UNIT 1: INTRODUCTION TO COMMUNITY HEALTH NURSING

Upon completion of this chapter, the student will be able to:

1. Define health and community
2. Discuss the focus of public health.
3. Explain the differences among community health nursing, public health nursing and community-
based nursing.
4. Cite the distinguishing features of community health nursing.
5. Discuss public health nursing practice in terms of public health's core functions and essential
public health functions..
6. Compare the different fields of community health nursing practice.
7. Apply the competency standards of nursing practice in the Philippines in community health
nursing practice.
8. Discuss community health nursing interventions as explained by the Intervention Wheel.
9. Outline the historical development of public health and public health nursing in the Philippines
Chapter 1: Fundamental Concepts of Community Health Nursing
 Community/ public health nursing is the synthesis of nursing practice and public health
practice.
 Major goal of CHN- preserve the health of the community and surrounding population by
focusing on health promotion and health maintenance of individual, family and group within
community.
- Thus CHN/ PHN is associated with health and identification of population at risks rather than
with an episodic response to patient demand.
 Mission of public health- is social justice that entitles all people to basic necessities, such as
adequate income and health protection, and accepts collective burdens to make possible.
 Definition of health according to:
a. WHO- “a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity.”
b. Murray- “a state of well-being in which the person is able to use purposeful, adaptive
responses and processes physically, mentally, emotionally, spiritually, and socially.”
c. Pender- “actualization of inherent and acquired human potential through goal-directed
behavior, competent self-care, and satisfying relationship with others.”
d. Orem- a state of person that is characterized by soundness or wholeness of developed
human structures and of bodily and mental functioning.”
 Social- “of or relating to living together in organized groups or similar close aggregates”
 Social health- connotes community vitality and is a result of positive interaction among groups
within the community with an emphasis on health promotion and illness prevention.
 Community- is seen as a group or collection of locality-based individuals, interacting in social
units and sharing common interests, characteristics, values, and/ or goals.
 Definition of community according to:
 a. Allender- “a collection of people who interact with one another and whose common
interests or characteristics form the basis for a sense of unity or belonging.”
b. Lundy and Janes- “a group of people who share something in common and interact with one
another, who may exhibit a commitment with one another and may share geographic
boundary.”
c. Clark- “a group of people who share common interests, who interact with each other, and
who function collectively within a defined social structure to address common concerns.”
d. Shuster and Goeppinger- “a locality-based entity, composed of systems of formal
organizations reflecting society’s institutions, informal groups and aggregates.”
 Maurer and Smith (2009)- two main types of communities:
a. Geopolitical communities- also called as territorial communities.
-are most traditionally recognized.
- defined or formed by both natural and man-made boundaries and include barangays,
municipalities, cities, provinces, regions and nations.
b. Phenomenological communities- also called as functional communities.
- refer to relational, interactive groups, in which the place or setting is more abstract, and
people share a group perspective or identity based on culture, values, history, interest and
goals.
 Population- is typically used to denote a group of people having common personal or
environmental characteristics.
 Aggregates- are subgroups or subpopulations that have some common characteristics or
concerns.

 Determinants of Health
1. Income and social status- higher income and social status are linked to better health. The
greater the gap between the richest and poor health, the greater differences in health.
2. Education- low education levels are linked with poor health, more stress and lower self-
confidence.
3. Physical environment- safe water and clean air, healthy workplaces, safe houses
communities and roads all contribute to good health.
4. Employment and working conditions- people in employment are healthier, particularly those
who have control over their working conditions.
5. Social support networks- greater support from families, friends and communities is linked to
better health.
6. Culture- customs and traditions, and the beliefs of the family and community all affect
health.
7. Genetics- inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing illnesses.
9. Personal behavior and coping skills- balanced eating, keeping active, smoking, drinking and
how we deal with life’s stresses and challenges all affect health.
10. Health services- access and use of services that prevent and treat disease influences health.
11. Gender- men and women suffer from different types of diseases at different ages.

Indicators of Health and Illness

 National Epidemiology Center of DOH, PSA and local health centers/ offices/ departments-
provide morbidity, mortality and other health status related data.
  Local health centers/ offices/ departments- are responsible for collecting morbidity and
mortality data and forwarding the information to the higher lever of health, such as Provincial
Health office.
 Nurses should participate in investigative efforts to determine what is precipitating the
increased disease rate and work to remedy the identified threats or risks.

Definition and Focus of Public Health and Community Health

 Definition of public health according to:
a. C. E. Winslow- “Public health is the science and art of (1) preventing disease, (2) prolonging
life, and (3) promoting health and efficiency through organized community effort for:
1. sanitation of the environment,
2. control communicable infections,
3. education of the individual in personal hygiene,
4. organization of medical and nursing services for the early diagnosis and preventive
treatment of disease, and
5. “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.” (Hanlon)
 Public health- key phrase definition: “through organized community effort”.
- connotes organized, legislated, and tax-supported efforts that serve all people through health
departments or related governmental agencies.
 9 Essential public health functions according to WHO Regional Office for the Western Pacific
1. Health situation monitoring and analysis
2. Epidemiological surveillance/ disease prevention and control
3. Development of policies and planning in public health
4. Strategic management of health systems and services for population health gain
5. Regulation and enforcement to protect public health
6. Human resources development and planning in public health
7. Health promotion, social participation and empowerment
8. Ensuring the quality of personal and population-based health service
9. Research, development, and implementation of innovative public health solution
 Community health- extends the realm of public health to include organized health efforts at the
community level through both government and private efforts

Health Promotion and Levels of Prevention

 Health promotion- activities enhance resources directed at improving well-being.
 Disease prevention- activities protect people from disease and effects of disease.
 Leavell and Clark’s Three Levels of Prevention
1. Primary prevention- relates to activities directed at preventing a problem before it occurs by
altering susceptibility or reducing exposure for susceptible individuals.
2. Secondary prevention- early detection and prompt intervention during the period of early
disease pathogenesis.
- implemented after a problem has begun but before signs and symptoms appear and targets
populations who have risk factors (Keller).
3. Tertiary prevention- targets populations that have experienced disease or injury and focuses
on limitations of disability and rehabilitation.
 -AIM: reduce the effects of disease and injury and to restore individuals to their optimum level
of functioning.

Community Health Nursing

-global or umbrella term; broader and more general specialty area that encompasses subspecialties
that include public health nursing, school nursing, occupational health nursing, and other developing
fields of practice, such s home health, hospice care, and independent nurse practice
-“the synthesis of nursing practice and public health practice applied to promoting and preserving
health of the populations (ANA, 1980)
Public Health Nursing
- a component or subset of CHN
- the synthesisof public health and nursing practice
PHC according to FREEMAN (1963):
- Public Health Nursing may be defined as the field of professional practice in nursing and in public
health in which technical nursing, interpersonal, analytical, and organizational skills are applied to
problems of health as they affect the community. These skills are applied in concert with those of other
persons engaged in health care, through comprehensive nursing care of families and other groups and
through measures for evaluation or control of threats to health, for health education of the public and
for the mobilization of the public for health action.
PHC according to ANA (1996):
- “the practice of promoting and protecting the health of populations using knowledge from nursing,
social and public health sciences”
- “population-focused, with the goals of the promoting health and preventing disease and disability for
all people through the creation of conditions in which people can be healthy.
Community-based Nursing
- application of the nursing process in caring for individuals, families and group where they live, work go
to go school or they move through the health care system
- setting-specific, and the emphasis is on acute and chronic care and includes practice areas such as
home health nursing and nursing in outpatient or ambulatory setting.
CHN vs. Community-based Nursing
CHN – emphasizes preservation and protection of heath
- the primary client is the community

Community-based Nursing
- Emphasizes on managing acute and chronic
 - the primary clients are the individual and the family
Population-focused Nursing:
-concentrates on specific groups of people and focuses on health promotion and disease prevention,
regardless of geographical location (Baldwin et al., 1998)
-focused practice:
1. focuses on the entire population
2. is based on assessment of the populations’ health status
3. considers the broad determinants of health
4. emphasizes all levels of prevention
5. intervenes with communities, systems, individuals and families
- goal:
promote healthy communities
CHN practice requires the ff. types of data for scientific approach and population:
1. the epidemiology or body of knowledge of a particular problem and its solution
2. information about the community

Types of information Sources

Demographic Vital Statistics; census
Groups at high risk Health statistics; disease statistics
Services/providers City directors, phone books, local/regional social workers, list of low income
available providers, CH nurse
Family – basic unit of care in CHN
Individual –focus in the clinic or health center
The Intervention Wheel
- proposed in the late 1990s by nurses from the Minnesota Department of Health to describe the
breadth and scope of public health nursing
practice; recognized as a framework for community and public health practice
- consist of 17 health interventions are grouped into 5 wedges

3 Important Elements:
1. It is population-based
2. It contains 3 levels of practice (Community, systens and individual/family)
3. It identifies and defines 12 public health interventions
Public Health Interventions and Definition (Keller et al., 2004)
  Surveillance – monitors health events
 Disease and other health event investigation – systematically gathers and analyzes data
regarding threats to the health of populations
 Outreach – locates populations of interests or populations at risk
 Screening – identifies indiduals with unrecognized health risk factors
 Case finding – identifies risk actors and connects them with resources
 Referral and follow-up – assists individuals and families, families, groups, organizations ad
communities to identify and access necessary resources
 Case management – optimizes self-care capabilities of individuals and families
 Delegated functions – direct care tasks that the nurse carries out
 Health teaching – communicates facts, ideas and skills that change knowledge, attitudes values,
behaviors and practice
 Counseling – establishes an interpersonal relationships; with the intention of increasing or
enhancing their capacity for self-care and coping
 Consultation – seeks information and generates optional solutions to perceived problems
 Collaboration – commits two or more persons or an organization
 Coalition building – develops alliances among organizations
 Community organizing – helps community groups to identify common problems or goals
mobilizes resources and develop and implement strategies
 Advocacy – pleads someone’s cause or acts on someone’s behalf
 Social marketing – utilizes commercial marketing principles for programs
 Policy development and enforcement – place issues on decision makers’ agendas, acquires plan
of resolution
EMERGING FIELDS OF CHN IN THE PHILIPPINES
 HOME HEALTH CARE – this practice involves providing nursing care nursing care to
individuals and families in their own places of residence mainly to minimize the effects of
illness and disability.
 HOSPICE HOME CARE – homecare rendered to the terminally ill. Palliative care is particularly
important

ENTREPRENURSE
- A project initiated by the Department of Labor and Employment (DOLE), in collaboration with
the Board of Nursing of the Philippines, Department of Health, Philippines Nurses Association
and other stakeholders to promote nurse entrepreneurship by introducing a home health care
industry in the Philippines. It aims to:
1. Reduce the cost of health care for the countries indigent population by bringing primary
health care services to poor rural communities
2. Maximize employment opportunities for the ountries unemployed nurses
3. Utilize the countries unemployed human resources for health for the delivery of public
health services and the achievement of the country’s Millenium Development Goals (MDG)
on maternal and child health, (DOLE, 2013)
MAIN PURPOSE OF ENTRPRENURSE
 - To deliver home health care services
COMPETENCY STANDARDS IN CHN
1. Safe and Quality Nursing Care
-knowledge of health/illness status of the client, sound decision making ; safety, comfort, privacy,
administration of meds and health therapeutics and nursing process.
2. Management of resources and environment
- organization of workload; use of financial resources for client care; mechanism to ensure proper
functioning of equipment and maintenance of a safe environment
3. Health Education
- assessment of client’s learning needs; development of health education plan and learning materials
and implementation and evaluation of health education plan
4. Legal Responsibility
- adherence to the nursing laws as well as to national, local and organizational policies including
documentation of care given to clients.
5. Ethico-moral Responsibility
- respect for the rights of the client; responsibility and accountability for own decisions and actions; and
adherence to the international and national codes of ethics for nurses
6. Personal and Professional Development
- identification of own learning needs, pursuit of continuing education; involvement in professional
image; positive attitude towards change and criticism

7. Quality Improvement
- data gathering for quality improvement; participation in nursing rounds; identification and reporting of
solutions to identifies problems related to client care.
8. Research
- research-based formulation of solutions to problems in client care and dissemination and application
of research findings
9. Records Management
- accurate and updated documentation of client care while observing legal imperatives and record
keeping
10. Communication
- uses therapeutic communication techniques, identities verbal and nonverbal cues, responds to client
needs, while using formal and informal channels of communication and appropriate information
technology
11. Collaboration and Teamwork
- establishment of collaborative relationship with colleagues and other members of health team

HISTORYOF PUBLIC HEALTH AND PUBLIC HEALTH NURSING IN THE PHILIPPINES

1577 - Franciscan FriarJuan Clemente opened medical dispensary in Intramuros for the indigent
1690 – Dominican Father Juan de Pergero worked toward installing a water system in San Juan del
Monte and Manila
1805 – smallpox vaccination was introduced by Francisco de Balmis , the personal physician of King
Charles IV of Spain
1876 – first medicos titulares were appointed by the Spanish government
1888 - 2-year courses consisting of fundamental medical and dental subjects was first offered in the
University of Santo Tomas. Graduated were known as “cirujanosministrantes” and serve as male nurses
and sanitation inspectors
1901 – United States Philippines Commission, through Act 157, created the Board of Health of the
Philippine Islands with a Commisioner of the Public Health ,as its chief executive officer (now the
Departmnt of Health
Fajardo Act of 1912 – created sanitary divisions made up of one to four municipalities. Each sanitary
division had a president who had to be a physician
1915 - the Philippine General hospital began to extend public health nursing services in the homes of
patients by organizing a unit called Social and Home Care services
Asociacion Feminista Filipina (1905) – Lagota de Leche was the first center dedicated to the service of
the mothers and babies
1947 – the Department of Health was reorganized into bureaus: quarantine, hospitals that took charge
of the municipal and charity clinics and health with the sanitary divions under it.
1954 – Congress passed RA 1082 or the Rural Health Act that provided the creation of RHU in every
municipality
RA 1891 – enacted in 1957 amendd certain provisions in the Rural Health Act
- Created 8 categories of rural health units corresponding to the population size of the
municipalities
RA 7160 (Local Government Code) – enacted in 1991, amended that devolution of basic health services
incuding health services, to ocal government units and the establishment of a local health board in every
province and city of municipality
Millennium Development Goals – adopted during the world summit in September 2000
FOURmula One (F1) for health, 2005 and Universal Health Care in 2010 – agenda launched in 1999
Universal Health Care – aims to achieve the health system goals of better health outcomes, sustained
health financing, and responsive health system that will provide equitable access to health care
Chapter 2: THEORETICAL FOUNDATIONS OF COMMUNITY HEALTH NURSING PRACTICE
Upon completion of this chapter, the students will be able to:
1. Describe different theories and their application to community/public health nursing.
2. Critique a theory in regard to its relevance to population health issues.
3. Explain how theory-based practice achieves the goals of community/public health nursing by
protecting and promoting the public's health.

 Historical Perspectives on Nursing Theory

 Florence Nightingale was the first nurse to formulate a conceptual foundation for nursing
practice.
 She believed that clean water, clean linen, access to adequate sanitation and a quiet
environment would improve health outcomes.
 Other early nursing theories were extremely narrow and depicted health care situations
that involved only one nurse and one patient. Noticeably, the family and other health care
professionals were absent from the context of the theories.
 From 1980 onwards, several nursing theorists including, Dorothy Johnson, Sister Callista
Roy, Imogene King, Betty Neuman and Jean Watson have included community
perspectives in their definition of health.
 How Theory Provides Direction to Nursing
 The goal of theory is to improve nursing practice by acting as a guide.
 General Systems Theory
 The General Systems Theory is the basis, in part, of several nursing theories.
 It is applicable to the different levels of the community health nurse’s clientele:
individuals, families, groups or aggregates and communities.
 The client is considered as a set of interacting elements that exchange energy, matter or
information with the external environment to exist (Katz and Kahn, 1966; von Bertalanffy,
1968)
 This theory is useful when analyzing interrelationships of the elements within the client
and the environment
 For example: the family has the basic structures that all open systems have.
 It has boundaries that separate it from its environment.
 Culture and the Family Code dictate the boundaries of the Filipino Family.
 The Family Environment constitutes everything outside its boundaries that may affect
it; the family home and the community and its institutions make up the immediate
environment and should be considered in the assessment of family health status.
 The family gets inputs of matter (food, water), energy, and information from the
environment
 Outputs are material products, energy and information that result from the family’s
processing of inputs. Examples are health practices and the health status of the family
members.
 Feedback is the information from the environment directed back to the system, it
allows the system to make the necessary adjustments for better functioning.
(a) For example: a nurse’s feedback to a mother that her child is underweight makes
the mother more aware of her child’s needs and allows her to take action.
 Subsystems are the components of a system that interact to accomplish their own
purpose. (Family members)
 Suprasystems are a bigger system composed of families who interrelate with and
affect one another. (Families)
 Social Learning Theory
 It is based on the belief that learning takes place in a social context; people learn from one
another and learning is promoted by modeling or observing other people.
 It assumes that all personas are thinking beings that are capable of making decisions and
acting according to expected consequences of their behavior.
 The environment affects learning but learning outcomes depend on the learner’s
individual characteristics.
 Application of the theory can be done by:
 Catching the person’s attention with different strategies
 Promoting retention of learning
 Providing opportunities for reproduction or imitation of the procedures
 Motivating the person by explaining the benefits possible by practicing the behavior
 The Health Belief Model
 Initially proposed in 1958, the model provides the basis for much of the practice of health
education and promotion today.
  This model found that information alone is rarely enough to motivate people to act for
their health. Individuals must know what to do and how to do it before they can take
action.
Concept Definition
Perceived susceptibility One’s belief regarding the chance of getting
a given condition
Perceived severity One’s belief in the seriousness of a given
condition
Perceived benefits One’s belief in the ability of an advised
action to reduce the health risk or
seriousness of a given condition
Perceived barriers One’s belief regarding the tangible and
psychologicalcosts of an advised action
Cues to an action Strategies or conditions in one’s
environment that activate readiness to take
action
Self-efficacy One’s confidence in one’s ability to take
action to reduce health risks
 The model’s concepts all relate to the client’s perceptions
 For example: the cue to action in the prevention of dengue fever may be provided
through an information campaign. This makes the people in a barangay aware of the
disease and that everyone is susceptible to the possibly fatal disease. The HBM would be
used by the nurse to help clients in making behavior modifications to avoid dengue.
 Milio’s Framework for Prevention
 Milio (1976) proposed that health deficits often result from an imbalance between a
population’s health needs and its health sustaining resources.
 She stated that diseases associated with excess occurred in affluent societies (obesity) and
diseases that result from inadequacies in food, shelter and water afflict the poor.
Therefore, poor people in affluent societies experience the least desirable combination of
factors.
 Personal and societal resources affect the range of health promoting or health damaging
choices available to individuals. Personal resources include the individual’s awareness,
knowledge and health beliefs. Money and time are also personal resources.
 She proposed that most human beings make the easiest choices available to them most of
the time. Health promoting choices must be more readily available and less costly than
health damaging options for individuals to gain health.
 This theory is broader than the HBM, it includes economic, political and environmental
health determinants rather than just the individual’s perceptions.
 This theory encourages the nurse to understand health behaviors in the context of their
societal milieu.
 Pender’s Health Promotion Model
 The model explores many biopsychosocial factors that influence individuals to pursue
health promotion activities.
 Constructs/Variables of HPM
Individual Each person’s unique characteristics and experiences affect
characteristics and his or her actions. Their effect depends on the behavior in
experiences question
Prior related Prior behaviors influence subsequent behavior through
behavior perceived self-efficacy, benefits, barriers and affects related
to that activity. Habit is also a strong indicator of future
behavior.
Behavior specific In the HPM, these variables are considered to be very
cognitions an affect significant in behavior motivation. They are a “core” for
intervention because they may be modified through nursing
actions assessment of the effectiveness of interventions is
accomplished by measuring the change in these variables.
Perceived benefits of The perceived benefits of a behavior are strong motivators o
action that behavior. These motivate the behavior through intrinsic
and extrinsic benefits. Intrinsic benefits include increased
energy and decreased appetite. Extrinsic benefits include
social rewards such as compliments and monetary rewards.
Perceived barriers to Barriers are perceived unavailability, inconvenience, expense,
action difficulty or time regarding health behaviors
Perceived self- Self-efficacy is one’s belief that he or she is capable of
efficacy carrying out a health behavior. If one has high self-efficacy
regarding a behavior, one I more likely to engage in that
behavior than if one has low self-efficacy.
Activity related affect The feelings associated with a behavior will likely affect
whether an individual will repeat or maintain the behavior
Interpersonal I the HPM, these are feelings or thoughts regarding the
influences beliefs or attitudes of others. Primary influences are family,
peers, and health care providers.
Situational influences These are perceived options available, demand
characteristics, and aesthetic features of the environment
where the behavior will take place.
For example, a lovely day will increase the probability of one
taking a walk; the fire code will prevent one from smoking
indoors.
Commitment to a Pender states that “commitment to a plan of action initiates a
plan of action behavioral event”. This commitment will compel one into the
behavior until completed, unless a competing demand or
preference intervenes.
Immediate These are alternative behaviors that one considers as possible
competing demands optional behaviors immediately prior to engaging in the
and preferences intended, planned behavior. One has little control over
competing demands, but one has great control over
competing preferences
Health promoting This is the goal or outcome of the HPM. The aim of health
behavior promoting behavior is the attainment of positive health
outcomes
  The model depicts complex multidimensional factors which people interact with as they
work to achieve optimum health.

 The Transtheoretical Model

 This model combines several theories of intervention.
 It is based on the assumption that behavior change takes place over time, and progresses
through stages
 Each stage is stable and is open to change; Meaning one may stop in one stage, progress
to the next stage or return to a previous stage.

Core constructs of the TTM

Stages of change
Precontemplation Individual has no intention to take action toward
behavior change in the next 6 months. May be in
this phase due to a lack of information about the
consequences of the behavior or due to failure on
previous attempts at change.
Contemplation The individual has some intention to take action
toward behavior change in the next 6 months.
Weighing pros and cons to change.
Preparation The individual intends to take action within the
next month, and has taken steps toward behavior
change. Has a plan of action.
Action The individual has changed overt behavior for
less than 6 months. Has changed behavior
sufficiently to reduce risk of disease
Maintenance The individual has changed overt behavior for
more than 6 months. Strives to prevent relapse.
The phases may last months to years.
Decisional balance
Pros The benefits of behavior change
Cons The costs of behavior change

 Change is difficult. People may resist change for many reasons. Change may be
unpleasant, require giving up pleasure, be painful, stressful, etc.
 PRECEDE-PROCEED Model
 It provides a model for community assessment, health education planning, and
evaluation.
 PRECEDE, which stands for predisposing, reinforcing and enabling constructs in
educational diagnosis and evaluation is used for community diagnosis.
  PROCEED, stands for policy, regulatory, and organizational constructs in education and
environmental development, is a model for implementing and evaluating health programs
based on PRECEDE.
 Predisposing factors: people’s characteristics that motivate them toward health related
behavior.
 Enabling factors: conditions in people and the environment that facilitate or impede
health related behavior.
 Reinforcing factors: feedback given by support persons or groups resulting from the
performance of health related behavior

CHAPTER 3: PRIMARY HEALTH CARE

Upon completion of this chapter student should be able to:

1. Define primary health care
 2. Ex plain the definition of health by WHO
3. Outline historical background of PHC
4. Enumerate the key principles of PHC
5. Cite the difference between PHC approach and primary care

SEPTEMBER 6-12, 1978 - first International Conference for PHC at Alma Ata, USSr, Russia
L.O.I. 949- legal basis for PHC in the Philippines
- signed by Pres. Ferdinand Marcos
- THEME : Health in the Hands of the People by 2020
Definition - the essential care made universally accessible to individuals and families in the community
through their full preparation.
Universal Goal - Health For All by the Year 2000
- this is achieved through community and individual self-reliance

5 KEY ELEMENTS :
1. Reducing exclusion and social disparities in health (universal coverage).
2. Organizing health services around people’s needs and expectations (health service
reforms).
3. Integrating health into all sectors (public policy reforms).
4. Pursuing collaborative models of policy dialogue (leadership reforms).
5. Increasing stakeholder participation.

8 Essential Health Services

E - Education for health
L - Locally endemic disease control
E - Expanded program for immunization
M - Maternal and child health including responsible parenthood
E - Essential drugs
N - Nutrition
T - Treatment of communicable and noncommunicable diseases
S - Safe water and sanitation

KEY PRINCIPLES
1. 4 A’s :
A. Accessibility - distance/travel time required to get to a health care facility/services.
- the home must be w/in 30 min. from the Brgy. health stations
B. Affordability - consideration of the individual, family, community and government can
afford the services
- the out-of-pocket expense determines the affordability of health care.
- in the the Philippines, government insurance is covered through PhilHealth
C. Acceptability - health care services are compatible with the culture and traditions of the
population.
D. Availability - is a question whether the health service are offered in health care facilities or
is provided on a regular and organized manner.
Examples :
* Botika ng Bayan and Botika ng Bayan - ensures the availability and accessibility of affordable
essential drugs. It sells low-priced generic home remedies, OTC and common antibiotics.
* Ligtas sa Tigdas ang Pinas - mass door-to-door measles immunization campaign.
- targetage : 9 months to below 8 y.o.
1. Support mechanism - there are 3 major resources:
1. People
2. Government
3. Private Sectors (e.g. NGO, church…)

1. Multisectoral approach
• Intrasectoral linkages (Two - way referral sys.) — communication, cooperation and
collaboration within the health sectors.
• Intersectoral Linkages - between the health sector and other sectors like education,
agriculture and local gvn. officials.

1. Community participation - a process in which people identify the problems and needs and
assumes responsibilities themselves to plan, manage, and control.

2. Equitable distribution of health resources

2 DOH programs to ensure equitable distribution:
• Doctor to the Barrio (DTTB) Program
- the deployment of doctors to municipalities that are w/o doctors.
- deployed to unserved, economically depressed 5th or 6th class municipalities for 2 years.
• Registered Nurses Health Enhancement and Local Service (RN HEALS)
- training and program for unemployed nurse
- deployed to unserved, economically depressed municipalities for 1 year.

2. Appropriate technology - health technology includes:

- tools
- drugs
- methods
- procedures and technique
- people’s technology
- indigenous technology

Criteria for Appropriate health technology

• Safety
• Effectiveness
• Affordability
• Simplicity
• Acceptability
• Feasibility and Reliability
• Ecological effects
• Potential to contribute to individual and community development
R.A. 8423 - Traditional and Alternative Medicine Act of 1997 (Juan Flavier)

Medicinal Plants Use/indication Preparation

Lagundi Asthma, cough and colds, fever, dysentry, pain Decoction

Skin disease (scabies, ulcer, eczema), wounds Wash affected site with decoction

Yerba Buena Headache, stomachache Decoction

Cough and colds Infusion
Rheumatism, Asthritis Massage sap

Sambong Antiedema/antiurolithiasis Decoction

Tsaang Gubat Diarrhea Decoction

Stomachache

Niyog-niyogan Antielminthic Seeds are used

Bayabas Washing wounds Decoction

Diarrhea, gargle, toothache

Akapulko Antifugal Poultrice

Ulasimang Bato/ Lowers blood uric acid (rheumatism and gout) Decoction
Pansit-pansitan Eaten raw

Bawang Hypertension, lowers blood cholesterol Eaten raw/fried

Toothache Apply on part

Ampalaya Diabetes mellitus (mild non-insulin-dependent) Decoction

Steamed
Medicinal Plant Preparation
1. DECOCTION - boiling the plant material in water for 20 min.
2. INFUSION - plant material is soaked in hot water for 10 - 15 minutes.
3. POULTRICE - directly apply plant material on the affected part, usually in bruises, wounds
and rashes.
4. TINCTURE - mix the plant material in alcohol.
Alternative health care modalities
Term Definition

Acupressure - application of pressure on acupuncture pts. w/o puncturing the skin

Acupuncture - uses special needles to puncture and stimulate specific part of the body

Aromatherapy - combines essential aromatic oils to then applied to the body

Nutritional -“nutritional healing”, this improves health by enhancing the nutritional value to
therapy reduce the risk of the disease

Pranic Healing - follows the principle of balancing energy

Reflexology - application of pressure on the body’s reflex joints to enhance body’s natural healing.
PRIMARY CARE
- includes health promotion, disease prevention, health maintenance, counseling, patient education and
diagnosis and treatment of acute and chronic illness in different health settings (American Association of
Family Medicine)
- refers to the first contact of a person with a professional
- a model of nursing care that emphasizes continuity of care
- nursing care is directed towards meeting all the patient’s need.

PHC PC

Focus of client family and community individual

Focus of care promotive and preventive curative

Decision-making process community-centered health worker driven

Outcome self-reliance reliance on health workers

Setting for services rural-based satellite clinics; mostly urban places; hospital,
community health centers clinics

Goal development and preventive care absence of disease

CHAPTER 6
: FAMILY HEALTH NURSING
Upon completion of this chapter, the student will be able to :
1. State a definition of family.
2. Identify characteristics of the family that have implications for community health nursing
practice.
3. Define family nursing.
4. Utilize the nursing process in the care of individuals within the family and the care of the family
as a whole.
5. Describe the different types of family-nurse contacts.
6. Depict provision of nursing care during a home visit.
7. Apply the principles of bag technique during a home visit.

Family Data Analysis

  Data analysis is done by comparing findings with accepted standards for individual family
members and for the family unit.
 The nurse correlates findings in the different data categories and checks for significant gaps in
information or the need for more details related to a finding.

System of Organizing Family Data (adapted from Nies and McEwen, 2011)
 Family Structure and characteristics are reflected in:
- Data on household membership
- Demographic characteristics
- Family members living outside the household
- Family mobility
- Family dynamics (emotional bonding, authority and power structure, autonomy of
members, division of labor, and patterns of communication, decision making, and problem
and conflict resolution).
- Data on family structure can be visualized clearly through graphic tools such as genogram
ecomap and family tree.

 Socioeconomic characteristics include:

- Data on social integration (ethnic origin, languages and dialects spoken, and social
networks)
- Educational experiences and literacy
- Work history
- Financial resources Leisure time interests
- Cultural influences
- Spirituality or religious affiliation

 Family environment
- Refers to the physical environment inside the family’s home/residence and its
neighbourhood.

 Family health and health behaviour include:

- Family’s activities of daily living
- Self care
- Risk behaviours
- Health history
- Current health status
- Health care resources (home remedies and health services)

Family Nursing Diagnosis

 Nursing diagnoses may be formulated at several levels:
- As a Individual family members
- As a family unit
- As the family in relation to its environment/community.
  International (NANDA-I, 2011)
- Serve as a common framework of expressing human responses to actual and potential
health problems.

 Family Coping Index

- This tool is based on premise that nursing action may help a family in providing for a
health need or resolving a health problem by promoting the family’s coping capacity.

Nine areas of assessment of the Family Coping Index (Freeman and Heinrich, 1981):
 Physical Independence – Family members’ mobility and ability to perform activities of daily
living (personal hygiene)
 Therapeutic Competence – Ability to comply with prescribed or recommended procedures and
treatments to be done at home.
 Knowledge of Health Condition – Understanding of the health condition or essentials of care
according to the developmental stages of family members.
 Application of principles of personal and general hygiene – practice of general health promotion
and recommended preventive measures.
 Health Care Attitudes – family’s perception of health care in general.
 Emotional Competence – Degree of emotional maturity of family members according to their
developmental stage.
 Family living patterns – Interpersonal relationships among family members, management of
family finances, and the type of discipline in the home.
 Physical Environment – includes home, school, work, and community environment that
influence the health of family members.
 Use of community facilities – ability of the family to seek and utilize, as needed, both
environment-run and private health.

Formulating the plan of Care

 Planning involves priority setting, establishing goals and objectives, and determining appropriate
interventions to achieve goals and objectives.
 Stancope and Lancaster (2010): The nurse’s role at this stage consists of offering guidance,
providing information, and assisting the family in the planning process.
 Priority setting – determining the sequence in dealing with identified family needs and
problems.

- Family safety: A life threatening situation is given top priority.

- Family perception: Priority is given to the need that the family recognizes as urgent or
important.
- Practicality: Together with the family the nurse looks into existing resources and
constraints.
- Projected effects: The immediate resolution of a family concern gives the family a sense of
accomplishment and confidence in themselves and the nurse.

Establishing Goals and Objectives

  Goal – Desired observable family response to planned interventions in response to a
mutually identified family need.
 Objectives – the desired step by step family responses as they work toward a goal.
- Workable, well stated objectives should be SMART:
- S: Specific
- M: Measurable
- A: Attainable
- R: Relevant
- T: Time bound

Determining Appropriate Interventions

Freeman and Heinrich categorize nursing interventions into three types:
1. Supplemental interventions – actions that nurse performs on behalf of the family when it is
unable to do things for itself.
2. Facilitative interventions – actions that remove barriers to appropriate health action such as
assisting the family to avail of maternal and early child care services.
3. Developmental interventions – aim to improve the capacity of the family to provide for its own
health needs such as guiding the family to make responsible health decisions.

Implementing the Plan of Care

 Implementation is the step when the family or the nurse execute the plan of action.

Evaluation
 To evaluate is to determine or fix the value.
 Formative evaluation – judgment made about effectiveness of nursing interventions as
they are implemented.
 Summative evaluation – determining the end results of family nursing care and usually
involves measuring outcomes or the degree to which goals have been achieved.
 Aspects of evaluation:
- Effectiveness – determination of whether goals and objectives were attained.
- Appropriateness – suitability of the goals/objectives and interventions
- Adequacy – degree of sufficiency of goals/objectives and interventions
- Efficiency – relationship of resources used to attain the desired outcomes

Family-Nurse Contacts
 The family-nurse relationship is developed through family-nurse contacts, which may take the
form of a clinic visit, group conference, telephone contact, written communication, or home
visit.

 Clinic Visit – takes place in a private clinic health center, barangay health station.
- Major advantage is the fact that a family member takes the initiative of visiting the
professional health worker, usually indicating the family readiness to participate in the
health care process.
- Because the nurse has greater control over the environment, distraction are lessened and
the family may feel less confident to discuss family health concerns.
  Group Conference – appropriate for developing cooperation, leadership, self-reliance and or
community awareness among group members.
- The opportunity to share experiences and practical solutions to common health concerns
is a strength of this type of family-nurse contact.
 Written Communication – used to give specific information to families, such as instructions given
to parents through school children.

Home Visit
 Home visit is a professional, purposeful interaction that takes place in the family’s residence
aimed at promoting, maintaining and restoring the health of the family or its members.

Advantages:
1. It allows first hand assessment of the home situation.
2. The nurse is able to seek out previously unidentified needs.
3. It gives the nurse an opportunity to adapt interventions according to family resources.
4. It promotes family participation and focuses on the family as a unit.
5. Teaching family members in the home is made easier by the familiar environment and the
recognition of the need to learn as they are faced by the actual home situation.
6. The personalized nature of home visit gives family a sense of confidence in themselves and
in the agency.

Disadvantages:
1. The cost in terms of time and effort.
2. There are more distractions because the nurse is unable to control the environment.
3. Nurse’s safety.

Phases of Home Visit

 Previsit phase – Nurse contacts the family, determines the willingness for a home visit, and sets
an appointment with them.
 A plan for the home visit is formulated during this phase. The ff. are specific principles in
planning for a home visit:
 Being a professional contact with the family, the home visit should have a purpose.

Purposes:
- To have a more accurate assessment
- To educate the family about measures of health promotion, disease prevention and control of
health problems.
- To provide supplemental interventions for the sick, disabled or dependent family member.
- To provide family with greater access to health resources in the community.
 Use information about the family collected from all possible sources such as records, other
personnel or agency, or previous contacts with the family.
 The home visit plan focuses on identified family needs, particularly needs organized by the
family as requiring urgent attention.
 The client and the family should actively participate in planning for continuing care.
 The plan should be practical and adaptable.

In-home phase
  This phase begins as the nurse seeks permission to enter and lasts until he or she leaves the
family’s home. It consists of initiation, implementation, and termination.
 Initiation – It is customary to knock or ring the doorbell and at the same time, in areasonably
loud but nonthreatening voice say, “Tao po. Si Jenny poi to, nurse sa health center?.”
- On entering the home, the nurse acknowledges the family members with a greeting and
introduces himself and the agency he represents.
- Observes environment for his own safety and sits as the family directs him to sit.
- Establish rapport by initiating a short conversation.
- States the purpose of the visit the source of information.
 Implementation – Involves the application of the nursing process, assessment, provision of
direct nursing care as needed, and evaluation.
 Termination – Consists of summarizing with the family the events during the home visit and
setting a subsequent home visit or another form of family-nurse contact.
- Use this time to record findings, such as vital signs of family members and body weight.

Postvisit phase
 Takes place when the nurse has returned to the health facility.
 Involves documentation of the visit.

The Nursing Bag

 Frequently called the PHN bag is a tool used by the nurse during home or community visits to be
able to provide care safely and efficiently.
 Serves as a reminder of the need for hand hygiene and other measures to prevent the spread of
infection.
 Nursing bag usually has the ff. contents:
- Articles for infection control
- Articles for assessment of family members
- Note that the stethoscope and sphygmomanometer are carried separately.
- Articles for nursing care
- Sterile items
- Clean articles
- Pieces of paper

Use of the Nursing Bag

 Bag technique helps the nurse in infection control.
 Bag technique allows the nurse to give care efficiently.
 It saves time and effort by ensuring that the articles needed for nursing care are available.
 Bag technique should not take away the nurse’s focus on the patient and the family.
 Bag technique may be performed in different ways, principles of asepsis are of the essence and
should be practiced at all times.

For infection control the ff. activities should be practiced during home visits:
1. Remember to proceed from “clean” to “contaminated”.
2. The bag and its contents should be well protected from contact with any article in the patient’s
home.
 3. Line the table/flat surface with paper/washable protector on which the bag and all of the
articles to be used are placed.
4. Wash your hands before and after physical assessment and physical care of each family
member.
5. Bring out only the articles needed.
6. Do not put any of the family’s articles on your paper lining/washable protector.
7. Wash your articles before putting them back into you bag.
8. Confine the contaminated surface by folding the contaminated side inward.
9. Wash the inner cloth lining of the bag as necessary.

Chapter 7
THE NURSING PROCESS IN THE CARE OF THE COMMUNITY
• Principles of Community Health Care
• Conditions in the Community Affecting Health
• Characteristics of a Healthy Community
• Nursing Process in Community Health Care
– Community Assessment
– Community Diagnosis
– Community Health Planning and Implementation
– Evaluation of Community Health Interventions
Objectives
• Upon completion of this chapter, the reader will be able to do the following:
• Illustrate the principles of community health nursing.
• Describe conditions affecting the health of a given community.
• Recognize characteristics of a healthy community.
• Utilize the nursing process in managing community health concerns.

The nursing process in the care of the community

A community is a group of people who:

 Have a common interest or characteristics
 Interact with one another
 Have sense of unity or belonging
 Function collectively within a defined social structure to address common concerns
A community may be phenomenological (functional) or geopolitical (territorial)

Principals of community health nursing

1. Community is the focus of care, nurse responsibility is to the community as a whole
2. Give priority to community needs
3. Work with the community as an equal partner of the health team
4. Focus on primary prevention for appropriate activities
5. Promote a healthful physical and psychosocial environment
 6. Reach out to all who may benefit from a specific service
7. Promote optimum use of resources
8. Collaborate with others working in the community health

Conditions in the community affecting health

 People
 Location
 Social system

Characteristics of a healthy community

 a shared sense of being a community based on history and values
 general feeling of empowerment
 existing structures that allow subgroups within the community to participate in decision making
 the ability to cope with change, solve problems, and manage conflicts within the community
through acceptable means
 open channels of communication
 equitable and efficient use of community resources
Aims
1. achieve a good quality life
2. create a health supportive environment
3. provide basic sanitation
4. supply access to health care

Community Assessment

the data needed to be collected depend on the objectives of community assessment. In general, the
nurse needs to collect data on the nurse needs to collect data on three categories of community health.
Determinants: people, place and social system.
DATA COLLECTED FOR THE HEALTH P.A.T.C.H(planed approach to community health) PROCESS FOR
HEALTH PLANING
1. community profile: demographic educational and economic data
2. morbidity and mortality data, including unique health events(e.g., completion of barangay health
station, a typhoon that caused flooding of residential areas)
3. behavioral data focusing on behavioral risk factors, such as smoking, drinking and leading a sedentary
life style, and prevailing good health practices in the community, such as breast feeding and getting
regular exercise
4. opinion data from community leaders, such as what they think about the main health problems of the
community their causes, measures that may alleviate or correct them

*problem oriented assessment is focused on a particular aspect of health: focusing on what’s problem
the community have in mind

TOOLS IN COMMUNITY ASSESSMENT

Collecting primary data
Observation
 ocular survey/ windshield survey
Survey
Informant interview
 talks to the community people
 key informants: consist of formal and informal community leaders or persons of position and
influence
Community forum
 pulong – pulong sa barangay
focus group
Secondary data source
 health records and reports
field health service information (FHSIS) recording and reporting tools
FHSIS is as basis for
1.priority setting by local goverments
2. planning and decision making at different levels(barangay, municipality, district, provincial,
and national)
3. monitoring and evaluating health program implementation

The FHSIS manual of operations

1.individual treatment record(ITR)(building block of FHSIS)
-health workers are advised not to rely on client-maintained
2.targent client list
a.tcl for prenatal care
b. tcl for postpartum care
c. tcl of under 1-year-old children
d. tcl for family planning
e. tcl for sick children
f. national tuberculosis program regiser.
g. national leprosy control program central registration form
3. summary table (accomplished by midwife)
4. monthly consolidation table(MTC)

The reporting forms, as enumerated in the FHSIS manual of operations

1. monthly forms( regularly prepared by the midwife and summited to the nurse)
a.program report(m1)
contains indicators categorized as maternal care, child care, family
planning
b. morbidity report(m2)
contains list of all cases of disease by age and sex.
2.quarterly forms(prepared by the nurse)
a.program report(q1)
3-month total indicators categorized as maternal care, family planning
child care, dental health and disease control
b.morbidity
3. annual forms
a. A-BHS
demographic, environmental, and natality data
b. annual form 1 (a-1)
prepared by the nurse and is the report of the RHU or health center . it
contains demographic and environmental data and data on natality and
mortality for the entire year
c. annual form 2 (a-2)
prepared by the nurse, is the yearly morbidity report by age and sex
d. annual for 3( a-3)
prepared by the nurse, yearly report of all mortality by age and sex
disease registrycensus data

COMMUNITY DIAGNOSIS
Community diagnosis is the process of determining the health status of the community and the
factors responsible for it.
In this phase the, the health workers makes a judgement about the community’s health satus,
resources and health action potential or likely hood that the community will act to meet health needs to
resolve health problems. And this consist of:

 the health risk or specific problem to which the community is exposed.

 The specific aggregate or community with whom the nurse will be working to deal with the risk
or problem.
 Related factors that influence how the community will respond to the health risk or problem
application of this nursing diagnosis

Planning Community Health Interventions

As in other fields of nursing practice, planning for community health interventions is based on findings
during assessment and formulated nursing diagnosis.

PLANNING phase – involves priority setting, formulating goals and objectives, and deciding on
community interventions.
 Active participation of the people
 To foster participation, the community should have genuine representation in the planning
group.
 Deciding on community representatives will be facilitated if the community has been
organized earlier.

Priority Setting
- Provides the nurse and the health team with a logical means of establishing priority among the
identified health concerns.

Criterias to decide on a community health concern for intervention according to The World Health
Organization (WHO):

1. Significance of the problem

- is based on the number of people in the community affected by the problem or condition.

If the concerns are:

DISEASE CONDITION – this may be estimated in terms of its prevalence rate.
POTENTIAL PROBLEM – its significance is determined by estimating the number of people at risk of
developing the condition.

2. The level of community awareness and the priority its members give to the health concern is a
MAJOR consideration. Related to the priority that the community gives to the health concern,
Shuster and Goeppinger (2004) also mention community motivation to deal with the condition.

3. Ability to reduce risk

- is related to the availability of expertise among the health team and the community itself.
- Involves the health team’s level of influence in decision making related to actions in resolving
the community health concern.

4. Cost of reducing risk

- The nurse has to consider economic, social, and ethical requisites and consequences of planned
actions.

5. Ability to identify the target population

- For the intervention is a matter of availability of data sources, such as FHSIS, census, survey
reports, and case-finding or screening tools.

6. Availability of resources
- to intervene the reduction of risk entails technological, financial, and other material resources of
the community, the nurse, and the health agency.

For a realistic and useful outcome, the priority-setting process requires the joint effort of the
community, the nurse, and other stakeholders, such as the other members of the health team.

- The group defines guidelines for discussion, particularly on the manner of reconciling differences
of opinion.
- Shuster and Goeppinger (2004) suggested a flexible process using the nominal group technique
wherein each group member has an equal voice in decision making, thereby avoiding control of
the process by the more dominant members of the group.
- This technique is appropriate for brainstorming and ranking ideas, when consensus-building is
desired over making a choice based on the opinion of the majority.
- The group makes a list of the identified community health problems or conditions. Each of the
identified problems is treated separately according to a set of criteria agreed upon by the group
such as those suggested by the WHO.

As suggested by Shuster and Goeppinger (2004), the following steps are carried out:
1. From a scale of 1 to 10, being the lowest, the members give each criterion a weight based on
their perception of a weight based on their perception of its degree of importance in solving the
problem.
2. From a scale of 1 to 10, being the lowest, each member rates the criteria in terms of the
likelihood of the group being able to influence or change the situation.
3. Collate the weights (from step 1) and ratings (from step 2) made by the members of the group.
4. Compute the total priority score of the problem by multiplying collated weight and rating of
each criterion.
 5. The priority score of the problem is calculated by adding the products obtained in step 4
After repeating the process on all identified health problems, compare the total priority scores of the
problems. The problem with the highest total priority score is assigned top priority, the next highest is
assigned to second, and so on.

FORMULATING GOALS AND OBJECTIVES

Goals are the desired outcomes at the end of interventions, whereas objectives are the short-term
changes in the community that are observed as the health team and the community work towards the
attainment of goals.

Objectives serve as instructions, defining what should be detected in the community as interventions
are being implemented.
Specific, measurable, attainable, relevant, and time-bound (SMART) objectives provide a solid basis for
monitoring and evaluation.

Deciding on community interventions

The group analyzed the reasons for the people’s health behavior and directs strategies to respond to the
underlying causes. For example, reasons for preference of home delivery over facility-based delivery
should be identified. If the majority of the women would choose to have a home delivery because of
cost or lack of access of birthing facilities, strategies should then be focused on improving facility-based
services. But if the primary reason is sociocultural, the planning team may opt to concentrate on
providing opportunities for skills development of traditional birth attendants and/or exerting effort to
gain the trust and confidence of the women and their families.

In the process of developing the plan, the group takes into consideration the demographic,
psychological, social, cultural, and economic characteristics of the target population on one hand and
the available health resources on the other hand.

Implementing the community health interventions

- Often referred to as the action phase, implementation is the most exciting phase for most health
workers. Aside from being able to deal with the recognized priority health concern, the entire
process is intended to enhance the community’s capability in dealing with common health
conditions/problems.
- The nurses role therefore may be to facilitate the process rather than directly implement the
process rather than directly implement the planned interventions.
- Implementation also entails coordination of the plan with the community and the other
members of the health team. This requires a common understanding of the goals, objectives
and planned interventions among the members of the implementing group.
- Collaboration with the other sectors such as the local government and other agencies may also
be necessary.

Evaluation of community health interventions

Evaluation approaches may be directed structure, process, and outcome.

Structure evaluation involves looking into the manpower and physical resources of the agency
responsible for community health interventions.
Process evaluation is examining the manner by which assessment, diagnosis, planning, implementation,
and evaluation were undertaken.
Outcome evaluation is determining the degree of attainment of goals and objectives.

Ongoing evaluation or monitoring is done during implementation to provide feedback on compliance to

the plan as well as on need for changes in the plan to improve the process and outcomes of
interventions.

STANDARD OF EVALUATION
The bases for a good evaluation are its utility, feasibility, propriety, and accuracy. (CDC, 2011)

Utility is the value of the evaluation in terms of usefulness of results. The evaluation of community
health interventions will be great use to the community health group, as it helps the group gain insight
into strengths and weaknesses of the plan and the manner of its implementation.

Feasibility answers the question of whether the plan for evaluation is doable or not, considering
available resources. Resources include facilities, time, and expertise for conducting the evaluation.

Propriety involves ethical and legal matters. Respect for the worth and dignity of the participants in data
collection should be given due consideration. The results of evaluation should be truthfully reported to
give credit where it is due and to show the strengths and weaknesses of the community: strengths to
encourage further growth and weaknesses for remedial action, if possible.

Accuracy refers to the validity and reliability of the results of evaluation. Accurate evaluation begins with
accurate documentation while the community health process is ongoing.

CHAPTER 8

APPLICATIONS OF EPIDEMIOLOGY IN COMMUNITY HEALTH

EPIDEMIOLOGY- is the study of the DISTRIBUTION and DETERMINANTS of health-related states or events
in specified populations, and the application of this study to the prevention and control of health
problems

DISTRIBUTION- refers to the analysis by time, places and classes of people affected.

DETERMINANTS- include all the biological, chemical, physical, social, cultural, economic, genetic, and
behavioral factors that influence health.
PRACTICAL APPLICATIONS OF EPIDEMIOLOGY
1. Assessment of the health status of the community or community diagnosis
2. Elucidation of the natural history of disease
3. Determination of disease causation
4. Prevention and control of disease
5. Monitoring and evaluation of health interventions
6. Provision of evidence for policy formulation

TYPES OF HEALTH INDICATORS AND THEIR EXAMPLES

TYPE OF HEALTH INDICATOR EXAMPLES

Health status indicators (morbidity) Prevalence, incidence
Health status indicators (mortality) Crude and specific death rates, maternal mortality,
infant mortality, neonatal mortality, postnatal
mortality, child mortality, etc.
Population indicators Age-sex structure of the population, population
density, migration, population growth (crude birth
rate, fertility rate)
Indicators for the provision of health care Access to health programs and facilities, availability
of health resources (facilities, health manpower,
finances)
Risk reduction indicators Causes consulting health provider., infants
exclusively breast-fed for the first 6 months
Social and economic indicators Quantity of suspended particulate matter,
hydrocarbons, oxidants. Portability of drinking water
Disability indicators DALYs, indicators of restricted activity, indicators of
long-term disability
Health policy indicators Allocation of manpower and financial resources,
mechanisms for community participation,
collaboration between government and non-
government organizations
Health indicators- these are quantitative measures usually expressed as rates, ratio, or proportions that
describe and summarize various aspects of the health status of the population. These are also used to
determine factors that may contribute to a causation and control of diseases, indicates priorities for
resource allocation, monitors implementation off health programs, and evaluates outcomes oh health
programs.

 MORBIDITY INDICATORS – are generally based on the disease specific incidence or prevalence
for the common and severe diseases such as malaria, diarrhea, and leprosy.

(P) Prevalence proportion measures the total number of existing cases of disease at a particular
point in time divided by the number of people at the point in time. Thus, if the point in time is the
time of examination, then the denominator is the number of people examined.

Prevalence can be calculated by:

P= number of existing cases of a disease at a particular point in time XF

Number of people examined at that point in time
  Where F is any number of the base 10 that is used as a multiplier to avoid having decimals as the
final value of the indicator.
 Incidence – measures the number of new cases, episodes, or events occurring over a specified
period of time, commonly a year within a specified population at risk.

FACTORS AFFECTING PREVALENCE

Increased by Decreased by
Longer duration of the disease Shorter duration of the disease
Prolongation of life of patients without care High case-fatality rate from disease
Increase in new cases Decrease in new cases
In-migration of cases In-migration of healthy people
Out-migration of healthy people Out-migration of cases
In-migration of susceptible people Improved cure rate of cases
Improved diagnostic facilities
 Cohort- is a group of people who share a common defining characteristics.

INCIDENT DENSITY RATE- is computed using the total person-time at risk for the entire cohort as the
denominator

- This indicators measures the average instantaneous rate of disease

occurrence.

ID= number of new cases that develop during the period XF

Sum of person-time at risk
MORTALITY INDICATORS

Crude death rate (CDR) – the rate with which mortality occurs in a given population. It is computed as

CDR= Number of deaths in a calendar year

Midyear population X 1,000

 Factors affecting CDR includes age, sex composition of the population, the adverse
environmental and occupational conditions.
 Specific mortality rate – shows rate of dying in a specific population groups.

SMR= number of deaths in a specified group in a calendar year

Midyear population of the same specified group XF

 Cause-of-death rate – identifies the greatest threat to the survival of the people, thereby
pointing to the need for preventing such deaths.

CODR= number of deaths from a certain cause in a calendar year XF

Midyear population
  Infant mortality rate – is a good index of health in a community because infants are very
sensitive to adverse environmental conditions. Thus, a high IMR means low levels of health
standards that may be secondary to poor maternal health and child health care, malnutrition.

IMR= deaths under 1 year of age in a calendar year

Number of live births in the same year X 1,000

 Neonatal mortality rate and postnatal mortality rate add up to the IMR. The reason for such
division is that the causes of neonatal deaths, that is, deaths among infants less than 28 days old
are due mainly to prenatal or genetic factors.

NMR= number of deaths among those under 28 days of age in a calendar year X 1,000
Number of live births in the same year

PNMR= number of deaths among those under 28 days of age

To less than 1 year of age in a calendar year X 1,000
Number of live births in the same year

 Maternal death - death of a female from any cause related to or aggravated by pregnancy or its
management during pregnancy and childbirth or within 42 days of termination of pregnancy,
irrespective of the duration and the site of the pregnancy.

MMR= number of deaths due to pregnancy, delivery, puerperium in a calendar year X 100
Number of live births in the same year

 Case fatality rate – is the proportion of cases that end up fatally. It gives the risk of dying among
persons afflicted within particular disease.
- It is similar to an incidence proportion because it also a measure of average
risk.
CFR= number of deaths from a specified cause
Number of cases of the same disease X 100

POPULATION INDICATORS

Include not only the population growth indicators but also other population dynamics that can affect the
age-sex structure of the population and vice versa.

 Crude birth rate- measures how fast people are added to the population through births.
- Measure of population growth.

CBR= number of registered live births in a year X 1,000

Midyear population

 A CBR greater than or equal to 45/1,000 live births implies high fertility while a level less than or
equal to 20/1,000 live births implies low fertility.
EXAMPLES OF HEALTH MILLENIUM DEVELOPMENT GOALS AND HEALTH INDICATORS
Goal/Target Health targets Health indicators
Goal: 4 Reduce child mortality Under-five mortality rate
Target: 5 Reduce by two-thirds between Infant mortality rate
1990 and 2015, the under-five Proportion of 1 year old children
mortality rate immunized against measles
Goal: 5 Improve maternal health Maternal mortality ratio
Target: 6 Reduce by three quarters Proportion of births attended by
between 1990 and 2015 the skilled personnel
maternal mortality ratio
Goal: 6 Combat HIV/AIDS, malaria and HIV prevalence among pregnant
Target: 7 other diseases women aged 15-24 years
Have halted by 2015 and begun Condom use rate of the
to reverse the spread of contraceptive prevalence rate
HIV/AIDS
Target 8 Have halted by 2015 and begun Ratio of school attendance of
to reverse the incidence of orphans to school attendance of
malaria and other diseases no orphanage aged 10-14 years

Prevalence and death rates

associated with malaria

Proportion of population in
malaria risk areas using effective
malaria prevention and
treatment measures
Prevalence and death rates
associated with TB
Proportion of TB cases detected
and cured under DOTS

 General fertility rate- is a more specific rate than CBR since births are related to the segment iof
the population deemed to be capable of giving birth, that is, the women in the reproductive age
groups.
GFR= number of registered live births in a year
Midyear population of women 15-44 years of age X 1,000

 Population pyramid – is a graphical representation of the age-sex composition of the population

that should also be examined during the assessment of the health status of the community.

SOURCES OF HEALTH DATA

Census Hospital data

Vital registration system Health insurance
Disease notification School health program
Disease registers Downloadable data sets
 Surveillance system Surveys

 Disease registry- is a compilation of information about a particular disease.

- The aim of disease registry is to include all cases of the disease in the
registry without duplication.

DISEASES SURVEILLANCE SYSTEMS IN THE PHILIPPINES

1. Notifiable Disease Reporting System ( NDRS)

2. Field Health Service Information System (FHSIS)
3. National epidemiology Sentinel Surveillance System ( NESSS)
4. Expanded Program on Immunization Surveillance System (IPE Surveillance)
5. HIV/AIDS Registry

STAGES IN THE NATURAL HOSTORY OF DISEASE AND THE LEVELS OF PREVENTION

Stage of susceptibility Stage of subclinical Stage of clinical disease Resolution stage

disease
 The person is  The person is  The patient  The patient
not yet sick but still apparently now manifests either recovers
may be exposed healthy since recognizable completely
to the risk clinical signs and from the
factors of the manifestations symptoms for disease
disease, for of the disease example, becomes a
instance, are not yet vaginal chronic case
multiple sex shown, bleeding. with or without
partners in the although  Tertiary level of disability or
case of cervical pathologic prevention is dies.
cancer. changes have applicable to
 Primary level of already limit the
prevention such occurred. disability and
as health  Secondary level restore the
education and of prevention functional
immunization like Pap smear capability of the
can detect this patient.
early stage so
that prompt
treatment can
be initiated to
avoid
progression of
the disease.
 Chapter 9

The Health Care Delivery System

Upon completion of this chapter, the reader will be able to do the following:

1. Discuss how the World Health Organization affects health issues in the Philippines.

2. List the Millennium Development Goals (MDGs) and the targets of the health-related MDGs.

3. Describe the Philippine health care delivery system

4. Explain how the Department of Health provides health leadership

5. Elucidate on the functions of the members of the health team in RHU

6. Differentiate the referral system from the inter-local health zone.

7. Relate the strategic thrusts of Universal Health Care to the current health situation

8. Enumerate major public health programs.

 A nation’s health care delivery system has a tremendous impact not only the health of its people but
also on their total development including their socioeconomic status. Anderson and Mcfarlane (2011)
emphasized the role of the following factors in shaping 21 st century health that further influence health
care delivery system:

1. Health care “reforms”

2. Demographics
3. Globalization
4. Poverty and growing disparities
5. Social disintegration

World Health Organization (WHO) as this specialized agency of the United Nations (UN) provides
global leadership on health matters. In the Philippines, health services are provided by the government
and the private sector – for profit as well as nonprofit, with the latter frequently referred to as
nongovernmental organizations or NGO’s. In the national level, director is set by department of health
(DOH) by virtue of mandate of the Local Government Code (R.A.7160) LGU’s should have operating
mechanism to meet the priority needs and service requirements of their communities. Basic Health
Services are regarded as priority services for which LGU’s are primary responsible.

A Health System consists of all organizations, peoples, and actions whose primary intent is to promote,
restore, or maintain health. A health system has six building blocks or components:

1. Service delivery
2. Health workface
3. Information
4. Medical products, vaccines, and technologies
5. Financing
6. Leadership and governance or Stewardship.

The World Health Organization

The WHO constitution came into force on April 7, 1948. Since then April 7 has been celebrated each
year as World Health Day. The WHO constitution states that its objective is the attainment of all peoples
of the highest possible level of health. To attain its objective, WHO carries out the following core
functions:

 Providing leadership on matters critical to health and engaging partnerships where joint action
is needed. WHO has 193 members of countries and 2 associate members. WHO and its
members work with UN agencies, NGO’s and the private sector. The WHO country focus is
directed toward providing technical collaboration with member states with accordance with
each country’s needs and capacities.
 Shaping the research agenda and stimulating the generation, translation, and disseminating
valuable knowledge. The WHO strategy on research for health has 5 goals:
 1. Capacity- in reference to capacity-building to strengthen the national health research
system
2. Priorities – to focus research on priority health need particularly in low and middle income
countries
3. Standards - to promote good research practice and enable the greater sharing of research
evidence, tools, and materials
4. Translation - to ensure that quality evidence is turned into products and policy
5. Organization – to strengthen the research culture within WHO and improve the
management and coordination of WHO research activities.

 Setting norms and standards and promoting and monitoring their implementation. WHO
develops norms and standards for various health and health –related issues, such as
pharmaceutical products including vaccines and other biological products used in immunization,
practices in maternal and child care, and environmental conditions.
 Articulating ethical and evidence-based policy options. Through its Department of Ethics and
Social Determinants, WHO is evolved in various issues on health ethics. In collaboration with
other governmental and nongovernmental organizations, WHO has worked on bioethical
concerns such as those related to human organ and tissue transplantation, reproductive
technology and public health response to threats of infectious diseases like AIDS, influenza, and
tuberculosis.
 Providing technical support, catalyzing change, and building sustainable institutional capacity.
WHO offers technical support training to its member countries in the fields of maternal and child
health, control of diseases, and environmental health services. WHO is involved in monitoring
the health situation and assessing health trends. WHO has developed guidance and tools and
measurement, monitoring and evaluation.

The Millennium Development Goals

On September 6 to 8, 2000, world leaders on UN General Assembly participate in Millennium

Summit. The result of the summit was a resolution entitled United Nations Millennium Declaration.
In this declaration, the world leaders recognized their collective responsibility to uphold the
principles of human dignity, equality and equity at the global level.

The declaration expressed the commitment of the 191 member states, including the
Philippines, to reduce extreme poverty and achieve seven other targets - now called the Millennium
Development Goals (MDG’s) by the year 2015.

The following are the eight MDG’s and the targets corresponding to health-related MDG’s 4,5,
and 6:

1. Eradicate extreme poverty and hunger.

2. Achieve universal primary education.
3. Promote gender equality and empower women.
 4. Reduce child mortality. Target: reduce by 2/3, between 1990 and 2015, the under-five mortality
rate.
5. Improve maternal health. Target:
a. Reduce by three quarters the maternal mortality ratio
b. Achieve universal access to reproductive health
6. Combat HIV/AIDS, malaria and other diseases. Targets:
a. Have halted by 2015 and begun to reverse the spread of HIV/AIDS
b. Achieve by 2010, universal access to treatment for all those who need it
c. Have halted by 2015, and begun to reverse the incidence of malaria and other major
diseases.
7. Ensure environmental sustainability
8. Develop a global partnership for development

SUSTAINABLE DEVELOPMENT GOALS AND TARGETS

A set of 17 goals, 169 targets and indicators that UN member states will be expected to use to frame
their agendas and political policies over the next 15 years (2030) if agreed at a UN summit in New York
in September, and will become applicable on January 2016.
In December Ban Ki-moon, UN secretary general clustered them into six essential elements:
1. Dignity
2. Prosperity
3. Justice
4. Partnership
5. Planet
6. People.
outcome of the Rio+20 summit in 2012 for the post-2015 goals that mandated the creation of an open
working group
Representatives from 70 countries formed a working group had its first meeting in March 2013 and
published its final draft, with its 17 suggestions, in July 2014.
Goal 1. End poverty in all its forms everywhere
Goal 2. End hunger, achieve food security and improved nutrition, and promote sustainable agriculture
Goal 3. Ensure healthy lives and promote well-being for all at all ages
Goal 4. Ensure inclusive and equitable quality education and promote life-long learning opportunities for
all
Goal 5. Achieve gender equality and empower all women and girls
Goal 6. Ensure availability and sustainable management of water and sanitation for all
Goal 7. Ensure access to affordable, reliable, sustainable, and modern energy for all
Goal 8. Promote sustained, inclusive and sustainable economic growth, full and productive employment
and decent work for all
Goal 9. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster
innovation
Goal 10. Reduce inequality within and among countries
Goal 11. Make cities and human settlements inclusive, safe, resilient and sustainable
Goal 12. Ensure sustainable consumption and production patterns
Goal 13. Take urgent action to combat climate change and its impacts *
Goal 14. Conserve and sustainably use the oceans, seas and marine resources for sustainable
development
Goal 15. Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage
forests, combat desertification, and halt and reverse land degradation and halt biodiversity loss
Goal 16. Promote peaceful and inclusive societies for sustainable development, provide access to justice
for all and build effective, accountable and inclusive institutions at all levels
Goal 17. Strengthen the means of implementation and revitalize the global partnership for sustainable
development

The Philippine Health Care Delivery System

The DOH serves as the main governing body of health services in the country. The DOH provides
guidance and technical assistance to LGUs through the center for health development in each of the
17 regions. Provincial governments are responsible for administration of provincial and district
hospitals. Municipal and city governments are in charge of primary care through rural health units
(RHUs) or health centers. Satellite outposts known as barangay health stations (BHSs) provide health
services in the periphery of the municipality or city.

The private sector is composed of for-profit and nonprofit agencies this sector provides all levels
of services and accounts for a large segment of health service providers in the country. About 30%
of Filipinos utilize private health facilities. Estimated 60% of national health expenditure goes to the
private sector which employs more than 70% of the health professionals in the Philippines.

Financing of health services is provided by three major groups: The government (national and
local), private sources and social health insurance. The National Insurance Act of 1995 (R.A. 7875)
created by the Philippine Health Insurance Corporation (PhilHealth). It is tax-exempt government
corporation attached to the DOH for policy coordination and guidance, and aims for universal health
coverage of all Filipino citizens.

The Department of Health

The DOH is the national agency mandated to lead the health sector towards assuring quality
health care for all Filipinos.

DOH Vision: is to be a global leader for attaining better health outcomes, competitive and
responsive health care system, and equitable health financing.

DOH Mission: to guarantee equitable, sustainable and quality health for all Filipinos, especially the
poor, and to lead the quest for excellence in health.

In the pursuit of its vision and execution of its mission, the following has the major roles:

1. Leader in health
2. Enabler and capacity builder
 3. Administrator of specific services

The DOH core values reflect adherence to the highest standards of work namely:
1. Integrity
2. Excellence
3. Compassion and respect for human dignity
4. Commitment
5. Professionalism
6. Teamwork
7. Stewardship

The DOH carries out its work through the various central bureaus and services in the central
office, Center for Health Development (CHD) in every region, DOH- attached agencies, and DOH-
retained hospitals.

Levels of Health Care Delivery

The DOH issued administrative order 2012-0012 (Rules and Regulations Governing the new
Classification of Hospitals and Other Health Facilities in the Philippines) that provides for a new
classification scheme of health facilities.

Hospitals Other Health Facilities

General A. Primary Care

 Level 1 Facility
 Level 2 B. Custodial
 Level 3 facility
(teaching/ C. Diagnostic/
training Therapeutic
facility
Specialty D. Specialized
outpatient
facility

DOH administrative Order 2012-0012 classifies other health facilities as follows:

Category A. Primary Health Care Facility – a first contact health care facility that offers basic
service including emergency services and provision for normal deliveries.

1. Without in-patient beds like health centers, out-patient clinics, and dental clinics.
2. With in-patient beds – a short-stay facility where the patient spends on the average of
one to two days before discharge.
Ex: Infirmaries and birthing (Lying-in) facilities.
 Category B. Custodial Care Facility – a health facility that provides long-term care, including basic
services like food and shelter, to patients with chronic conditions requiring ongoing health and
nursing care due to impairment and a reduced degree of independence in activities of daily
living, and patients in need of rehabilitation.

Ex: Custodial health care facilities, substance/drug abuse treatment and rehabilitation centers,
sanitaria, leprosaria, and nursing homes.

Category C. Diagnostic/Therapeutic Facility - a facility for the examination of the human body,
specimens from the human body for the diagnosis, sometimes treatment of disease or water for
drinking analysis. The test covers the preanalytical, analytical and post analytical phases of
examination.

Category D. Specialized outpatient facility – a facility that performs highly specialized procedures
on a outpatient basis.

Ex: Dialysis clinic, ambulatory surgical clinic, cancer chemotherapeutic center/clinic, cancer
radiation facility, and physical medicine and rehabilitation center/clinic.

The Rural Health Unit

The RHU, commonly known as health center, is a primary level health facility in the
municipality. The focus of RHU is preventive and promotive health services and the supervision
of BHSs under its jurisdiction. The recommended ratio of RHU to catchment population is 1 RHU:
20,000 populations.

The BHS is the first contact health care facility that offers basic services at the barangay level. It
is a satellite station of the RHU. It is manned by Volunteer Barangay Health Workers (BHW’s)
under the supervision of Rural Health Midwife (RHM).

The Rural Health Unit Personnel

The Municipal Health Officer (MHO) or Rural Health Physician heads the health services at the
municipal level and carries out the following roles and functions:

1. Administrator of the RHU

a. Prepares the municipal health plan and budget
b. Monitors the implementation of basic health services
c. Management of the RHU staff
2. Community physician
a. Conducts epidemiological studies
b. Formulates health education campaigns on disease prevention
c. Prepares and implements control measures or rehabilitation plan
3. Medico-legal officer f the municipality.

The revised implementing rules and regulations (IRRSs) of R.A. 7305 or the Magna Carta of
Public Health Workers stipulate that there be one rural health physician to a population of
20,000.
 Local Health Boards
 R.A 7160 or Local Government Code was enacted to bring about genuine and
meaningful local autonomy.
 This will enable local governments to attain their fullest development as self-reliant
communities and make them more effective partners in the attainment of national
goals.
 Devolution refers to the act by which the national government confers power and
authority upon the various LGU’s to perform specific functions and responsibilities.
 RA 7160 - Devolution Code Local Government Code Aim: to transform local
government units into:
 o Self-reliant communities
 o Active partnership with the people
 o Responsive government representatives
 o Accountable government representatives
 o Decentralization system of health decision making

 R.A 7160 provided for the creation of the Provincial Health Board and the
City/Municipal Health boards, or Local Health Boards.

The functions of local health boards are as follows:

1. Proposing to the Sanggunian annual budgetary allocations for the operation and maintenance
of health facilities and services within the province/city/municipality;
2. Serving as an advisory committee to the Sanggunian on health matters; and
3. Creating committees that shall advise local health agencies on various matters related to health
service operations.

The Health Referral System

 A referral is a set of activities undertaken by a health care provider or facility in

response to its inability to provide the necessary health intervention to satisfy a
patient’s need.
 A functional referral system is one that ensures the continuity and complementation of
health and medical services.
 It usually involves movement of a patient from the health center of first contact and the
hospital at first referral level.
 When hospital intervention has been completed, the patient is referred back to the
health center. This accounts for the term two-way referral system.
 Referrals may be internal or external
 Internal referrals – occur within the health facility; may be made to request for an
opinion or suggestion, comanagement, or further management or specialty care.
  External referral – is a movement of a patient from one health facility to another. It may
be vertical, where the patient referral may be from a lower to a higher level of health
facility or the other way round.

The Inter-Local Health Zone

 The referral system functioning within the context of the Inter-Local Health Zone (ILHZ)
provides a means for consolidating health care efforts.
 The ILHZ is based on the concept of the District Health System, a generic term used by
WHO to describe an integrated health management and delivery system based on a
defined administrative a geographical area.
 An ILHZ has a defined catchment population within a defined geographical area, it has a
central or core referral hospital and a number of primary level facilities such as RHUs
and BHSs.

The ILHZ has the following components:

 People. Although WHO has described the ideal population size of a health district between
100,000 and 500,000, the number of people may vary from zone to zone, especially when taking
into consideration the number of LGUs that will decide to cooperate and cluster.
 Boundaries. Clear boundaries between ILHZs establish accountability and responsibility of health
service providers.
 Health facilities. RHUs, BHSs, and other health facilities that decide to work together as an
integrated health system and a district or provincial hospital, serving as the central referral
hospital.
 Health workers. To deliver comprehensive services, the ILHZ health workers include personnel
of the DOH, district or provincial hospitals, RHUs, BHSs, private clinics, volunteer health workers
from NGOs, and community based organizations.

Health Sector Reform: Universal Health Care

 Also called the Aquino Health Agenda, is the latest in a series of continuing efforts of the
government to bring about health sector reforms.
 UHC was built upon strategies of two previous platforms of reform: the initial Health
Sector Reform Agenda and FOURmula One for health.

Goals and Objectives

1. Better health outcomes

2. Sustained health financing, and
3. A responsive health system by ensuring that all Filipinos, especially the disadvantaged
group, have equitable access to affordable health care.
 Strategic thrusts

The attainment of the goal of UHC is through the pursuit of three strategic thrusts:

A. Financial risk protection through expansion in NHIP enrollment and benefit delivery
B. Improved access to quality hospitals and health care facilities
C. C. attainment of the health-related MDGs

To achieve the three strategic thrusts, six strategic instruments shall be optimized:

1. Health financing - instrument to increase resources for health that will be effectively allocated
and utilized to improve the financial protection of the poor and the vulnerable sectors.
2. Service delivery – instrument to transform the health service delivery structure to address
variations in health service utilization and health outcomes across socioeconomic variables.
3. Policy, standards, and regulation – instrument to ensure equitable access to health services,
essential medicines, and technologies of assured quality, availability and safety.
4. Governance for health – instrument to establish the mechanisms for efficiency, transparency,
and accountability, and prevent opportunities for fraud.
5. Human resources for health – instrument to ensure that all Filipinos have access to professional
health care providers the appropriate level of care.
6. Health information – instrument to establish a modern information system that shall:
a. Provide evidence for policy and program development;
b. Support for immediate and efficient provision of health care and management of province-
wide health systems.

Public Health programs

1. Reproductive and maternal health: prepregnancy services and care during pregnancy, delivery,
and postpartum period
2. Expanded Garantisadong Pambata (child health): advocacy for exclusive breastfeeding in the
first 6 months of life, newborn screening program, immunization, nutrition services, and
integrated management of childhood illness.
3. Control of communicable disease such as tuberculosis, mosquito-borne diseases, rabies,
schistosomiasis, and sexually transmitted infections
4. Control of noncommunicable or lifestyle diseases
5. Environmental health

CHAPTER 10
Upon completion of this chapter, the reader will be able to do the following:
1. Describe the current maternal and child health situation in the Philippines.
2. Explain the components of the core package of services in the Maternal, Newborn, and Child
Health and Nutrition (MNCHN) Strategy.
3. Elucidate on the MNCHN Service Delivery Network.
 4. Recognize the role of the nurse in the delivery of the core package of services in the Maternal,
Newborn, and Child Health and Nutrition (MNCHN) Strategy.
5. Express appreciation of the impact Maternal, Newborn, and Child Health and Nutrition
(MNCHN) Strategy on national development.

Maternal, Newborn, and Child health and Nutrition

Maternal, Newborn, and Child health and Nutrition Strategy
Four Key Strategies of MNCHN
1. Ensuring universal access to and utilization of MNCHN core package services and interventions
directed not only to individual women of reproductive age and newborns at different stages of
the life cycle.
2. Establishment of a service delivery network at all levels of care.
3. Organized use of instruments for health systems development
4. Rapid build-up of institutional capacities of DOH and PhilHealth.
MNCHN aims to achieve the following intermediate results:
1. Every pregnancy is wanted, planned, and supported
2. Every pregnancy is adequately managed throughout its course.
3. Every delivery is facility-based and managed by skilled birth attendants or skilled health
professionals
4. Every mother-and-newborn pair secures proper postpartum and newborn care with smooth
transition to women’s health care package for the mother and child survival package for the
newborn.
MNCHN core package of services
a paradigm shift from the risk approach that focuses on identifying pregnant women at risk of
complications to one that considers all pregnant women at risk of such complications
Prepregnancy package
1. Nutrition
 Nutritional counselling
 Promotion of use of iodized salt
 Provision of micronutrient supplementation
2. Promotion of healthy lifestyle including advice relative to smoking cessation, healthy diet,
regular exercise, and moderate alcohol drinking
3. Advice on family planning and provision of family planning services
4. Prevention and management of lifestyle-related diseases like diabetes and cardiovascular
disease
5. Prevention and management of infection, including deworming of women of reproductive age
to reduce other causes of iron deficiency anemia
6. Counselling on STD/HIV/AIDS, nutrition, personal hygiene, and consequences of abortion
7. Adolescent health services
8. Provision of oral health services

Prenatal Package
The pregnant woman who avails of the prenatal package obtains adequate care.
1. Prenatal visits
 At least four visits throughout the course of pregnancy
 Prenatal assessment
2. Micronutrient supplementation
3. Tetanus toxoid (TT) immunization
4. Promotion of exclusive breastfeeding, newborn screening (NBS) and infant immunization.
5. Counseling on healthy lifestyle with focus on smoking cessation, healthy diet and nutrition,
regular exercise, STI and HIV prevention and oral health.
6. Early detection and management of complications of pregnancy.
7. Prevention and management of other conditions where indicated: hypertension, anemia,
diabetes, TB, malaria, schistisomiasis and STI/HIV/AIDS
8. Birth planning and promotion of facility-based delivery.
Childbirth package
1. Skilled birth attendant/ skilled health professional- assisted delivery and facility based deliveries
including the use of partograph
2. Proper management of pregnancy and delivery complications and newborn complications.
3. Access to basic emergency obstetric and newborn care ( BEmONC) or comprehensive
emergency obstetric and newborn care (CEmONC) services.
Postpartum package
1. Postpartum visits: within 72hours and on the 7 th day postpartum check for conditions such as
bleeding or infections
2. Micronutrient supplementation
3. Counseling on nutrition, child care, family planning and other available services
Newborn (first week of life) care package
1. Interventions within the first 90 minutes
 Immediate thorough frying
 Skin-to-skin contact between mother and newborn.
 Cord clamping 1-3 minutes after birth is recommended
 Early initiation of breastfeeding (within 1 hour after birth)
 Non-seperation of baby from the mother (rooming-in)
2. Essential newborn care after 90 minutes to 6 hours
 Vit. K prophylaxis
 Examination of baby for birth injury, malformation or defects
 Additional care for a small baby

3. Care prior to discharge; (after 90 min)

 Support unrestricted, per demand breastfeeding day and night.
 Ensure warmth of the baby.
 Washing and bathing
 Look for danger signs and start resuscitation if necessary, keep warm, give first doses of
IM antibiotics give oxygen
 Look for signs of jaundice and infection
  Perform newborn screening and newborn hearing screening
 Provide instruction on discharge
Childcare package
1. Immunizations
2. Nutrition
 Exclusive breastfeeding up to 6 mos
 Sustained breastfeeding up to 24 mos with complementary feeding
 Micronutrient supplementation
3. IMCI
4. Injury prevention
5. Oral health
6. Insecticide-treated nets for mothers and children in malaria-endemic areas
Three levels of care in the MNCHN service delivery network
1. Community level service providers or community health care team.
TWO BASIC FUNCTIONS
 Navigations functions
 Basic Delivery functions

2. A BemONC-capable facility
6 signal obstetric function
 Parenteral administration of oxytocin in the third stage of labor
 Parenteral administration of loading dose of anticonvulsant
 Performance of assisted deliveries (imminent breech delivery)
 Removal of retained products or conception
 Manual removal of retained placenta

Emergency newborn interventions

 Newborn resuscitation
 Oxygen support

3. A CEmONC- capable Facility

 Can perform the six signal function as in BEmONC as well as CS delivery services, blood
blanking and transfusion services and other highly specialized obstetric interventions.

THE REPRODUCTIVE HEALTH PROGRAM

RA 10254- responsible parenthood and reproductive health Act of 2002 informally known as
Reproductive Health Law signed by Benigno Aquinom II on January 17, 2013.
Refers to the constellation of methods, techniques and services that contribute to reproductive health
and wellbeing by preventing and solving reproductive health problems.
The reproductive health program of the Philippines adopts the life-span approach. It recognizes the fact
that RH is a concern that affects different age brackets.
10 elements of reproductive health care
1. Family planning
2. Maternal and child health and nutrition
3. Prevention and control of reproductive tract infections, STIs and HIV/AIDS
4. Adolescents reproductive health
5. Prevention and management of abortions and its complications
6. Prevention and management of breast and reproductive tract cancers and other gynecological
conditions.
7. Education and counseling on sexuality and sexual health
8. Men’s reproductive health and involvement
9. Prevention and management of violence against women and children
10. Prevention and treatment of infertility and sexual dysfunction

THE PHILIPPINE FAMILY PLANNING PROGRAM (PFFP)

The Family Planning program started in the 1970s as a family planning service delivery component to
achieve fertility reductions.
FP is means to prevent high- risk pregnancies brought about by the following conditions.
1. Being too young( less than 18 years old) or too old ( over 34 years old)
2. Having had too many (4 or more) pregnancies
3. Having closely spaced (too close) pregnancies (less than 36 months)
4. Being too ill or unhealthy/ too sick or having an existing disease or disorder like iron deficiency
anemia.
Four Pillars of PFFP
The guiding principles of the FP program also called the four pillars of the (PFFP) are as follows.
1. Responsible parenthood
2. Respect for life
3. Birth spacing
4. Informed choice

Client counseling and assessment

Counseling must be based on client’s needs, the following are essential content of the nurse-client
interaction regarding the chosen method
1. Effectiveness
2. Advantages and disadvantages
3. Possible side effects, complications and signs that require an immediate visit to the health
facility
4. How to use the chosen method
5. Prevention of STIs
6. When to return to the health facility

Benefits of Family Planning

 Benefits to mothers
1. Enables her to regain her health after delivery
 2. Gives enough time and opportunity to love and provide attention to her husband
and children
3. Gives more time for her family and own personal advancement
4. When suffering from an illness, gives enough time for treatment and recovery
 Benefits for children
1. Lightens the burden and responsible in supporting his family
2. Enables him to give his children their basic needs
3. Gives him time for his family and own personal advancement
Family Planning Methods
Natural family planning
 Lactation Amennorhea method (LAM)
FAB Method
Based on scientific analysis of fertile time in the woman’s menstrual cycle.
1. Billings’ovulation method (BOM)
2. Basal body temperature (BBT)
3. Symptothermal method
4. Standard Days Methods (SDM)
5. Two-day Method
Artificial family planning methods
1. Combined oral contraceptives (COCs)
2. Depot medroxyprogesterone acetate
3. Intrauterine device (IUD)
4. Barrier method
 Condom, diaphragms, cervical caps and spermicides
5. Permanent Method
 Vasectomy
 Bilateral tubal ligation (BTL)

Newborn Screening
Newborn Screening (NBS) – a simple procedure to find out if a baby has a congenital metabolic disorder
that may lead to mental retardation or death if left untreated.
- ideally done on the 48th -72nd hour of life; also be done after 24hours of life but not later than
3days from the complete delivery of the newborn.
RA 9288 – also known as NEWBORN SCREENING ACT OF 2004
Newborn Screening Reference Center (NSRC) – responsible for the national testing database and case
registries, training, technical assistance and continuing education for laboratory staff.
Located at the following sites:
1. NSC-NIH for the NCR and Luzon: National Institute of Health, University of the Philippines
Manila, Pedro Gil St., Ermita, Manila
2. NSC-Central Luzon for Regon I, II, III and CAR: Angeles University Foundation Medical
Center, Angeles City.
3. NSC-Visayas: Western Visayas State University Medical Center, Iloilo City
4. NSC-Mindanao: Southern Philippines Medical Center, Davao City

Disorders detected by NBS and their long-term effects:

 Disorder Definition Long-term Effects
Congenital Hypothyroidism Inability to produce thyroid hormone Severe Mental Retardation
Congenital Adrenal Inherited disorder; inability of the adrenal Death
Hyperplasia gland to secrete cortisol or aldosterone,
or both.
Galactosemia Inherited disorder; the body unable to Death or Cataracts
metabolize galactose and the person is
unable to tolerate any form of milk.
Phenylketonuria Without the ability to properly break Severe Mental Retardation
down an amino acid called phenylalanine.
Glucose-6-phosphate- The read blood cells break down when Severe Anemia, Kernicterus
dehydrogenase (C6PD the body is exposed to certain drugs,
Deficiency) food, severe stress or severe infection.
Maple Syrup Urine disease Unable to break down amino acid Death
leucine, isoleucine and valine; urine of
affected person smells like maple syrup.
Newborn screening procedure:
- The specimen is obtained through a heal prick.
- A few drops of blood are taken, blotted on a special absorbent filter card and then sent to NSC
Blood sample may be obtained by:
 Physician  Medical technologist
 Nurse  Trained midwife
NBS is available in:
 Hospitals  Health centers
 Lying-in clinics  Some private clinics
 RHUs
- Normal (Negative) – results are available 7 – 14 working days from the time samples are
received at the NSC.
- Positive – results should be relayed to the parents immediately and must be referred to a
specialist for confirmatory testing and further management.
Newborn Hearing Screening – the early detection of congenital hearing loss among newborns and
referral for early intervention services to infants with hearing loss.
- among 3months and below.
- Early detection and intervention facilitate speech development and prevent future learing and
psychosocial difficulties of the child with hearing impairement.
RA 9709 – also known as the UNIVERSAL NEWBORN HEARING SCREENING AND INTERVENTION

Expanded Program on Immunization (EPI)

EPI- established in 1976 to ensure that infant/children and mothers have access to routinely
recommended vaccines.
RA 10152 – also known as MANDATORY INFANT AND CHILDREN HEALTH IMMUNIZATION ACT OF 2011
RA 7846 – provided for COMPULSARY IMMUNIZATION AGAINST HEPATITIS B FOR INFANTS AND
CHILDREN BELOW 8 YEARS OLD.
The specific goals of the program:
1. To immunize all infants/children against the most common vaccine-preventable diseases,
2. To sustain the polio-free status of the Philippines
 3. To eliminate measles infection.
4. To eliminate maternal and neonatal tetanus.
5. To control diphtheria, pertussis, hepatitis B, and German measles.
6. To prevent extrapulmonary TB among children.
The nurses uses the following formulas to estimate eligible population:
Estimated number of infant = total population x 2.7%
Estimated number 12–59 month old children = total population x 10.8%
Estimated number of pregnant women = total population x 3.5%
EPI vaccines and the special diluents have the following cold chain requirements:
 OPV : -15 to 25oC; must stored in the freezer.
 All other vaccines have to be stored in the refrigerator at a temperature of +2 to +8 oC
 Hepatitis B, Pentavalent vaccine, Rotavirus vaccine and TT should not be stored in the freezer.
Wrap the container with paper before putting in the vaccine bag with cold packs.
 Keep diluents cold by storing them in the refrigerator in the lower or door shelves
Fully immunized children (FIC) – are those who were given BCG, 3doses of OPV, 3doses of DPT and
hepatitis B or 3doses of Pentavalent vaccine and 1dose of anti-measles.
Completely immunized children – who completed their immunization schedule at the age of 12 -23
months.
A child protected at birth (CPAB) – used to describe a child whose mother has received:
a. 2doses to TT during this pregnancy, provided that the 2 nd dose was given at least a month
prior to delivery; or
b. at least 3doses of TT anytime prior to pregnancy with this child.

Infant and Young Child Feeding

EO no. 51 – also known as the MILK CODE
EO no. 382 – provided for the observance of the NATIONAL FOOD FORTIFICATION day in November 7.
RA 7600 – also known as ROOMING-IN AND BREAST FEEDING ACT
RA 8172 – also known as ASIN (ACT FOR SALT IODIZATION NATIONWIDE)
RA 8976 – also known as the PHILIPPINE FOOD FORTIFICATION ACT
RA 10028 – also known as EXPANDED BREASTFEEDING PROMOTION ACT
AO 36, s2010 – also known as EXPANDED GARANTISADONG PAMBATA
Different feeding practices:
 Exclusive breastfeeding – infant receives breast milk and allows to receive oral hydration salt,
drops, syrups(minerals, vitamins, medicines) but nothing else.
 Predominant breastfeeding- infant’s predominant source of nourishment has been breast milk,
including milk expressed or from a we nurse as the predominant source of nourishment.
 Complementary feeding – the process of giving the infant food and liquids, along with breast
milk, when breast milk is no longer sufficient to meet the infant’s nutritional requirements.
 Bottle feeding – the child is given food or drink from a bottle with nipple/teat.
 Early initiation of breastfeeding – initiating breastfeeding of the newborn after bith within
90mins of life in accordance to essential newborn care protocol.
Nutritional assessmentinclude any or several of the following:
 Anthropometry
 Weight-for-age
 Length/Height-for-age
 Mid-upper arm circumference (MUAC)
  Clinical examination
 Biochemical examination
Recommended infant and young child feeding practices:
 Early initiation of breastfeeding
 Exclusive breastfeeding for the first months, which possible, exept for afew medical conditions,
such as galactosemia.
 Extent breastfeeding up to 2years and beyond.
 Appropriate complementary feeding with the use of locally available and culturally acceptable
foods
 Micronutrients supplementation
 Universal salt iodization since ordinary salt contains very little iodine that cannot provide for the
needs of the human body
 Food fortification
Benefits of breastfeeding to the infant includes:
 It provides all of the nutrients an infant needs for growth in the 1 st 6months.
 It carries antibodies from the mother to help combat disease.
 It prevents diarrhea because of reduce risk from contaminated formula as well as of the
antibodies in the breast milk.
 It lowers risk of developing later in life chronic conditions, like allergies, asthma, obesity,
diabetes and heart disease.
 It provides benefit for intellectual and motor development of the infant
Benefits of breastfeeding to the mother:
 Early initiation of breastfeeding helps to contract the uterus and therefore reduce bleeding.
 It may help in the return to prepregnancy weight.
 Exclusive breastfeeding delays the return of fertility
 A long term benefit is a lower risk of premenopausal breast cancer and ovarian cancer.
Types of position when breast feeding the baby:
1. Cradle hold –the mother sits with her arms supported and, using her arm on the same side as
the nursing breast cracle the infant of her body.
2. Cross-cradle hold – same to the cradle hold, except that the mother cradles her infant with arm
on the opposite side of the nursing breast.
3. Football, clutch or underarm hold – the mother sits, hold the infant between her flexced arm
and body, positions the infant facing her, and supports the infant’s head with her open arm.
Twins may be fed at the same time using the double-football hold.
4. Side-lying hold – the mother lies on her side with one arm supporting her head. The infant lies
aside beside the mother, facing the breast. The mother grasps and offers her breast to the infant
with the other hand. Once the infant has latched on, she supports her infant’s body.
Ensuring the nutritional needs are met requires complementary foods be:
 Timely – complementary foods are introduced when the energy and nutrients exceeds when can
be provided through exclusive and frequent breastfeeding.
 Adequate – they should provide sufficient energy, protein, and macronutrients to meet a
growing child’s nutritional goal.

 Properly fed – food are given consistent with a child’s signal of appetite and satiety, and that
meal frequency and feeding method – actively encouraging the child, even during illness, to
consume sufficient food using finger, spoon, or self-feeding – are suitable for age.
Deworming - of children aged 1-2years is done every 6months.
 - 12-24months are given Abendazole 200mg or half tablet or Mebendazole 500mgtablet.
Possible adverse effect of antihelminthic drug:
 Local sensitivity or allergy – give an antihistamine.
 Mild abdominal pain – give an antispasmodic
 Diarrhea – give oral rehydration solution
 Erratic worm migration – pull out worms from mouth/nose or from other orifeces.
Vitamin A Capsule – 100,000 IU is given to 6-11months; 200,000 IU is given to 12-71months old.

Integrated Management of Childhood Illness (IMCI)

IMCI – initiated by WHO, offers simple and effective methods for child survival, healthy growth and
development, and is based on the combined community and health facility.
3 Main components of IMCI strategy:
1. Improvements in case management skills of health care staffs.
2. Improvements in health systems needed for effective management of childhood illness.
3. Improvements in family and community practices.
The IMCI protocol guides the health worker in:
 Assessing signs that indicate severe disease
 Assessing the child’s nutrition immunization and feeding.
 Teaching parents how to care for a child at home
 Counseling parents to solve feeding problems
 Advising parents about when to return to a health facility.
Elements of IMCI Case Management:
1. Assess by checking first for danger signs including the other health problems.
2. Classify a child’s illness using a color-coded triage system. Each illness is classified according to
whether it requires:
 Urgent referral treatment and referral (PINK)
 Specific medical treatment and advices (YELLOW)
 Simple advice on home management (GREEN)
3. Identify specific treatments for the child
4. Provide practical treatment instruction including teaching the mother on how to give oral drugs,
how to feed and give fluids during illness, and how to treat local infections at home.
5. Counsel to solve any feeding problems found. Then counsel the mother about her own health.
6. When a child is brought back to the clinic as requested, give follow-up care and, if necessary,
reassess the child for new problems.

LAWS AFFECTING PRACTICE OF PUBLIC HEALTH NURSING

Public health nurses need to know the laws affecting health and nursing practice in the Philippines. As
practicing nurse in the community setting, the PHN nurse must be familiar with the existing laws and
standards that governs safe nursing practice. This chapter should serve as a guide and basis for
understanding these laws.

Republic Act No. 6713 - March 25, 1983 known as the Code of Conduct and Ethical Standards for Public
Officials and Employees. This code upholds a time honored principle that public office is a public trust. It
is the policy of the state to promote high standards of ethics in public office. Public Officials and
employees shall at all items be accountable to the people and shall discharge their duties with utmost
responsibility, integrity, competence and loyalty, act with patriotism and justice, lead modest lives and
uphold public interest over personal interest.

Letter of Instruction No. 949 the legal basis of primary health care date October 19, 1979, instructs the
Department of Health and all officials and personnel of the Department to design, develop and
implement programs which will focus on health development at the community level particularly in rural
areas; effectively utilize these system in order to control or eradicate the immediate and specific health
problems confronting Filipino communities.

With the passage of R.A. 7160 of the Local Government Code, the responsibility for the delivery of basic
services and facilities of the national government has been transferred to the local government. This
involves the devolution of powers, functions and responsibilities to the local government both provincial
and municipal.

Executive Order No. 503 provides for the rules and regulations implementing the transfer of personnel,
assets, liabilities and records of national government agencies whose functions are to be devolved to the
local government units.

Republic Act No. 7305 is known as Magna Carta for Public Health Workers. this Act aims: to promote and
improve the social and economic well-being or health workers, their living and working conditions and
terms of employment to develop their skills and capabilities in order that they will be more responsive
and better equipped to deliver health projects and programs; and to encourage those with proper
qualifications and excellent abilities to join and remain in government service.

Republic Act No. 6758 standardized the salaries of government employees which includes the nursing
personnel.

Republic Act 7883(February 20, 1995) Barangay Health Worker's Benefit's and Incentive.

Republic Act 2382 is known as the Philippine Medical Act. This Act defines the practice of medicine in
the country. A person shall be considered as engaged in the practice of medicine who shall, for
compensation, fee, salary or reward in any form paid to him directly or through another, physically
examine any person, diagnose, treat, operate or prescribe any remedy for any human disease, injury,
deformity, physical, mental condition or ailment, real or imaginary regardless of the remedy or
treatment administered, prescribed or recommended.

Republic Act 1082, the first Rural Health Act implemented in 1953 called for the employment of more
physicians, dentists, nurses, midwives and sanitary inspectors who will live in rural areas where they are
assigned to help raise health condition of the barrio people and thus help abate the still high incidence
of preventable diseases in the country as a whole. It created the first 81 Rural Health Units.

Republic Act 9173- "Philippine Nursing Act of 2002". An act providing for a more responsive nursing
profession, repealing for the purpose RA 7164 otherwise known as Philippine Nursing Act of 1991" and
for other purposes. It is an act declaring the policy of the state to assure responsibilities for the
protection and improvement of the nursing profession instituting measures that will result in relevant
nursing education, humane working conditions, better career prospects and a dignified existence for our
nurses.
Republic Act 3573 in 1929 declared that all communicable diseases should be reported to the nearest
health station, and that any person may be inoculated, administered or injected with prophylactic
preparations. These diseases include: actinomycosis, acute anterior (adult or infant) poliomyelitis,
cerebro-spinal meningitis (epidemic), diphtheria, food poising, glanders, influenza, leprosy, malaria,
measles, plague, pneumonia, mumps, opthalmia, neonatorum, tetanus, trachoma, tuberculosis, typhoid,
paratyphoid fever, typhus fever, variola or smallpox, varioloid, varicella, viscount's angina, whooping
cough and yellow fever.

Republic Act 1891 amended R. A. 1082 in 1957. It strengthened health and dental services in the rural
areas and created rural health units of eight categories of staffing pattern corresponding to population
groups of municipalities to be based on a more equitable and scientific distribution on the radio of
personnel to population.

Republic Act 8749, The Clean Air Act approved in year 2000 but took effect in January 2001. Presidential
Decree No. 825 requires penalty for improper disposal of garbage and other forms of uncleanliness.

Presidential Decree No. 856, the Code on Sanitation provides for the control of all factors in man's
environment that affect health including the quality of water, food, milk, control of insects, animal
carriers, transmitters of disease, sanitary and recreation facilities, noise, pollution, unpleasant odors and
control of nuisance.

Republic Act 9211 Tobacco Regulation Act. June 23, 2003

Republic Act 8976 Philippine Food Fortification. November 7, 2000

Republic Act 6365 established a National Policy on Population and created the Commission of
Population.

Presidential Decree No. 1204 amends P.D. No. 79 which included the active participation of the
Secretaries of the Department of Local Government and Community Development and the Department
of Labor and Employment in the formulation and implementation of policies of the national family
planning health and welfare program; it also strengthens the power of the POPCOM in carrying out the
purpose and objectives of the national family planning, health and welfare program.

Presidential Decree No. 791 the revised Population Act defines the objectives, duties and functions of
the POPCOM. Among others it empowers nurses and midwives to provide, dispense and administer
acceptable methods of contraception after having training and authorization by the POPCOM in
consultation with the appropriate licensing bodies.

Executive Order No. 2009. The Family Code of the Philippines.

Republic Act 9255 (February 24, 2004)- Provides for legitimate children to use the surname of their
fathers.

Presidential Decree No. 965 requires applicants for marriage license to receive instruction on family
planning and responsible parenthood.
Republic Act 7432 (April 23, 1992)- Maximize the Contribution of Senior Citizens to Nation Building,
Grant Benefits and Special Privileges. It entitles the elderly to a twenty percent (20%) discount in all
public establishments and free medical and dental check up and hospitalization in all government
hospitals.

Republic Act 7600 Rooming-in and Breastfeeding. 1992 - provides that babies born in private and
government hospitals should be roomed in with their mother to promote breastfeeding and ensure
made and adequate nutrition to children.

Republic Act 9288 - Newborn Screening. April 4, 2004

Republic Act 9262 (March 8, 2004) Anti-Violence Against women a Children. March 8, 2004

Organ Donation Act of 1991

Republic Act 7885 Advance Corneal Transplantation in the Philippines.

Republic Act 7719 (May 5, 1994)- National Blood Service.

Republic Act 7875 (February 14, 1995) - National Health Insurance Act of 1995.

Presidential Decree No. 996 requires the compulsory immunization of all children below 8 years of age
against the six childhood immunizable diseases.

Republic Act No. 6675-the Generics Act of 1988 which promotes, requires and ensures the production of
an adequate supply, distribution, use and acceptance of drugs and medicines identified by their generics
name.

Republic Act 6425, known as the Dangerous Drug Act states that the sale, administration, delivery,
distribution and transportation of prohibited drugs is punishable by law.

Republic Act 4073 liberalized the treatment of leprosy. Except when the patient requires institution
treatment, no person afflicted with leprosy shall be confined in a leprosarium. They shall be treated in a
government skin clinic, rural health unit or by a duly licensed physician on domiciliary basis.

Republic Act 8423- created the Philippine Institute of Traditional and Alternative Health Care(PITAHC).

Republic Act 8203 (September 4, 1996) Special Law on Counterfeit.

Republic Act 4226 Hospital Licensure Act requiring all hospitals in the Philippines to be licensed before it
can offer to serve to the community.

Presidential Decree 148 Ammending RA 679 (Woman and Child Labor Law) states that the employee's
age shall be 16 years.

Administrative Order No. 114 s.1991 revised/updated the roles and functions of the Municipal Health
Officers, Public Health Nurses and Rural Health Midwives.

Republic Act 8504 -Philippine AIDS Prevention and Control.

Ministry Circular No. 2's 1986 includes Acquired Immune Deficiency Syndrome (AIDS) as a notifiable
disease
 eHealth in the community

Information and communication technologies (ICTs) – diverse set of technological tools and resources
used to communicate and to create, disseminate, store, and manage information.
eHealth – Use of ICT for health. May 25, 2005 the fifty – eight World Health Assembly, was adopted by
the WHO recognizing eHealth as the cost -effective way using ICT in the health care service, health
surveillance, health literature, health education and research.
Extensive capabilities of eHealth
Communicating with a patient through a teleconference, electronic mail (email), short message service.
Providing patient teaching with aid of electronic tools such as radio, television, computers,
smartphones, and tablets
Recording, retrieving, and mining data in an electronic medical record.

According to the WHO, ehealth encompasses three main areas.

- The delivery of the health information, for health professionals and health consumers, through
the internet and communications.
- Using the power of information technology and e-commerce to improve public health services.
Ex. Through education and training of health workers.
- The use of e-commerce and e-business practice in health systems management.

Healthcare system builds heavily on accurate recording of obtained data.

Paper based methods may bring inconvenience when it comes on interoperability of health services,
information backup and instant data access. Problems may also emerge.
1. Continuity and interoperability of care stops in the unlikely event that a record gets misplaced.
2. Illegible handwriting poses misinterpretation of data.
3. Patient privacy is compromised.
4. Data are difficult to aggregate.
5. Actual time for patient care gets limited.

Internal and external changes affecting health careinformatics

1. The ability to manipulate large amounts of data.
2. The ability to relate data to cohorts of people who shares similar health problems
3. The ability to link to genomic data.

Information system benefits

1. Data are readily mapped, enabling more targeted interventions and feedback.
2. Data can be easily retrieved and recovered.
3. Redundancy of data is minimized
4. Data for clinical research becomes more available.
5. Resources are used efficiently

Data must have the following characteristics

1. Accuracy. Ensures that documentation reflects the event as it happened.
2. Accessibility. Data availability should the patient or any member of the health care staff needs.
3. Comprehensiveness. Data inputted should be complete.
4. Consistency / Reliability. Having no discrepancies in data recorded makes it consistent.
5. Currency. All data must be up-to-date and timely.
 6. Definition. Data should be properly labeled and clearly defined.

DOH introduced several health information systems that aim to improve the access of health data.
1. Electronic Field Health Service Information System
2. Online National Electronic Injury Surveillance System
3. Philippine Health Atlas
4. Unified Health Management Information System

Factor affecting eHealth in the country

1. Limited health budget
2. The emergence of free and open source software
3. Decentralized government
4. Target users are unfamiliar with the technology
5. Surplus of “digital native” registered nurses. Digital native describes a person who grew up and
is familiar with digital technologies and who uses them in daily living.

DOH Administrative Order No. 2010-0036, outlined the policy directions of universal health care. Known
as Kalusugan Pangkalahatan this reform agenda has three priority health directions:
1. Financial risk protection through program enrolment and benefit delivery.
2. Improved access to quality hospitals and health care facilities.
3. Attainment of the health- related Millennium Development Goals

Electronic medical records - is basically comprehensive patient records that are stored and accessed
from a computer or server.

Telemedicine – WHO define telemedicine as, “the delivery of health care services, where distance is a
critical factor, by all health care professionals using information and communications technologies for
the exchange of valid information for diagnosis, treatment and prevention of disease and injuries,
research and evaluation and for the continuing education of the health care providers, all in the
interests of advancing the health of individuals and their communities”

Four elements for telemedicine

1. Its purpose is to provide clinical support.
2. It is intended to overcome geographical barriers, connecting users who are not in the same
physical location.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.

eLearning is basically the use of electronic tools to aid in teaching. Can also be used to educate fellow
health professionals.

Roles of community health nurses in eHealth

1. Data and records manager. Maintain the quality of data inputs in the EMRS, making sure that
information is accurate, complete, consistent, correct and current.
2. Change agent. Working closely with community and implementing eHealth with them and not
for them.
3. Educator. Nurses provide health education to individual and families through ICT tools.
4. Telepresenter. Needs may need to present the patient’s case to a remote medical specialist.
 5. Client Advocate. Nurse must safeguard patient records, ensuring that security, confidentiality,
and privacy of all patient information are being upheld.
6. Researcher. Responsible for identifying possible points for research and developing a
framework, based on data aggregated by the system.

Chapter 16

The use of tobacco, alcohol and drugs, poor nutritional habits, inadequate physical activity, irresponsible
sexual behaviour, violence, suicide and reckless driving are examples of behaviour that often begin
during youth and increase the risk of serious health problems.

 The school nurse visits four to six schools per month, with each visit lasting for 3 days or more,
depending on the type of school and school location and population.
 Revisits may be done within the month in a particular school.
 Teachers who also serve as school guardians, provide primary care as necessary. Such as
detection of obvious health problems and administration of first aid.
 The school nurse is responsible for planning and conducting training programs for teachers on
health and nutrition.
 Poverty is associated with decreased or inferior health care and has been linked to serious
health problems that result in absenteeism and failure in school.
 The school nurse and in the absence of the school nurse, the well-prepared school teacher,
serving as school health guardian, can effectively manage minor complaints of illnesses, helping
these children to return to or remain in class.
 There is a need for mental and physical health services for student of all ages in an effort to
improve both academic performance and the sense of well-being.
 School health program were defined as :
1. School health services
2. School health education
3. A healthy school environment to include both physical and psychosocial aspects of
environment( WHO, 1997)

 RA 124 in 1947- an act to provide for Medical Inspection of Children Enrolled in Private
Schools, Colleges and Universities in the Philippines. This law stated that it was the duty of
the school heads of private schools with a total enrolment of 300 or more to provide for a
part-or full time physician for the annual medical examination of pupils and students.
 The physicians were to render of their school health activities at the end of every quarter
of each school year to the Director of Health.
 SCHOOL HEALTH SERVICES:
 Health Education- these are culture sensitive and based on the identified
educational needs of the target population.
 Areas of concern for health education:
1. Oral Hygiene- the oral health care program involves the 7 o‘clock toothbrushing habit
activity.
2. Injury prevention and developing safety conscious behaviour in the use of the school
playground, while engaging in sports, and the like. MAPEH period is a good time for the
school nurse or teacher to talk with and counsel students about risk of developing health
problems related too physical acivity.
3. Tobacco Use- Smoking is a major problem in this country.
- Prevention should be emphasized in young people.
4. Substance Abuse- The use of alcohol and other drugs is associated with problems in schools,
injuries, violence and motor vehicle deaths.
- National Drug Education Program- designed to promote collaboration of other sectors with
the school system by establishing linkages among government, private and sociocivic
organizations.
- Random drug testing is also carried as part of this program.
5. HIV, AIDS- School-base HIV and AIDS Education and prevention program is an information
dissemination campaign to educate the general
population on the risks of HIV and AIDS.

EIGHT COMPONENTSOF SCHOOL HEALTH RPOGRAMS

Health Physical Health Nutrition Services

education Education Services
Family and
Counseling,
Healthy school Health promotion for community
psychological and
environment staff involvement
social services

 Physical Education - Sedentary lifestyle is associated with obesity, hypertension, heart disease and
diabetes
- Regular Physical activity helps build and maintain healthy bones and muscles.

 Health services
1. Health Screening- one of the objective of the school health nursing program in the
Philippines is to detect early signs and symptoms of illness, disabilities and deviations from
normal.
1.1 Annual Individual health assessment- examination of the eyes, ears, nose, throat, neck,
mouth, skin, extremities, posture, nutritional status, heart and lungs.
- Visual acuity test is done with the use of snellen‘s chart, E-chart or symbol chart.
- Ballpen click test(auditory screening)- test for hearing acuity.
 1.2 Height and weight measurement- done at the beginning and at the end of the school year.
1.3 Rapid Classroom Inspection- inspection of the pupils in the classroom or while they are in
line formation outside the classroom.
- Done to detect illness, particularly when there is outbreak in the community.
 Emergency Care- emergencies can include natural events such as typhoons, floods, and
earthquake and man-made disasters, such as hazardous material spills, fires and civil
disobedience.
- Basic first aid equipment should be available in all schools.
- The school nurse and school health guardians must be knowledgeable about standard
first aid.
- EMS activation and Referral system should be in place.
 Nutrition- a variety of foods must be ingested to meet their daily requirement.
- Diets should include a proper balance of carbohydrates, proteins, and fats with sufficient
intake of vitamins and minerals. S
- Skipping meals, especially breakfast and eating unhealthy snacks contribute to poor
childhood nutrition.
- Food preparation is expected to be undertaken by the home economics, feeding
teachers, homeroom Parent-Teachers Association on a rotation basis or both.
 Obesity – not considered as an eating disorder
- must be of concern to the school nurse
- 3 most common eating disorder:
1. Anorexia- severely restricted intake of food based on an extreme
fear of weight gain.
2. Bulimia- chaotic eating pattern with recurrent episodes of binge
eating.
3. Binge eating-out-of control eating of large amounts of food whether
hungry or not.
 Counseling, Psychological and social services- children and teens struggle with
depression, substance abuse, conduct disorders,self-esteem, suicide ideation,
eatingdisorders and under oroverachievement.
- One of the most importantroles of the nurse with variousvague complaints, such
asrecurrent stomachaches,headaches, or sexuallypromiscuous behaviour.
- early dtetction and treatment mayprevent untoward consequences.
- It is important for the nurse to becognizant of the warning signs associated with
suicide and to recognize and referat-risk adolescents to appropriate mentalhealth
professionals.
 Healthy School Environment- the healthy school environment should consist of (WHO, 1997)
1. A Physical, psychological and social environment
2. A healthy organizational culture within the school
3. Productive interaction between the school and community.
 Health Promotion for school staff- staff that participate in health promotion increase their health
knowledge and positively change their attitudes and behaviors relative to smoking practices,
nutrition, physical activity, stress and emotional health.

Truths about adolescent suicide

1. Most adolescent who attempt suicide are torn between wanting to die and wanting to live
2. Any threat of suicide should be taken seriously
3. There are usually warning signs preceding an attempt(depression, isolation, sleep changes)
4. Suicide is more common in adolescents than Homicide
5. Education concerning suicide
does not lead to an increased number of attempts.
6. Females are more likely to attempt suicide. Males are more likely to suicide
7. One attempt can result in a subsequent attempt
8. Firearms and strangulation are predominant modalities of completed suicides in children and
adolescents.
9. Most adolescents who attempted suicide have not been diagnoses as having mental disorder.
10. All socioeconomic groups are affected by suicide.

Warning Signs Of Stress

 Difficulty eating or sleeping

 Use of alcohol or other substances(sedatives, sleep enhancer)
 Difficulty in making decisions
 Persistent angry or hostile feelings
 Inability to concentrate
 Increased boredom
 Frequent headaches and ailments
 Inconsistent school attendance

 Healthy School Environment- the healthy school environment should consist of (WHO, 1997)
4. A Physical, psychological and social environment
5. A healthy organizational culture within the school
6. Productive interaction between the school and community.
 Health Promotion for school staff- staff that participate in health promotion increase their health
knowledge and positively change their attitudes and behaviors relative to smoking practices,
nutrition, physical activity, stress and emotional health.

Standards of school nursing practice

Standards Of Practice
Standard 1. Assessment Nurse collects comprehensive data pertinent to
the clients health or the situation
 Standard 2. Diagnosis Nurse analyzes the assessment data to determine
the diagnoses or issues
Standard 3. Outcomes identification Nurse identifies expected outcome for a plan
individualized to the client or the situation
Standard 4. Planning School nurse develops a plan that prescribes
strategies and alternatives to attain expecte
outcome.
Standard 5 A. Coordination of care Nurse provides health education and employs
strategies to promote health and a safe
environment.
Standard 5 B. health teaching and health Nurse provides health education and employs
promotion strategies to promote health and a safe
environment.
Standard 6. Evaluation School nurse evaluates the clients progress
towards attainment of outcomes.
Standards of professional performance
Standard 7. Quality of practice School nurse systematically enhances the quality
and effectiveness of nursing practice
Standard 8. Education School nurse attains knowledge and competency
that reflects current school nursing practice.
Standard 9. Profession practice evaluation Nurse evaluates ones own nursing practice
Standard 10. Collegiality Nurse interacts with to the professional
development of peers and school personnel as
colleagues.
Standard 11. Collaboration School collaborates with the client, family, school,
staff
Standard 12. Ethics School nurse integrates ethical provision in all
areas of practice.
Standard 13. Research School nurse integrates research findings into
practice.
Standard 14. Resource utilization School nurse considers factors related to safety,
effectiveness, cost and impact.
Standard 15. Leadership School nurse provides leadership in the
professional practice setting and the profession
Standard 16. Program Management Manages school health services.

School Nursing Practice- is a specialty unto itself. School nurses need education in specific areas, such as
growth and development, public health, mental health nursing, case management, family theory,
leadership and cultural sensitivity to effectively perform their roles.
CHAPTER 17 – OCCUPATIONAL HEALTH

 Occupational Health Nursing is defined as a specialty practice that focuses on the promotion,
prevention, and restoration of health within the context of a safe and healthy environment. It
includes the prevention of adverse health effects from occupational and environmental hazards.

 Department of Labor and Employment – the lead agency on Occupational Safety and Health

 They are given RULE MAKING and RULE ENFORCEMENT powers to implement stipulations of the
Philippine Constitution and the Philippine Labor Code.

 The National Profile on Occupational Safety and Health (of the Department of Labor and
Employment – Occupational Safety and Health Center (OSHC) – defined OSH as a discipline
involved in “the promotion and maintenance of the highest degree of physical, mental and social
well-being of workers in all occupations.”

EVOLUTION OF OCCUPATIONAL HEALTH NURSING IN THE PHILIPPINES

 MS. MAGDALENA VALENZUELA – she instituted the INDUSTRIAL NURSING UNIT of the Philippine
Nurses Association on November 11, 1950.

 MS. PERLA GORRES – from the Philippine Manufacturing Company (PMC) served as the first
chairperson of the said unit.

 MS. ANITA SANTOS – was elected as first president on August 19, 1964. She paved way to the
modification in the name of the organization to Occupational Health Nurses Association of the
Philippines, Inc. on November 12, 1966.

 June 5 – 6, 1970 – first annual convention was held.

 September 25, 1979 – the organization was registered with the Securities and Exchange
Commission.

ASSESSMENT AND CONTROL OF HAZARDS IN THE WORKPLACE

 HEALTH HAZARDS – are the elements in the work environment that can cause work-related
disease.
 SAFETY HAZARDS – are the unsafe conditions or unsafe acts that significantly increase the risk of
a worker to be injured.

TYPES OF HAZARDS:
 1. Biological-infectious hazards – infectious agents such as bacteria, viruses, fungi.
2. Chemical hazards – various forms of chemical agents.
3. Enviromechanical hazards – factors that cause accident, injuries, strains or discomfort (eg. Poor
equipments)
4. Physical hazards – radiation, electricity, temperature, and noise
5. Psychosocial hazards – anything that causes emotional stress and strain or interpersonal
problem.

CONTROL MEASURES FOR OCCUPATIONAL HAZARDS:

1. Administrative Control – refers to the development and implementation of policies, standards,
trainings, job design and the like.
2. Engineering – refers to the adoption of physical, chemical or technological improvements to
limit exposure to hazards.
3. Materials Provision – refers to providing the workers with supplies or supplements that can
decrease their exposure to hazards.

DUTIES OF OCCUPATIONAL HEALTH NURSE as stated in Rule 1965.04 of the amended OSHS by DOLE:

“The duties and functions of the Occupational Health Nurse are:

(1) In the absence of a physician, to organize and administer a health service program integrating
occupational safety, otherwise, these activities of the nurse shall be in accordance with the physician;

(2) Provide nursing care to injured or ill workers;

(3) Participate in health maintenance examination. If a physician is not available, to perform work
activities which are within the scope allowed by the nursing profession, and if more extensive
examinations are needed, to refer the same to a physician;

(4) Participate in the maintenance of occupational health and safety by giving suggestions in the
improvement of working environment affecting the health and well-being of the workers; and

(5) Maintain a reporting and records system, and, if a physician is not available, prepare and submit an
annual medical report, using form DOLE/BWC/HSD/OH-47, to the employer, as required by this
Standards.

CODE OF ETHICS OF THE AMERICAN ASSOCIATION OF OCCUPATIONAL HEALTH NURSES:

1. The American Association of Occupational Health Nurses (AAOHN) articulates occupational and
environmental health nursing values, maintains the integrity of our specialty practice area and the
nursing profession, and integrates principles of social justice into nursing and health policy
2. The occupational and environmental health nurse (OHN) practices with compassion and respect for
the inherent dignity, worth, and unique attributes of every person.

3. The occupational and environmental health nurse's (OHN) primary commitment is to the client,
whether an individual, group, community, or population.

4. The occupational and environmental health nurse (OHN) promotes, advocates for, and protects the
rights, health, and safety of the client.

5. The occupational and environmental health nurse (OHN) has authority, accountability, and
responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to
prevent illness and injury, promote health, and provide optimal health care.

6. The occupational and environmental health nurse (OHN) owes the same duties to self as to others,
including the responsibility to promote health and safety, preserve wholeness of character and integrity,
maintain competence, and continue personal and professional growth.

7. The occupational and environmental health nurse (OHN), through individual and collective effort,
establishes, maintains, and improves the ethical environment of the work setting and conditions of
employment that are conducive to safe, quality health care.

8. Occupational and environmental health nurses (OHN) help advance the nursing profession and our
specialty practice through research and scholarly inquiry, professional standards development, and the
generation of nursing and health policy.

9. The occupational and environmental health nurse (OHN) collaborates with other health professionals
and the public to protect human rights, promote health, and reduce health disparities.

COMPETENCY CATEGORY IN OCCUPATIONAL AND ENVIRONMENTAL HEALTH NURSING by AAOHN

1. Clinical and primary care

2. Case management
3. Workforce, workplace and environmental issues
4. Regulatory and legislative
5. Management
6. Health promotion and disease prevention
7. Occupational and environmental health and safety education and training
8. Research
9. Professionalism

IMPACT OF LEGISLATION ON OCCUPATIONAL HEALTH:

The DOLE possesses legislative and rule-making powers with regards to the following laws and
standards:
1. Presidential Decree 442 Philippine Labor Code on prevention and compensation
2. The Administrative Code on Enforcement of Safety and Health Standards
3. The Occupational Safety and Health Standards
 4. Executive Order 307
5. Presidential Decree 626
6. RA 9165 or the Comprehensive Drug Act
7. RA 8504 of the National HIV/AIDS Law
8. DOH: Sanitation Code
9. DA: Fertilizer and Pesticide Act
10. DENR: RA 6969
11. RA 9185 or the Comprehensive Dangerous Drug Act
12. RA 6541 of the National Building Code of the Philippines
13. RA 9231 or the Special Protection of Children against Child Abuse, Exploitation and
Discrimination

THE PHILIPPINE LABOR CODE (PD 442)

- Aims to protect every citizen desiring to work locally or overseas by securing the best possible
terms and conditions of employment.
- Under Article 6, all rights and benefits granted to workers under this Code shall, except as may
otherwise be provided herein, apply alike to all workers, whether agricultural or non-
agricultural. 

WORKING CONDITIONS AND REST PERIODS:

Article 83. Normal hours of work. The normal hours of work of any employee shall not exceed eight (8)
hours a day.
Health personnel in cities and municipalities with a population of at least one million (1,000,000) or in
hospitals and clinics with a bed capacity of at least one hundred (100) shall hold regular office hours for
eight (8) hours a day, for five (5) days a week, exclusive of time for meals, except where the exigencies
of the service require that such personnel work for six (6) days or forty-eight (48) hours, in which case,
they shall be entitled to an additional compensation of at least thirty percent (30%) of their regular wage
for work on the sixth day. For purposes of this Article, "health personnel" shall include resident
physicians, nurses, nutritionists, dietitians, pharmacists, social workers, laboratory technicians,
paramedical technicians, psychologists, midwives, attendants and all other hospital or clinic personnel.
Article 84. Hours worked. Hours worked shall include (a) all time during which an employee is required
to be on duty or to be at a prescribed workplace; and (b) all time during which an employee is suffered
or permitted to work.
Rest periods of short duration during working hours shall be counted as hours worked.
Article 85. Meal periods. Subject to such regulations as the Secretary of Labor may prescribe, it shall be
the duty of every employer to give his employees not less than sixty (60) minutes time-off for their
regular meals.

MEDICAL, DENTAL AND OCCUPATIONAL SAFETY

Article 156. First-aid treatment. Every employer shall keep in his establishment such first-aid medicines
and equipment as the nature and conditions of work may require, in accordance with such regulations
as the Department of Labor and Employment shall prescribe.
The employer shall take steps for the training of a sufficient number of employees in first-aid treatment.
Article 157. Emergency medical and dental services. It shall be the duty of every employer to furnish his
employees in any locality with free medical and dental attendance and facilities consisting of:
The services of a full-time registered nurse when the number of employees exceeds fifty (50) but not
more than two hundred (200) except when the employer does not maintain hazardous workplaces, in
which case, the services of a graduate first-aider shall be provided for the protection of workers, where
no registered nurse is available. The Secretary of Labor and Employment shall provide by appropriate
regulations, the services that shall be required where the number of employees does not exceed fifty
(50) and shall determine by appropriate order, hazardous workplaces for purposes of this Article;
The services of a full-time registered nurse, a part-time physician and dentist, and an emergency clinic,
when the number of employees exceeds two hundred (200) but not more than three hundred (300);
and
The services of a full-time physician, dentist and a full-time registered nurse as well as a dental clinic and
an infirmary or emergency hospital with one bed capacity for every one hundred (100) employees when
the number of employees exceeds three hundred (300).
In cases of hazardous workplaces, no employer shall engage the services of a physician or a dentist who
cannot stay in the premises of the establishment for at least two (2) hours, in the case of those engaged
on part-time basis, and not less than eight (8) hours, in the case of those employed on full-time basis.
Where the undertaking is non-hazardous in nature, the physician and dentist may be engaged on
retainer basis, subject to such regulations as the Secretary of Labor and Employment may prescribe to
insure immediate availability of medical and dental treatment and attendance in case of emergency. (As
amended by Presidential Decree NO. 570-A, Section 26).
Article 159. Health program. The physician engaged by an employer shall, in addition to his duties under
this Chapter, develop and implement a comprehensive occupational health program for the benefit of
the employees of his employer.

COMPENSATION

Article 86. Night shift differential. Every employee shall be paid a night shift differential of not less than
ten percent (10%) of his regular wage for each hour of work performed between ten o’clock in the
evening and six o’clock in the morning.

Article 89. Emergency overtime work. Any employee may be required by the employer to perform
overtime work in any of the following cases:
When the country is at war or when any other national or local emergency has been declared by the
National Assembly or the Chief Executive;
When it is necessary to prevent loss of life or property or in case of imminent danger to public safety
due to an actual or impending emergency in the locality caused by serious accidents, fire, flood,
typhoon, earthquake, epidemic, or other disaster or calamity;
When there is urgent work to be performed on machines, installations, or equipment, in order to avoid
serious loss or damage to the employer or some other cause of similar nature;
When the work is necessary to prevent loss or damage to perishable goods; and
Where the completion or continuation of the work started before the eighth hour is necessary to
prevent serious obstruction or prejudice to the business or operations of the employer.

Article 91. Right to weekly rest day.

It shall be the duty of every employer, whether operating for profit or not, to provide each of his
employees a rest period of not less than twenty-four (24) consecutive hours after every six (6)
consecutive normal work days.
The employer shall determine and schedule the weekly rest day of his employees subject to collective
bargaining agreement and to such rules and regulations as the Secretary of Labor and Employment may
provide. However, the employer shall respect the preference of employees as to their weekly rest day
when such preference is based on religious grounds.
Article 92. When employer may require work on a rest day. The employer may require his employees to
work on any day:
In case of actual or impending emergencies caused by serious accident, fire, flood, typhoon, earthquake,
epidemic or other disaster or calamity to prevent loss of life and property, or imminent danger to public
safety;
In cases of urgent work to be performed on the machinery, equipment, or installation, to avoid serious
loss which the employer would otherwise suffer;
In the event of abnormal pressure of work due to special circumstances, where the employer cannot
ordinarily be expected to resort to other measures;
To prevent loss or damage to perishable goods;
Where the nature of the work requires continuous operations and the stoppage of work may result in
irreparable injury or loss to the employer; and
Under other circumstances analogous or similar to the foregoing as determined by the Secretary of
Labor and Employment.
Article 93. Compensation for rest day, Sunday or holiday work.
Where an employee is made or permitted to work on his scheduled rest day, he shall be paid an
additional compensation of at least thirty percent (30%) of his regular wage. An employee shall be
entitled to such additional compensation for work performed on Sunday only when it is his established
rest day.
When the nature of the work of the employee is such that he has no regular workdays and no regular
rest days can be scheduled, he shall be paid an additional compensation of at least thirty percent (30%)
of his regular wage for work performed on Sundays and holidays.
Work performed on any special holiday shall be paid an additional compensation of at least thirty
percent (30%) of the regular wage of the employee. Where such holiday work falls on the employee’s
scheduled rest day, he shall be entitled to an additional compensation of at least fifty per cent (50%) of
his regular wage.
Where the collective bargaining agreement or other applicable employment contract stipulates the
payment of a higher premium pay than that prescribed under this Article, the employer shall pay such
higher rate.
ETHICAL INSIGHT: CONFIDENTIALITY OF EMPLOYEE HEALTH INFORMATION

In dealing with health information, the employee has a right to privacy and should “be protected from
unauthorized and inappropriate disclosure of personal information” (AAOHN, 2004). However,
exemptions must be made. These include:
(1) life-threatening emergencies
(2) authorization by the employee to release information to others
(3) worker’s compensation information
(4) compliance with government laws and regulations

LEVELS OF CONFIDENTIALITY
 LEVEL 1: relates to the information required by law (eg. Data on occupational illness and
injuries)
 LEVEL 2: covers information that will assist in management of human resources (eg. Info from
job placement and workability status of employee)
  LEVEL 3: focuses on personal health information
- disclosure of levels 1 and 2 information to management should be allowed only on a need-to-know
basis.
- disclosure of level 3 information to management and regulatory agencies should only be allowed as
required by law.
- disclosure of level 3 information to health insurance providers should only be made with the written
authorization of the employee.