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CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING
N. Bacalso Ave. cor Panganiban St., 6000 Cebu City, Cebu, Philippines
Tel. Nos. (032)316-5128/(032) 4186105
Email address: ctuccmc_cn@ymail.com

MODULE 1
COMMUNITY HEALTH NURSING CONCEPTS
Instructor: Glenn M. Gamalier, Ed.D, RN

Overview of the lesson:

Since the late 1800s, public/community health nurses have been leaders in making improvements
in the quality of health care for individuals, families, and aggregates, including populations and
communities. As nurses around the world collaborate with one another, it is clear that, from one country to
another, population – centered nursing has more similarities than differences.

Recognizing the above scenario, this module discusses the general concepts of Community Health
Nursing. The primary goal of community health nursing is to preserve the health of the community and
surrounding populations focusing on health promotion and health maintenance of individuals, families, and
groups within the community.

Desired Learning Outcomes:

After reading this module, the student should be able to do the following:

§ Define health, community and primary health care.

§ Integrate relevant principles of public/community health in the practice of nursing.
§ Recognize the importance of different theoretical models in the practice of public/community
health.
§ Identify the different fields in the practice of public/community health nursing.

Something to Ponder On

Lesson 1. Community Health Nursing: An Overview

– Defining Community Health Nursing (CHN)

What is a community?

• A group of people with common characteristics or interests living together within a territory or
geographical boundary.

• Place where people under usual conditions are found.

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• It is a system of formal and informal groups characterized by interdependence and whose function
is to meet the collective needs of the group members. (E.g. need for education, shelter, leadership
etc.)
• Is a social unit in which there is a transaction of a common life among the people making up the
unit. Geographical or interest communities consisting of relatively small, non-institutionalized
aggregates of people linked together for common goals or other purposes.

• A locality based entity, composed of systems of formal organizations reflecting societal institutions,
informal groups and aggregates which are interdependent and whose function is to meet the wide
variety of collective needs.

• A group of people who share some type of bond and commonalities; who engage in interaction
with each other and which functions collectively regarding common concerns.

Operational definition - as a group of people in a specific time and place and have a common purpose.
Includes the components as people, location, social climate, social structure, social activity and sentiment
as well as the concept of outside influences.

Functional definition – “wherever the needs of the individual are being met”

Eclectic view – defined in terms of either geography or special interest.

COMMON IN THESE DEFINITIONS

1. Network of interpersonal relationship that provide friendship and support to members

2. Residence in common locality
3. Solidarity sentiments and activities

¯COMMUNITY AS CLIENT / PATIENT IN CHN

World Views on Community:

1. The community is an integral part of society and is composed of families

2. Contradictions/conflicts are inherent in a community
3. The community is always in state of continuous movement and change

¯COMMUNITY AS SETTING IN CHN PRACTICE

- place where people under usual or normal conditions are found

(homes, schools and places of work) outside of purely curative institutions

• What is health?
1. Health-illness continuum model
Health is a dynamic state at any point between optimal wellness and death; a balance between
internal and external environments
Holistic as it reflects physical, emotional, intellectual, developmental, social and spiritual
dimensions
2. High-level wellness model
model recognizes health as an ongoing process toward a person’s highest potential of
functioning
3. Agent-host-environment (Epidemiologic) model
The agent, host and environment interact in ways that create risk factors, and understanding
these is important for the promotion and maintenance of health
4. Health belief model
People take preventive actions if the three conditions exist:
§ Seriousness of the disease
§ Susceptibility to the disease
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§ Cost effectiveness of the preventive action

5. Evolutionary-based model
Illness and death sometimes serve an evolutionary purpose
6. Health promotion model
refers to the policies, activities and codes of practice aimed that positively enhancing well-
being
7. WHO definition
Not merely the absence of disease
The state of complete physical, mental and social well-being
A social phenomenon
An outcome of the interplay of biological, physical, ecological, political, economic, and socio-
cultural factors

What is community health?

• Part of paramedical and medical intervention/approach, which is concerned on the health of the
whole population.
• Aims:
o Health promotion
o Disease prevention
o Management of factors affecting health

Public Health Nursing: the term used before for Community Health Nursing

Public Health (definitions)

Winslow
- Science and art of preventing disease, prolonging life, promoting health and efficiency through organized
community effort 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

According to Dr. C.E. Winslow, Public Health is a science and art of 3 P’s

• Prevention of Disease
• Prolonging life
• Promotion of health and efficiency through organized community effort

Hanlon

- Dedicated to the common attainment of the highest level of physical, mental and social well-being and
longevity consistent with available knowledge and resources at a given time and place towards most
effective total development life of the individual and society.

Purdom

- Prioritizes survival of human species and recognizes that each phase in human development is of equal
importance with the other phases

What is Community Health Nursing?

“ The utilization of the nursing process in the different levels of clientele – individuals, families, population
groups and communities, prevention of disease and disability and rehabilitation” – Maglaya, et al

Goal: “To raise the level of citizenry by helping communities and families to cope with the discontinuities in
and threats to health in such a way as to maximize their potential for high level wellness”.

- Nisce, et al
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COMMUNITY HEALTH NURSING (definitions):

WHO Expert Committee on Health

• A specialized field of nursing practice that combines the skills of nursing, public health and some
phases of human assistance and functions.
• A science of Public Health combined with Public Health Nursing Skills and Social Assistance with
the goal of raising the level of health of the citizenry, to raise optimum level of functioning of the
citizenry. (characteristic of CHN)

Jacobson
Promotion of client’s optimum level of functioning through teaching and delivery of care.

Freeman
Developing and enhancing health capabilities of people.

– Basic Concepts of CHN

1. Primary focus is health promotion and disease prevention.
2. Practice extends from individual to family, population group and community.
3. CHNurses are generalists.
4. Contact with client continues through time and all types of health care.
5. Nature of practice require application of concepts of various sciences.
6. Implicit in CHN is the nursing process.

– 12 Principles of Community Health Nursing

Community health nursing is a vital part of Public Health and there are 12 principles that govern CHN.

1. The recognized need of individuals, families and communities provides the basis for CHN
practice. Its primary purpose is to further apply public heath measures within the framework of the
total CHN effort.
2. Knowledge and understanding of the objectives and policies of the agency facilities goal
achievement. The mission statement commits Community Health Nurse to positively actualize
their service to this end.
3. CHN considers the family as the unit of service. Its level of functioning is influenced by the
degree to which it can deal with its own problems. Therefore the family is an effective and available
channel for the most of the CHN efforts.
4. Respect for values, customs and beliefs of clients contributes to the effectiveness of care to the
client. CHN services must be available sustainable and affordable to all regardless of race, creed,
color or socio-economic status.
5. CHN integrate health education and counseling as vital parts of functions. These encourage
and support community efforts in the discussion of issues to improve the people’s health.
6. Collaborative work relationships with co-workers and members of the health team facilitates
accomplishments of goals. Each member is helped to see how his/her work benefits the whole
enterprise.
7. Periodic and continuing evaluation provides and means for assessing the degree to which
CHN goals and objectives are being attained. Clients are involved the appraisal of their health
program through consultations, observations and accurate recording.
8. Continuing staff education program quality services to client and are essential to upgrade
and maintain sound practices in their setting. Professional interest and needs of Community
Health Nurses are considered in planning staff development programs of the agency.
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9. Utilization of indigenous and existing community resources maximizing the success of the
efforts of the community health nurses. The use of local available ailments. Linkages with
existing community resources, both public and private, increase the awareness of what care they
need what are entitled.
10. Active participation of the individual, family and community in planning and making
decisions for their health care needs, determine, to a large extent, the success of the CHN
programs. Organized community groups are encouraged to participate in the activities that will
meet community needs and interests.
11. Supervision of nursing services by qualified by CHN personnel provides guidance and
direction to the work to be done. Potentials of employees for effective and efficient work are
developed.
12. Accurate recording and reporting serve as the basis for evaluation of the progress of
planned programs and activities and as a guide for the future actions. Maintenance of
accurate is utilized in studies and researches and as legal documents.

Objectives, Strategies and Methodologies in CHN

– Strategies and Health Status Targets to Achieve Objectives

Strategies to promote equity in health

► priority for the vulnerable and marginalized
► primary Health Care as the Key Approach

ŒHealth Promotion
- Consists of activities directed towards increasing the level of well-being and actualizing the health
potential of individuals, families, communities and societies.
Methods:
• Health education
• Nutrition
• Personality development
• Adequate housing, recreation, agreeable working condition
• Genetic counseling
• Periodic selective examination

 Disease Prevention

Primary Level of Disease Prevention

- Consists of activities directed towards decreasing probability of specific illnesses or dysfunctions in
individuals, families and communities
Through people
• immunization
• chemoprophylaxis
• nutrition
• personality development
• personal hygiene
• child spacing
• protection against carcinogens and allergens
Environmental control
• safe water supplies
• good food hygiene
• safe excreta and rubbish disposal
• disinfection and sterilization
• vector and animal reservoir control
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• good living nag working conditions

Secondary Level of Disease Prevention

- Emphasizes early diagnosis and prompt intervention to halt pathological process, thereby shortening its
duration and severity and enabling individual regain normal function at the earliest possible time.

Screening - the presumptive identification of unrecognized disease or defect by the application of tests,
examinations or other procedures that can be applied rapidly and inexpensively to populations
Screening Methods:
1mass screening
1 case-finding
1contact-tracing
1 multi-phasic screening
1 surveillance

Characteristics of an ideal screening test:

§ High sensitivity
§ High specificity

Tertiary Level of Disease Prevention

- Comes into play when a defect or disability is fixed. Rehabilitation goal is more than halting the
disease process itself’ it is restoring the individual to an optimum level of functioning within the constraints
of disability.

Methods of Tertiary Prevention:

o Diagnosis
o Treatment
o Management
o Rehabilitation

3 Levels of Prevention
PRIMARY LEVEL SECONDARY LEVEL TERTIARY LEVEL
Health Promotion and Illness Prevention of Complications thru Prevention of Disability, etc.
Prevention Early Dx and Tx
Provided at – ► When hospitalization is ► When highly-specialized
► Health care/RHU deemed necessary and medical care is necessary
► Brgy. Health Stations referral is made to emergency ► referrals are made to hospitals
►Main Health Center (now district), provincial or and medical center such as
►Community Hospital and regional or private hospitals PGH, PHC, POC, National
Health Center Center for Mental Health, and
►Private and Semi-private other gov’t private hospitals
agencies at the municipal level

Ž Community Organizing
Process by which the people organize themselves to “take change” of their situation and thus develop a
sense of being a community together.

Principles:

• People, especially the most oppressed and exploited sectors, are most open to change and are
able to bring about change.
• CO should be for the interest of the poorest sector of the society.
• CO should lead to self reliant communities.
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– HISTORY OF PUBLIC HEALTH AND PUBLIC HEALTH NURSING IN THE PHILIPPINES

• Record of public health services in the Philippines date back to the Spanish regime
• 1577; Franciscan Friar Juan Clemente; opened a 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: Dr. Francisco de Balmis ( personal physician of King Charles IV); introduced the
smallpox vaccination
• 1876; provincial health officers (medicos titulares); appointed by the Spanish government
• 1888; 2-year course consisting of fundamental medical and dental subjects was first offered in
the University of Santo Tomas; Graduates of this course as cirujanos ministrantes serves as
male nurses and sanitation inspectors
• 1901; United States Philippine Commission, through Act 157, created the Board of Health of
the Philippine Islands, with a Commissioner of Public Health as its Chief executive officer
• The Board of Health is now the Department of Health
• Provincial and municipal boards of health were formed.
• 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; a nurse as a sanitation inspector
• 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 Service, with two nurses
as staff.
• Associacion Feminista Filipina in 1905 founded La Gota de Leche, as the 1st center dedicated
to the service of mothers and babies
• 1947; Department of Health was reorganized into bureaus: quarantine, hospitals that took
charge of the municipal and charity clinics, and health with the sanitary divisions under it.
• The reorganization also placed the administration of city health departments at the bureau
level
• 1954; Congress passed R.A. 1082 or the Rural Health Act that provided for the creation of a
rural health unit in every municipality
• 1957; R.A 1891; equitable distribution of health personnel; amended provisions in the Rural
Health Act
• 1970; Philippine Health Care Delivery System was restructured, paving the way for the health
care system that exists to this day where health services are classified into primary, secondary,
and tertiary levels
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• 1991; R.A 7160 (Local Government Code); mandated devolution of basic services, including
health services, to local government units and the establishment of a local health board in
every province and city or municipality.
• 2000; The Philippines is a signatory to the United Nations Millennium Declaration adopted
during the World Summit; the member nations committed themselves to the attainment of the 8
Millennium Development Goals (MDGs). DOH is committed to the MDGs.
• 1999; DOH launched the Health Sector Reform Agenda; it implementation framework
FOURmula One (F1) for Health in 2005 and Universal Health Care in 2010

 PRIMARY HEALTH CARE

History of Primary Health Care:

• September 6-12, 1978; health leaders around the 200 countries attended the International
Conference for Primary Health Care held at Alma Ata, USSR initiated by the WHO and UN
Children’s Fund (International Conference on Primary Health Care, Alma Ata, 1978)
• The Alma Ata Declaration on Primary Health Care emerged from this conference:
1. Health is a basic fundamental right.
2. There exists a global burden of health inequalities among populations
3. Economic and social development is of basic importance for the full attainment of
health for all
4. Governments have responsibility for the health of their people
• PHC strategy was adopted in the Philippines by virtue of LOI 949 of 1979, making the
Philippines the 1st country in Asia to embark on meeting the challenge of PHC.
• Government is driven to increase investment on health care. The WHO recommend
governments to allocate 5% of the gross national product (GNP) to health services.

Primary Health Care

• Essential health care based on practical, scientifically sound and socially acceptable methods
and technology made universally accessible to individuals and families in the community
through their full participation and at a cost to maintain at every stage of their development in
the spirit of self-reliance and self-determination
• The universal goal of PHC, as stated in the Alma Ata Declaration, is “Health for All” by the year
2000.

Three main objectives:

1. Promotion of healthy lifestyles
2. Prevention of diseases
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3. Therapy for existing conditions

• PHC in the Philippines, President Ferdinand Marcos signed the LOI 949 with the theme “ HEALTH
IN THE HANDS OF THE PEOPLE BY 2020”

WHO identified 5 key elements to achieve the goal of “Health for All ”
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

Alma Ata Declaration listed essential health services:

E- Education for health

o Potent methodology for information dissemination.

o Promotes partnership.
o Improves health of the people.

L- Locally endemic disease control

o Focuses on the prevention of the occurrence of continually present diseases in a

certain locality.

E- Expanded program for immunization

o Araw ng Sangkap Pinoy responses to the above wherein immunizations for

various diseases are given for free by the government and is an ongoing program
of the DOH.
o Launched in July 1976 by the DOH in cooperation with the WHO.
o Legal Basis: P.D. 996 (Sept. 16, 1976)

M- Maternal and Child Health including responsible parenthood

o Most delicate members of the community, thus maternal and infant mortality rates
are among the common indications of a particular community.

E- Essential drugs

o Focuses on information campaign on the proper utilization and acquisition of

drugs.

N- Nutrition

o Food is one of the basic needs of the family; if food is properly prepared, on may
be assured of healthy family.
o Malnutrition is one of the problems in the country.
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T- Treatment of communicable and non-communicable diseases

o Most communicable disease that affects the country are preventable; thus the
focus is on prevention treatment of these illness.

S- Safe water and sanitation

o A safely managed drinking water service is defined as one located on premises,

available when needed and free from contamination. Goal: By 2030 achieve
universal and equitable access to safe and affordable drinking water for all.

Principles of PHC
4As
1. Accessibility
2. Affordability
3. Acceptability
4. Availability

Levels of Prevention

• Level 1: Primary Prevention Activities: Prevention of Problems before they occur.

Example: The community health nurse develops a health education program for a
population of school-age children that teaches them about the effects of smoking on
health.

• Level 2: Secondary Prevention Activities: Early detection and intervention.

Example: The community health nurse provides toxin screening for migrant workers who
may be exposed to pesticides.

• Level 3: Tertiary Prevention Activities: Correction and Prevention of deterioration of a

disease state.

Example: The community health nurse provides a diabetes clinic for a defined population
of adults in a low-income housing unit of the community.

R.A. 8423 - Traditional and Alternative Medicine Act of 1997 (Juan Flavier)

Medicinal Plants Use/indication Preparation

Lagundi Asthma, cough and colds, fever, Decoction
dysentery, pain Wash affected site with a
Skin disease (scabies, ulcer, eczema), decoction
wounds
Yerba Buena Headache, stomachache Decoction
Cough and colds Infusion
Rheumatism, Arthritis Massage sap
Sambong Antiedema /antiurolithiasis Decoction
Tsaang Gubat Diarrhea, Stomachache Decoction
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Niyog-niyogan Antielminthic Seeds are used

Bayabas Washing wounds Decoction
Diarrhea, gargle, toothache
Akapulko Antifungal Poultrice
Ulasimang Bato/ Lowers blood uric acid (rheumatism and Decoction
Pansit-pansitan gout) Eaten raw
Bawang Hypertension, lowers blood cholesterol Eaten raw/fried
Toothache Apply on part
Ampalaya Diabetes mellitus (mild non-insulin- Decoction
dependent) 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
- uses special needles to puncture and stimulate a specific part of the
Acupuncture
body
Aromatherapy - combines essential aromatic oils to then applied to the body
-“nutritional healing”, this improves health by enhancing the nutritional
Nutritional therapy
value to reduce the risk of the disease
Pranic Healing - follows the principle of balancing energy
- application of pressure on the body’s reflex joints to enhance body’s
Reflexology
natural healing.
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Learning Activities:

Test your understanding

1. Define the following for your personal understanding, and suggest ways to check
whether your understanding is correct:

A. Community Health
B. Community Health Nursing
C. Primary Health Care

2. Choose a specific Public Health Program of Primary Health Care and identify its goals,
objectives and strategies for implementation.
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Lesson 2. Theoretical Models in Community Health Nursing

Overview of the lesson

Community health nursing is a community-oriented, population-focused nursing specialty that is

based on interpersonal relationships. The unit of care is the community or population rather than the
individual, and the goal is to promote healthy communities. Theories and models of community/public
health nursing practice aid the nurse in understanding the rationale behind community-oriented care.

In lieu with the above situation, this module will help the students to assess, plan, intervene and
evaluate the care they provide in the community. Furthermore, it will equip the students with adequate
knowledge and appropriate skills that will promote and protect the health of the populations.

Desired Learning Outcomes:

After reading this module, the student should be able to do the following:

§ Explain the different theoretical models in community health nursing.

§ Compare and contrast the different theoretical models applicable in the practice of community
health nursing.
§ Construct a conceptual models of community health nursing.

Something to Ponder On

A. PRECEDE-PROCEED MODEL
The PRECEDE-PROCEED model is a comprehensive structure for assessing health needs for
designing, implementing, and evaluating health promotion and other public health programs to meet those
needs.
• PRECEDE provides the structure for planning a targeted and focused public health
program.

• PROCEED provides the structure for implementing and evaluating the public health
program.

PRECEDE stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and
Evaluation. It involves assessing the following community factors:

• Social assessment: Determine the social problems and needs of a given population and identify
desired results.
• Epidemiological assessment: Identify the health determinants of the identified problems and set
priorities and goals.
• Ecological assessment: Analyze behavioral and environmental determinants that predispose,
reinforce, and enable the behaviors and lifestyles are identified.
• Identify administrative and policy factors that influence implementation and match appropriate
interventions that encourage desired and expected changes.
• Implementation of interventions.
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PROCEED stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental
Development. It involves the identification of desired outcomes and program implementation:

• Implementation: Design intervention, assess availability of resources, and implement program.

• Process Evaluation: Determine if program is reaching the targeted population and achieving
desired goals.
• Impact Evaluation: Evaluate the change in behavior.
• Outcome Evaluation: Identify if there is a decrease in the incidence or prevalence of the identified
negative behavior or an increase in identified positive behavior.

B. HEALTH BELIEF MODEL

Health Belief Model (HBM) is one of the most widely used conceptual frameworks for
understanding health behavior.

The HBM is based on the understanding that a person will take a health-related action (i.e., use
condoms) if that person:

1. Feels that a negative health condition (i.e., HIV) can be avoided,

2. Has a positive expectation that by taking a recommended action, he/she will avoid a negative
health condition (i.e., using condoms will be effective at preventing HIV), and

3. Believes that he/she can successfully take a recommended health action (i.e., he/she can use
condoms comfortably and with confidence).

The Health Belief Model is a framework for motivating people to take positive health actions that uses
the desire to avoid a negative health consequence as the prime motivation.

Health Belief Model: Major Concepts

HBM is based on six key concepts. The following table, excerpted with minor modifications from
"Theory at a Glance: A Guide for Health Promotion Practice" (1997), presents definitions and applications
for each of the six key concepts. Examples of the concepts as they apply to sexuality education are
presented after this table.

CONCEPT DEFINITION APPLICATION

1. Perceived Susceptibility One’s belief of the chances of getting a § Define population(s) at risk
condition and their risk levels
§ Personalize risk based on a
person’s traits or behaviors
§ Heighten perceived
susceptibility if too low
2. Perceived Severity One’s belief of how serious a condition § Specify and describe
and its consequences are consequences of the risk and
the condition
3. Perceived Benefits One’s belief in the efficacy of the § Define action to take – how,
advised action risk or seriousness of where, then
impact § Clarify the positive effects to
expected
§ Describe evidence of
effectiveness
4. Perceived Barriers One’s belief in the tangible and § Identify and reduce barriers
psychological costs of the advised through reassurance,
behavior incentives and assistance
5. Cues to Action Strategies to activate “readiness” § Provide how-to information
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§ Promote awareness
§ Provide reminders
6. Self-efficacy Confidence in one’s ability to take action § Provide training, guidance,
and positive reinforcement

C. NOLA PENDER’S HEALTH PROMOTION MODEL

The health promotion model (HPM) proposed by Nola J Pender (1982; revised, 1996) was
designed to be a “complementary counterpart to models of health protection.”

It defines health as a positive dynamic state not merely the absence of disease. Health promotion
is directed at increasing a client’s level of well-being.

The health promotion model describes the multi dimensional nature of persons as they interact
within their environment to pursue health.

The model focuses on the following three areas:

o Individual characteristics and experiences
o Behavior –specific cognitions and affect
o Behavioral outcomes

The health promotion model notes that:

o Each person has a unique personal characteristics and experiences that affect subsequent
actions.
o Person’s Behavior and Knowledge have important motivational significance.

ASSUMPTIONS OF THE HEALTH PROMOTION MODEL

The HPM is based on the following assumptions, which reflect both nursing and behavioral science
perspectives:

o Individuals seek to actively regulate their own behavior.

o Individuals in all their biopsychosocial complexity interact with the environment, progressively
transforming the environment and being transformed over time.
o Health professionals constitute a part of the interpersonal environment, which exerts influence on
persons throughout their life span.
o Self-initiated reconfiguration of person-environment interactive patterns is essential to behavior
change

THEORETICAL PROPOSITIONS OF THE HEALTH PROMOTION MODEL

Theoretical statements derived from the model provide a basis for investigative work on health
behaviors. The HPM is based on the following theoretical propositions:

1. Prior behavior and inherited and acquired characteristics influence beliefs, affect, and enactment of
health-promoting behavior.

2. Persons commit to engaging in behaviors from which they anticipate deriving personally valued benefits.

3. Perceived barriers can constrain commitment to action, a mediator of behavior as well as actual
behavior.

4. Perceived competence or self-efficacy to execute a given behavior increases the likelihood of

commitment to action and actual performance of the behavior.
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5. Greater perceived self-efficacy results in fewer perceived barriers to a specific health behavior.

6. Positive affect toward a behavior results in greater perceived self-efficacy, which can in turn, result in
increased positive affect.

7. When positive emotions or affect are associated with a behavior, the probability of commitment and
action is increased.

8. Persons are more likely to commit to and engage in health-promoting behaviors when significant others
model the behavior, expect the behavior to occur, and provide assistance and support to enable the
behavior.

9. Families, peers, and health care providers are important sources of interpersonal influence that can
increase or decrease commitment to and engagement in health-promoting behavior.

10. Situational influences in the external environment can increase or decrease commitment to or
participation in health-promoting behavior.

11. The greater the commitments to a specific plan of action, the more likely health-promoting behaviors
are to be maintained over time.

12. Commitment to a plan of action is less likely to result in the desired behavior when competing demands
over which persons have little control require immediate attention. 13. Commitment to a plan of action is
less likely to result in the desired behavior when other actions are more attractive and thus preferred over
the target behavior.

13. Persons can modify cognitions, affect, and the interpersonal and physical environment to create
incentives for health actions.

THE MAJOR CONCEPTS AND DEFINITIONS OF THE HEALTH PROMOTION MODEL

o Individual Characteristics and Experience

o Prior related behavior
o Frequency of the similar behavior in the past. Direct and indirect effects on the likelihood of
engaging in health promoting behaviors.

ü PERSONAL FACTORS

Personal factors categorized as biological, psychological and socio-cultural. These factors are
predictive of a given behavior and shaped by the nature of the target behavior being considered.

• Personal biological factors

o Include variable such as age gender body mass index pubertal status, aerobic capacity,
strength, agility, or balance.
• Personal psychological factors
o Include variables such as self esteem self motivation personal competence perceived
health status and definition of health.
• Personal socio-cultural factors
o Include variables such as race ethnicity, acculturation, education and socioeconomic
status.
o Behavioral Specific Cognition and Affect

ü PERCEIVED BENEFITS OF ACTION

o Anticipated positive out comes that will occur from health behavior.
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ü PERCEIVED BARRIERS TO ACTION
o Anticipated, imagined or real blocks and personal costs of understanding a given behavior

ü PERCEIVED SELF EFFICACY

o Judgment of personal capability to organize and execute a health-promoting behavior.
Perceived self-efficacy influences perceived barriers to action so higher efficacy result in
lowered perceptions of barriers to the performance of the behavior.

ü ACTIVITY RELATED AFFECT

o Subjective positive or negative feeling that occur before, during and following behavior
based on the stimulus properties of the behavior itself. Activity-related affect influences
perceived self-efficacy, which means the more positive the subjective feeling, the greater
the feeling of efficacy. In turn, increased feelings of efficacy can generate further positive
affect.

ü INTERPERSONAL INFLUENCES
o Cognition concerning behaviors, beliefs, or attitudes of the others. Interpersonal influences
include: norms (expectations of significant others), social support (instrumental and
emotional encouragement) and modeling (vicarious learning through observing others
engaged in a particular behavior). Primary sources of interpersonal influences are families,
peers, and healthcare providers.

ü SITUATIONAL INFLUENCES
o Personal perceptions and cognitions of any given situation or context that can facilitate or
impede behavior. Include perceptions of options available, demand characteristics and
aesthetic features of the environment in which given health promoting is proposed to take
place. Situational influences may have direct or indirect influences on health behavior.

Behavioral Outcome

ü COMMITMENT TO PLAN OF ACTION

o The concept of intention and identification of a planned strategy leads to implementation of
health behavior.

ü IMMEDIATE COMPETING DEMANDS AND PREFERENCES

o Competing demands are those alternative behavior over which individuals have low control
because there are environmental contingencies such as work or family care
responsibilities. Competing preferences are alternative behavior over which individuals
exert relatively high control, such as choice of ice cream or apple for a snack

ü HEALTH PROMOTING BEHAVIOUR

o Endpoint or action outcome directed toward attaining positive health outcome such as
optimal well-being, personal fulfillment, and productive living.
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D. MILIO’S FRAMEWORK FOR PREVENTION

Nancy Milio developed a framework for prevention that includes concepts of community – oriented,
population- focused care.

Milio stated that behavioral patterns of the populations-and individuals who make up populations –
are a result of habitual selection from limited choices.

She challenged the common notion that a main determinant for unhealthful behavioral choice is
lack of knowledge.

Milio’s framework described a sometimes neglected role of community health nursing to examine
the determinants of a community’s health and attempt to influence those determinants through public
policy.

Learning Activity

Connect It to Art

Directions: Select one theoretical model in CHN and create a poster to illustrate how these models
contribute to the total health in the community. Use any medium you may want, such as crayon, water
color, oil pastel, etc. Digital drawing can be use.

Evaluation Rubric for Poster Making

Criteria Excellent Good Fair Poor Score

10 pts. 8 pts. 6 pts. 4 pts.
Given
Content is accurate Content is either Content is inaccurate.
Content is accurate but some required questionable or Information is
and all required information is missing incomplete. incomplete,
Content
information is and/or not presented Information is not inaccurate, or not
presented in a logical in logical order, but is presented in a logical presented in a logical
order. still generally easy to order, making it order, making it
follow. difficult to follow. difficult to follow.
Information is
Information is very
Information is organized, but titles The information
organized with clear
Organization organized with titles and subheadings are appears to be
titles and subheadings.
and subheadings. missing. disorganized.

The poster is The poster is The poster is The poster is

exceptionally attractive attractive in terms of acceptably attractive distractingly messy or
Attractiveness
in terms of design, design, layout, and though it may be a bit very poorly designed.
layout, and neatness. neatness. messy. It is not attractive.

Mostly free of Frequent Too frequent

Free of grammatical
grammatical errors. grammatical errors. grammatical errors.
Writing Mechanics errors. Words are
Most words are Presentation is Distractive elements
legible and pertinent to
legible and pertinent illegible and make illustration
topic.
to topic. confusing. ineffective.

Total
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Lesson 3. Different Fields in Community Health Nursing

Overview of the lesson

Community health nurses are frontline public health workers who have close
understanding of the community they serve. This trusting relationship enables them to serve as liaison/link
intermediary between health/social services and the community to facilitate access to services and improve
the quality and cultural competence of service delivery. Hence this module will help students to appreciate
the role of the community health nurse in promoting the health of community in the different fields such as
school and the workplace.

Learning Outcomes
After reading this module, the student should be able to do the following:

§ Discuss professional standards expected of school nurses.

§ Describe the different variations of school health services and coordinated school health
programs.
§ Analyze the nursing care given in schools in terms of the primary, secondary, and tertiary
levels of prevention.
§ Describe the nursing role in occupational health.
§ Use the epidemiological model to explain work health interactions
§ Differentiate between functions of OSHA and NIOSH

Something to ponder on

A. SCHOOL NURSING

History of School Nursing

The history of school nursing began with the earliest efforts of nurses to care for people in the
community.

Decade High Points in School Nursing History

1890s English and American Nurses are used in schools to examine
children for infectious diseases and to teach about alcohol
abuse.
1900s Henry St. Settlement in N.Y. sends nurses into schools and
homes to investigate children’s overall health.
1910s School nursing course added to teachers college nursing
program.
1920s & 1930s School nurses are employed by community health
departments.
1940s School districts employ school nurses.
1950s Children are screened in schools for common health problems.
1960s Educational preparation for school nurses is debated.
1970s School nurse practitioner programs begun. Increased
emphasis put on mental health counseling in schools.
1980s Children with long – term illness or disabilities attend schools.
1990s School – based and school – linked clinics are started. Total
family and community health care is offered.
2000s School nurses give comprehensive primary, secondary, and
tertiary levels of nursing care.
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Federal Legislation Affecting School Nursing.

Law Effect on School Nurses and Children

1973: PL 39 – 112, Sec. 504 of Rehabilitation Act Children cannot be excluded from schools because of a
handicap. The school must provide health services that each
child needs.
1975: PL 94 – 142, Education for All Handicapped Children All children should attend school in least restrictive
Act environment. Requires school district’s committee on
handicapped to develop individualized education plans (IEPs)
for children.
1922: Americans with disabilities Act. Persons with disabilities cannot be excluded from activities.
1997: PL 105 – 17, Individuals with disabilities education act Educational services must be offered by schools for all
disabled children from birth through age 22 years.
2001: No child left behind act of 2001 All children must receive standardized education in healthy
environment.
2004: Child Nutrition and WIC Reauthorization act of 2004 Every local education agency participating in federal school
meal programs must establish a local school wellness policy.

Standards of Practice for School Nurse

§ National Association of School Nurses (NASN) provides the general guidelines and support for all
school nurses.
§ Require all school nurses use the nursing process throughout their practice
o Assessment
o Analysis
o Planning
o Implementation
o Evaluation
§ 11 criteria for professional school nursing practice:
o develop school health policies and procedures.
o Evaluate their own nursing practice.
o Interact with the interprofessional healthcare team.
o Ensure confidentiality in providing health care.
o Use research findings in practice.
o Ensure the safety of children, including when delegating care to other school personnel.
o Have a good communication skills.
o Manage a school health program effectively.
o Teach others about wellness.
§ American Academy of Pediatric (AAP) stated that school nurses should ensure the following:
o That children get the health care they need, including emergency care in the school.
o That the nurse keeps track of the state-required vaccinations that children have received.
o That the nurse carries out the required screening of the children based on state law.
o That children with health problems are able to learn in the classroom.

Educational Credentials of School Nurses

§ NASN recommended that school nurse must be:

o Registered Nurse
o Has a bachelor’s degree in nursing and a special certification in school nursing.
o School nurse must have prior experience in nursing – most from working either in hospitals
or with communities.
o Must have spent years working with children, so they are aware of their special health
needs.
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Roles and Functions of School Nurses

§ School nurses give care to children as direct caregivers, educators, counselors, consultants, and
case managers.
§ Healthy People 2020 Proposed Objectives state that there should be 1 nurse for every 750 children
in each school.
§ School Nurse Roles
o Direct Caregiver – school nurse is expected to give immediate nursing care to the ill or
injured child or school staff member. (traditional role of the school nurse).
o Health Educator – the school nurse in the health educator role may be asked to teach
children both individually and in the classroom.
o Case Manager – the school nurse is expected to function as a case manager, helping to
coordinate the health care for children with complex health problems.
o Consultant – the school nurse is the person best able to provide health information to
school administrators, teachers, and parent – teacher groups.
o Counselor – the school nurse have a reputation as being a trustworthy person to whom the
children can go if they are in trouble or if they need to confide about a personal matter.
Privacy and confidentiality, as in all health care are important.
o Community Outreach – when participating in community outreach, nurses can be involved
in community health fairs or festivals in the schools using that opportunity to teach others.
o Researcher – the school nurse is responsible for making sure that the nursing care given
is based on solid, evidence-based practice.

The Levels of Prevention in Schools

§ Primary Prevention
o Health promotion activities:
Ø Teaching healthy lifestyles
Ø Immunizing children for school entry
§ Secondary Prevention
o Screening of children for various illness
o Monitoring their growth and development
o Caring for ill or injured children and staff
§ Tertiary Prevention
o Caring for children with chronic health problems
o Health referrals and continuity of care

B. OCCUPATIONAL HEALTH NURSING

Definition and scope of occupational health nursing

§ Adapted from the American Association of Occupational Health Nurses (AAOHN) (2004),
occupational and environmental health nursing is the specialty practice that focuses on the
promotion, prevention, and restoration of health within the context of safe and healthy environment.
 P a g e | 22

History and Evolution of Occupational Health Nursing

Decade High Points in Occupational Health Nursing History

1888 Nursing care for workers began. A graduate of the Blockery
Hospital School of Nursing in Philadephia, to take care of their
ailing co-workers and families.
1885 Ada Mayo Stewart who was hired by Vermont Marble
Company in Ruthland Vermont, is often considered the first
industrial nurse.
1900s Employee health services grew rapidly, and companies
recognized the provision of worksite health services led to a
more productive workforce.
1942 American Association of Occupational Health Nurses was
established as the first national nursing organization.
1960s and 1970s Passage of laws to protect workers’ safety and health led to an
increased need for occupational health nurses.
1988 First occupational health nurse was hired by OSHA
(Occupational Safety and Health Administration)
1999 AAOHN published its first set of competencies in occupational
health nursing.

Roles and Professionalism in Occupational Health Nursing

§ Customary role of the occupational health nurse

o Emergency treatment
o Prevention of illness & injury
o Promotion & maintenance of health
o Care for the environment
o Reduce health – related costs in business
§ Interprofessional role
o Frequently collaborate closely with multiple disciplines and industry management
§ Other roles:
o Clinician
o Case manager
o Coordinator
o Manager
o Nurse practitioner
o Corporate director
o Health promotion specialist
o Educator
o Consultant
o Researcher

Application of the Epidemiologic Model

The agent-host-environment model of health and illness, also called the epidemiologic model,
originated in the community health work of Leavell and Clark (!965) and has been expanded into a general
theory of the multiple causes of disease. The model is used primarily in predicting illness rather than in
promoting wellness, although identification of risk factors that result from the interactions of agent, host,
and environment are helpful in promoting and maintaining health.

1. Agent. Any environmental factor or stressor (biological, chemical, mechanical, physical, or

psychosocial) that by its presence or absence (e.g. lack of essential nutrients) can lead to illness or
disease

2. Host. Person(s) who may or may not be at risk of acquiring a disease. Family history, age, and
lifestyle habits influence the host’s reaction.
 P a g e | 23

3. Environment. All factors external to the host that may or may not predispose the person to the
development of disease. Physical environment includes climate, living conditions, sound (noise)
levels, and economic level.

Worker Assessment

§ History and physical assessment – emphasizing exposure to occupational hazards and

individual characteristics that may predispose the client to the increased health risk of certain jobs.
§ Occupational health history – indispensable component of the health assessment of individuals.
§ Identifying workplace exposure – influence client’s course of illness and rehabilitation and may
also prevent similar illnesses among others with potential for exposure.
§ Identifying work – related health problems – a systematic approach for evaluating the potential
for workplace exposures is the most effective intervention for detecting and preventing
occupational health risks.

Workplace Assessment

§ Worksite walk-through – purpose of this is to make the nurse to become knowledgeable about
the work processes and the materials, requirements of various jobs, the presence of the actual or
potential hazards, and the work practices of the employees.

ü How to Assess a Worker and the Workplace

Assessing the worker for a work-related problem is a critical practice element. The nurse need to do the
following:

• Complete general and occupational health history-taking with emphasis on workplace exposure
assessment, job hazard analysis, and list of previous jobs.
• Conduct a health assessment to identify agent and host factors that interact to place workers at
risk.
• Identify patterns of risk associated with illness/injury.
• Assessing the work environment is necessary to determine workplace exposures that create
worker health risk. The nurse need to do the following:
o Understand the work being done
o Understand the work process
o Evaluate the work-related hazards
o Gather data about incidence / prevalence of work-related illness/injuries and related
hazards
o Conduct a walk-through of the work environment
o Examine prevention and control strategies in place for eliminating exposures
 P a g e | 24

Learning Activities:

Get inside the Picture

Study the pictures closely and answer the questions in the box. Remember that these pictures are closely
associated with the lesson that you read.

What will you feel when you see this sign?

What will you feel when you meet your
school nurse during your elementary
________________
or high school?
________________

References and Supplementary Resources:

Berman, Audrey, Snynder, Shirlee J, and Kozier, Barbara. (2016). Fundamentals of Nursing: Concepts,
Process, and Practice. (10th Ed). New Jersey: Pearson Education Inc.

Clark, MJ., Famorca, Z., Nies, M., McEwen, M. (2013). Nursing care of the community: A comprehensive
text on community and Public health nursing in the Philippines

Leddy, S.K. (2006). Integrative Health Promotion: Conceptual Bases for Nursing Practice Sudbury, MA:
Jones and Bartlett.

Maglaya, Araceli (2009). Nursing Practice in the Community

Pender, N.J. Murdaugh, C.L. and Parsons, M.A. (2006). Health Promotion in Nursing Practice New
Jersey:Pearson Prentice Hall.

Stanhope, M., Lancaster, J. (2014). Foundation of nursing in the community: community- oriented practice