cooperatives, literacy programmes, provision of safe water. Teach and demonstrate healthy ways of living (health education) according to local needs. Assist in the prevention and control of communicable disease. Visit people in their own homes and villages to identify health needs and priorities, and deal with the, effectively. Promote the health of school children (through the health service.) Promote the health of the worker (occupational health). Maintain and promote the health of the elderly and handicapped. Work in close cooperation with government and other local organizations to promote health and welfare of individuals, families and communities. Duties of a Community Health Nurse Home visiting Running child welfare clinic Running family planning clinic or assisting Assist in running ANC and PHN Conducts School Health Services (Hygiene Inspection) Carries out or assist the PHN in inspection of Day Care Centres Collection of information or data from the community Health Education Record Keeping Responsibilities of the CHO The CHOs duties mainly involve: Disease Prevention Health Promotion Community Mobilization Health Information Advocacy Improvement in communication for behaviour change PRINCIPLE OF COMMUNITY HEALTH NURSING When posted to a new community under takes the following: Introduces self to the in charge and other team members.

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Surveys area to acquaint self with important structures like chiefs palace, schools churches, hospital etc. Study previous records if any to identify existing problems. Understands the peoples way of life their traditions, beliefs etc to identify useful ones and discourages harmful ones. Address health needs of the people through their own efforts and materials available in the community. Identify felt needs and put them in other of preference. Involve community members in planning and implementation of services so that she can gain support. Never decide for the people but use knowledge to educate them on service rendered. Procedures and duties must be systematic making sure that people under stand. Be familiar with organized groups and opinion leaders and work through them Help people to assume responsibility so that in your absence work can still be carried out. Do not give a promise which cannot be fulfilled. Find out how people feel about your work so that you can institute the necessary changes to suit them. Do not expect any material reward from community members. Write report on work done and submit to immediate supervisor. Assignment Break into groups of 10 and role play the qualities of CHN Question 1 Describe the trend of Community Health Nursing in Ghana. Question 2 Explain the objectives of community health nursing. Definition: The Alma Ata Conference defines Primary Health Care as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally, accessible to individuals and families in the community by means of acceptable to them, through their full participation and at a cost that community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part of both the countrys health system, of which it is the central function and the main focus and of the overall social and economic development of the community. Goal: The global goal as stated in the Alma Ata Declaration is Health for All by the year 2000 through self-reliance. Health begins at home, in schools and in the workplace because it is there where people live and work that health is made or broken. It also means that people will use better approaches than they do now for preventing diseases and alleviating unavoidable disease and disability and have better ways of growing up, growing old and dying gracefully. It also means that here will be even distribution among the population of whatever resources for health are available. It means that essential health services will be accessible to all individuals and families in an acceptable and affordable way. Principles and Strategies: 1. Accessibility, Availability, Affordability and Acceptability of Health Services o Strategies: Health services delivered where the people are Use of indigenous/resident volunteer health worker as a health care provider with a ratio of one community health worker per 10-20 households Use of traditional (herbal medicine) with essential drugs. 2. Provision of quality, basic and essential health services o Strategies: Training design and curriculum based on community needs and priorities. Attitudes, knowledge and skills developed are on promotive, preventive, curative and rehabilitative health care. Regular monitoring and periodic evaluation of community health workers performance by the community and health staff. 3. Community Participation o Strategies: Awareness, building and consciousness raising on health and health-related issues. Planning, implementation, monitoring and evaluation done through small group meetings (10-20 households cluster) Selection of community health workers by the community. Formation of health committees. Establishment of a community health organization at the parish or municipal level. Mass health campaigns and mobilization to combat health problems. 4. Self-reliance

Strategies Community generates support (cash, labor) for health programs. Use of local resources (human, financial, material) Training of community in leadership and management skills. Incorporation of income generating projects, cooperatives and small scale industries.

Recognition of interrelationship of health and development o Strategies: Convergence of health, food, nutrition, water, sanitation and population services. Integration of PHC into national, regional, provincial, municipal and barangay development plans. Coordination of activities with economic planning, education, agriculture, industry, housing, public works, communication and social services. Establishment of an effective health referral system. 6. Social Mobilization o Strategies Establishment of an effective health referral system. Multi-sectoral and interdisciplinary linkage. Information, education, communication support using multi-media. Collaboration between government and non-governmental organizations. 7. Decentralization o Strategies Reallocation of budgetary resources. Reorientation of health professional and PHC. Advocacy for political and support from the national leadership down to the barangay level. 8 Essential Health Services in Primary Health Care (ELEMENTS) 1. E Education for Health 2. L Locally endemic disease control 3. E Expanded program for immunization 4. M Maternal and Child Health including responsible parenthood 5. E Essential drugs 6. N Nutrition 7. T Treatment of communicable and non-communicable diseases 8. S - Safe water and sanitation Bag technique Definition Bag technique a tool making use of public health bag through which the nurse, during his/her home visit, can perform nursing procedures with ease and deftness, saving time and effort with the end in view of rendering effective nursing care. Public health bag - is an essential and indispensable equipment of the public health nurse which he/she has to carry along when he/she goes out home visiting. It contains basic medications and articles which are necessary for giving care. Rationale To render effective nursing care to clients and /or members of the family during home visit. Principles 1. The use of the bag technique should minimize if not totally prevent the spread of infection from individuals to families, hence, to the community. 2. Bag technique should save time and effort on the part of the nurse in the performance of nursing procedures. 3. Bag technique should not overshadow concern for the patient rather should show the effectiveness of total care given to an individual or family. 4. Bag technique can be performed in a variety of ways depending upon agency policies, actual home situation, etc., as long as principles of avoiding transfer of infection is carried out. Special Considerations in the Use of the Bag 1. The bag should contain all necessary articles, supplies and equipment which may be used to answer emergency needs. 2. The bag and its contents should be cleaned as often as possible, supplies replaced and ready for use at any time. 3. The bag and its contents should be well protected from contact with any article in the home of the patients. Consider the bag and its contents clean and /or sterile while any article belonging to the patient as dirty and contaminated.

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The arrangement of the contents of the bag should be the one most convenient to the user to facilitate the efficiency and avoid confusion. Hand washing is done as frequently as the situation calls for, helps in minimizing or avoiding contamination of the bag and its contents. The bag when used for a communicable case should be thoroughly cleaned and disinfected before keeping and re-using.

Contents of the Bag Paper lining Extra paper for making bag for waste materials (paper bag) Plastic linen/lining Apron Hand towel in plastic bag Soap in soap dish Thermometers in case [one oral and rectal] 2 pairs of scissors [1 surgical and 1 bandage] 2 pairs of forceps [ curved and straight] Syringes [5 ml and 2 ml] Hypodermic needles g. 19, 22, 23, 25 Sterile dressings [OS, C.B] Sterile Cord Tie Adhesive Plaster Dressing [OS, cotton ball] Alcohol lamp Tape Measure Babys scale 1 pair of rubber gloves 2 test tubes Test tube holder Medicines o betadine o 70% alcohol o ophthalmic ointment (antibiotic) o zephiran solution o hydrogen peroxide o spirit of ammonia o acetic acid o benedicts solution Note: Blood Pressure Apparatus and Stethoscope are carried separately. Steps/Procedures Actions 1. Upon arriving at the clients home, place the bag on the table or any flat surface lined with paper lining, clean side out (folded part touching the table). Put the bags handles or strap beneath the bag. 2. Ask for a basin of water and a glass of water if faucet is not available. Place these outside the work area. 3. Open the bag, take the linen/plastic lining and spread over work field or area. The paper lining, clean side out (folded part out). Rationale To protect the bag from contamination.

To be used for handwashing. To protect the work field from being wet. To make a non-contaminated work field or area.

4. Take out hand towel, soap dish and To prepare for handwashing. apron and the place them at one corner of the work area (within the confines of the linen/plastic lining). 5. Do handwashing. Wipe, dry with Handwashing prevents possible infection towel. Leave the plastic wrappers of the from one care provider to the client. towel in a soap dish in the bag. 6. Put on apron right side out and To protect the nurses uniform. Keeping

wrong side with crease touching the the crease creates aesthetic body, sliding the head into the neck appearance. strap. Neatly tie the straps at the back. 7. Put out things most needed for the To make them readily accessible. specific case (e.g.) thermometer, kidney basin, cotton ball, waste paper bag) and place at one corner of the work area. 8. Place waste paper bag outside of work area. 9. Close the bag. To prevent contamination of clean area. To give comfort and security, maintain personal hygiene and hasten recovery.

10. Proceed to the specific nursing care To prevent contamination of bag and or treatment. contents. 11. After completing nursing care or treatment, clean and alcoholize the things used. 12. Do handwashing again. 13. Open the bag and put back all articles in their proper places. 14. Remove apron folding away from the body, with soiled sidefolded inwards, and the clean side out. Place it in the bag. 15. Fold the linen/plastic lining, clean; place it in the bag and close the bag. 16. Make post-visit conference on matters relevant to health care, taking anecdotal notes preparatory to final reporting. To be used as reference for future visit. To protect caregiver and prevent spread of infection to others.

17. Make appointment for the next visit For follow-up care. ( either home or clinic), taking note of the date, time and purpose. After Care 1. Before keeping all articles in the bag, clean and alcoholize them. 2. Get the bag from the table, fold the paper lining ( and insert), and place in between the flaps and cover the bag. Evaluation and Documentation 3. Record all relevant findings about the client and members of the family. 4. Take note of environmental factors which affect the clients/family health. 5. Include quality of nurse-patient relationship. 6. Assess effectiveness of nursing care provided.