Public Health Community Health Nursing

According to WHO According to Dr. Araceli Maglaya

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

Science and Art of Preventing Disease, Prolonging CHN Process: Assessment (diagnosis is embedded)
Life, Promoting Health and efficiency Planning
Implementation
Evaluation
Goal: Maglaya
1. Promotion of Health
Through: Organized 2. Preservation of Health
Community Effort for
Nisce, et. al
Medical & Nursing Standard of "To raise the level of health of the citizenry by
Environmental
services for living adequate helping communities and families to cope with
Sanitation
1. Early Diagnosis to maintain the discontinuities in and threats to health in
Communicable 2. Preventive health such a way as to maximize their potential for
Disease Control Treatment high-level wellness"

Setting: Community -place where people under usual

Goal: to Enable Every or normal conditions are found (villages,
schools, workplaces, etc.)
Citizen to Realize His -must be outside the institutional setting
Birthright to Health and (hospitals, etc. are excluded)
Longevity
Nature of Practice: Comprehensive, general, continual
Not limited to a particular specialization, not
episodic, and spans the entire life cycle.
Public Health Nursing Knowledge: Integration of nursing with public health as
well as sociology, psychology, anthropology,
According to WHO Expert Committee on Nursing economics and political science
Special Field of Nursing that Combines the Skills of Important concepts to note in answering questions:
Nursing, Public Health, and Some Phases of Social 1. “Greatest good for the greatest number”
Assistance and Functions as part of the Total Public 2. Health promotion & disease prevention
Health Program for the promotion of health, the are prioritized over curative care
improvement of the conditions in the social and 3. The primary responsibility of the nurse is to
physical environment, rehabilitation of illness and the population as a whole
disability. 4. Client is an active, equal partner of the
nurse, not a passive recipient of care
5. CHN is affected by its immediate context,
the healthcare delivery system, as well as
overall political, economic, socio-cultural, and
environmental factors
6. CHN is dynamic and flexible due to varying
objective and subjective realities in different
settings
7. Community PARTICIPATION is key!!!

Remember! CHN means “The philosophy of

CHN is based on the
Community  the worth and dignity of
client man.” -Dr. Margaret
Includes nurses in the public sector or the government.
Health  the goal Shetland
Nursing  the means
CHN is HUMANISTIC. It is guided by these beliefs:
■ Supervisor
Humanistic values of nursing are upheld
Unique and distinct component of healthcare monitors and supervises the performance of
Multiple factors of heath considered midwives and other auxiliary health workers; also
initiates the formulation of staff development and
Active participation of clients encouraged training programs for midwives and other auxiliary
Nurse considers availability of resources health workers as part of their training function as
supervisors
Interdependence among health team members practiced
Scientific and up-to-date ■ Leader and Change Agent
Tasks of CH nurse vary with time and place
influences people to participate in the overall
Independence or self-reliance of the people is the end-goal process of community development
Connectedness of health and development is regarded
■ Manager

Roles of a Community Health Nurse organizes the nursing service component of the
local health agency or local government unit (ex.
Nursing service plan component of the overall
Clinician municipal health plan); also, as program manager,
the PHN is responsible for the delivery of the
Coordinator and Educator package of services provided by the health
Collaborator program to the target clientele (ex. The PHN is
almost always the program manager of the
Supervisor National Tuberculosis Program)
Manager
■ Researcher
Leader and
Change Agent participates in the conduct of research and utilizes
research findings in practice (ex. disease
surveillance or the continuous collection and
Researcher analysis of data on diseases and causes of death)

In the event that the Municipal Health Officer

(MHO) is unavailable or is unable to perform
his duties, the Public Health Nurse will take

■ Clinician or Health Care Provider

Specialized Fields in CHN
utilizes the nursing process in the care of the
client in the home setting through home visits ■ Community Mental Health Nursing
and in public health care facilities; conducts A unique clinical process which includes an
referral of patients to appropriate levels of care integration of concepts from nursing, mental
when necessary health, social psychology, psychology, community
networks, and the basic sciences
■ Health Educator
■ Occupational Health Nursing
utilizes teaching skills to improve the health The application of nursing principles and
knowledge, skills and attitude of the individual, procedures in conserving the health of workers in
family and the community and conducts health all occupations
information campaigns to various groups for the
purpose of health promotion and disease ■ School Health Nursing
prevention
The application of nursing theories and principles
■ Coordinator and Collaborator in the care of the school population

establishes linkages and collaborative

relationships with other health professionals,
government agencies, the private sector, non-
government organizations and people's
organizations to address health problems
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Three Levels of Healthcare Services
Primary Level of Care - the first contact between the community people and the different levels of health facility; refers
to health care provided by the health center staff
Secondary Level of Care - rendered by physicians with basic health training in district hospitals, provincial hospitals and
city hospitals; these facilities are capable of basic surgical procedures and simple laboratory examinations; serves as the
referral center of primary health facilities
Tertiary Level of Care - rendered by specialists in medical centers, regional hospitals and specialized hospitals like the
Heart Center of the Philippines; serves as the referral center of secondary health facilities

PRIMARY

SECONDARY

TERTIARY

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

Two levels of Primary Healthcare Workers

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

Four Levels of Clientele in the Community -most service provisions are in the community level

Individual Healthcare Delivery System

-sick or well individuals in homes and health centers
-considered as entry point in working with the family MAJOR PLAYERS

Family Public Sector - tax-based

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

Population group Vision: Leader

-a group of people sharing the same characteristics,
developmental stage or common exposure to
Advocate in promoting health for all
particular environmental factors thus resulting in Model
common health problems
Mission: Equitable
Community Sustainable Health for all Filipinos
-group of people sharing common geographic
boundaries and/or common values and interests
Quality especially the poor
-no 2 communities are alike
-exerts a strong influence on health of individuals,
families, and communities
Roles and Functions (based on EO 102): LACE

Leadership in health
-Leader in the formulation, monitoring, and
evaluation of national health policies, plans, and
programs
-Advocate adoption of health policies, plans,
programs
-National policy and regulatory institution
Administrator of specific services
-Manage selected health facilities e.g. national
centers like special or tertiary hospitals
-Administer service for emerging health concerns
the require complicated technologies
-Provide emergency health response for
catastrophic events, epidemics, and widespread
The Private Sector
public danger upon authorization by the President
and consultation with the local government.
Capacity builder and Enabler Commercial Non-Commercial
-Ensure highest achievable standards of quality • Profit-oriented • Oriented to social development, relief,
health care, health promotion and health protection rehabilitation, and community
organizing
-Innovate new strategies in health to improve
• Manufacturing Socio-civic groups
the effectiveness of health programs companies Religious organizations/foundations
-Initiate public discussion on health issues and • Advertising NGO’s which assume the following roles
disseminate policy research outputs to ensure agencies -Policy and Legislative advocacies
informed public participation in policy decision- • Private -Organizing, Human Rights advocacies
making practitioners -Research and Development
-Oversee implementation, monitoring and • Private -Health Resource Development
evaluation of national health plans, programs institutions Personnel
and policies -Relief and Disaster Management
-Networking
Goal of the DOH: Implementation of the HSRA (Health
Sector Reform Agenda) Primary Health Care
Framework for implemention of HSRA: FOURmula One Essential health care made universally accessible to
for Health individuals and families in the community by means
acceptable to them, through their full participation and
Elements of FOURmula One for Health
at a cost that the community and country can afford at
GOod GOvernance – enhance performance; key every stage of development. --WHO
player is PhilHealth
Health FInancing – health investments Conceptual Framework:
Health REgulation – quality and affordable a. Health is a fundamental human right
health goods and services b. Health is both an individual and
collective responsibility
Health Service Delivery – accessibility and c. Health should be an equal opportunity
availability of health services to all
d. Health is an essential element of
socio-economic development

■ Local Government Units

TRANSLATED into ACTION, the PHC APPROACH healthcare
focuses on:
Structure • Health is isolated • Intra and inter-
Partnership with the community from other sectors sectoral linkages
of society allow health to be
Equitable distribution of health resources integrated with
Organized and appropriate health system over-all socio-
infrastructure economic
Prevention of disease and promotion of development
health is the focus efforts
Linked multisectorally Process • Decision-making • Decision-making
from top to bottom from bottom to
Emphasis on appropriate technology
top
5A’s of PHC Technology  Curative case  Promotive and
based on modern preventive care
vailable medicine and blend traditional
ccessible sophisticated and modern
ffordable technology medicine
cceptable  Physician  Use of
ttainable dominated appropriate
technology
Outcome • Reliance on health • People
PHC GOAL (in 1978): Health for All by the year 2000
professionals empowerment or
PHC was declared in Alma-Ata (now Almati), self-reliance
Kazakhstan, USSR during the First International
Conference on PHC held on September 6-12, 1978 Four Pillars of PHC
through the sponsorship of WHO and UNICEF.

LEGAL BASIS OF PHC IN THE PHILIPPINES: Letter of Use of appropriate technology

Instruction (LOI) 949 signed in October 19, 1979 by Support mechanism made available
former President Ferdinand E. Marcos
Active community participation
NEW GOAL for the Philippine implementation of PHC: Intra and inter-sectoral linkages
Health in the Hands of the People by 2020

PHC as a service delivery policy of the DOH permeates Appropriate technology means…Super Capal FACES
all strategies and thrusts of government health (SC FACES)!!!
programs from the national to the community levels. Scope of technology – serves a variety of purposes
Complexity – should be simple and easy to apply under
Dimension Commercialized Primary local conditions
Healthcare Healthcare
Goal • Absence of the • Prevention of
disease for the disease and Feasibility – compatible with local conditions
individual • Socio-economic Acceptability – measured in terms of the degree of
development utilization of the people
Focus of • Sick • Sick and well Cost – should be affordable
Care individuals Effectiveness – should produce the desired effect
Setting for • Hospital-based • Satellite health
Safety – effect of utilization should produce no harm
Services • Urban-centered centers
• Accessible only to • Community
a few people health centers
PHC is a Multisectoral Approach – recognizes intra and
• Rural-based
intersectoral linkages.
• Accessible to all
People • Passive recipients • Active Intrasectoral linkages means relationship within and
of healthcare participants in between different levels of healthcare services…
 Primary HC ELEMENTs: Sectors most closely 6. LAGUNDI
Health education related to health: Indications: Cough, Asthma, Fever, Muscle Pain
LEAPPS Preparation: Decoction or syrup
Communicable disease
Local Governments 7. ULASIMANG BATO
control
Indications: lowers serum uric acid in gouty arthritis
Education
Preparation: Salad or decoction
Expanded program on Agriculture 8. BAYABAS
immunization
Public Works Indications: wound cleansing, as mouthwash in cases of
Locally endemic disease oral cavity infections & gingivitis (antiseptic properties)
treatment
Population Control
Preparation: Decoction
Environmental sanitation Social Welfare 9. BAWANG
Maternal and child health Indications: lowers serum cholesterol
and family planning Preparation: May be roasted, soaked in vinegar or used
Essential drugs provision for sauteing
10. YERBABUENA
Nutrition and adequate food Indications: for muscle pain
provision
Preparation: Decoction
Treatment of emergency
cases and provision and In "23 in '93", the utilization of the 10 Herbal Plants was
provision of medical care aggressively prescribed through community wide
implementation of projects such as herbal garden in
communities
DOH-Approved Medicinal Plants
RA 8423: utilization of medicinal plants as alternative
for high cost medications.
Sambong Lagundi Policies:
Ampalaya Ulasimang bato The indications/uses of plants
Niyog-niyogan Bawang The part of the plant to be used
Tsaang gubat Bayabas Preparation of herbal medicines

Akapulko Yerba Buena Guidelines:

Properly labelled herbal medicine containers
1. SAMBONG Appropriate herbal plant to specific symptom only
Indications: edema and urolithiasis (diuretic effect) Palayok or clay pots and a wooden spoon are used
Preparation: Decoction when cooking herbal medicines
2. AMPALAYA
Indications: Diabetes Mellitus CHemical pesticides or insecticides should not be used
Preparation: Decoction or steamed
on herbal plants
3. NIYUG-NIYOGAN
Indications: Ascaris lumbricoides intestinal infestation Use only the recommended plant part
Preparation: Prepare dried, mature niyug-niyugan seeds Administer only at recommended dose
Dosage: Consume by chewing the right amount of seeds Remove the pot cover when the herbal preparation
two hours after meals. Repeat same dose after 1 week. starts to boil
Side-effects: stomachache, diarrhea
If the symptoms persists despite using the herbal
4. TSAANG GUBAT
medicine 2-3 times, consult the nearest physician
Indications: Stomachache
Preparation: Decoction Watch out for allergic reactions ~ if observed, stop
5. AKAPULKO using the herbal preparation
Indications: Ringworm, Tinea Flava, Athlete's foot and Always keep out of reach of children
other types of fungal infection Prepare the herbal medicine as suggested
Preparation: Poultice or ointment
 partially, or non-modifiable)
Community Health Nursing Process x1 Preventive potential  magnitude of future
problems that can be minimized by solving this
■ Assessment x1 Salience  family’s perception of the problem
-initiate contact x3 Magnitude of the problem severity:
-collect data proportion of population affected by problem
-identify health problems Total=10
-assess coping ability
-analyze and interpret data Why Undertake Community Dx?
1. To have a clear picture of the problems of the
2 Levels of Family Assessment
community and to identify the resources available to
1. First level – determine actual and potential health
the community people.
problems. Answers ‘what’ questions.
2. Community diagnosis enables the nurse/program
2. Second level – determine barriers to family’s
coordinator to set priorities for planning and developing
performance of tasks. Answers ‘why’ questions.
programs of health care for the community. The data
Categories of Health Problems (according to priority) gathered through the process serves as the material for
1. Wellness state – readiness to achieve higher level or analysis.
state of health
Health deficit – presence of illness; gap between Types of Community Dx
actual and ideal health 1. Comprehensive Community Dx — general view
*both are equally considered as priority #1 2. Problem-oriented Community Dx – specific problem
2. Health threat – condition that promote disease or
injury Components of Community Dx
3. Stress point/foreseeable crisis – anticipated periods 1. Demographic variables
of unusual demands 2. Socio-economic and cultural variables
3. Health and illness patterns
Initial Data Base 4. Health resources
1. Family structure and characteristics 5. Political and leadership patterns
2. Socio-economic and cultural factors
3. Environmental factors Components of Community Dx
4. Health assessment of each member 1. Primary Data - source would be the community
5. Value placed on prevention of disease people through survey, interview, focused group
discussions, observation and through the actual minutes
Family Diagnosis of community meetings
Point Component 2. Secondary Data - source would be organizational
given records of the program, health center records and other
x1 Nature  (1)Deficit/Wellness, (2)Threat, public records through review of records
(3)Stress Point
x2 Modifiability  possibility of success (highly, ■ Planning
partially, or non-modifiable) -goal setting
x1 Preventive potential  magnitude of future -constructing plan of action and operational plan
problems that can be minimized by solving this
x1 Salience  family’s perception of the problem ■ Implementation
Total=5 -put nursing plan to action
-coordinate care/services
Community Diagnosis -utilize community resources
Point Component -delegate and supervise
given -provide health education
x1 Nature  health status (illness, stats), health -document responses
resource (material, manpower), health-related
(social, economic, political, environmental) 2 Levels of Nursing Intervention in CHN
x4 Modifiability  possibility of success (highly, 1. Anticipatory – primary level of prevention
2. Participatory – secondary & tertiary levels ■ COPAR is Group-centered and not Leader-
oriented. Leaders are identified, emerge and are
■ Evaluation tested through action rather than appointed or
-nursing audit selected by some external force or entity.
-evaluate care outcomes
-performance appraisal for workers Phases of the COPAR Process
-estimate cost-benefit ratio (determine efficiency)
-identify necessary alterations 1. Pre-entry Phase
-revise plans • The initial phase of the organizing process where
the community organizer looks for communities to
Framework for Evaluation serve/help
• Designing criteria for the selection of site
1. Structural elements – physical: manpower, • Actually selecting the site for community care
equipment, infrastructure
2. Process elements – actions, procedures, protocols 2. Entry Phase
3. Outcome elements – changes in clients’ health status • Sometimes called the social preparation phase as
vis-à-vis objectives and goals of care outcomes the activities done here include the sensitization of
the people on the critical events in their life,
motivating them to share their dreams and ideas
COPAR (Community Organizing on how to manage their concerns and eventually
Participatory Action Research) mobilizing them to take collective action on these.
• Signals the actual entry of the community
worker/organizer into the community with the
CO: A Manual of Experience; PCPD following guidelines:
» recognize the role of the local authorities by
A continuous and sustained process of educating the paying them visits to inform them of their
presence and activities
people to understand and develop their critical » his/her appearance, speech, behavior & lifestyle
awareness of their existing conditions, working with should be in keeping with those of the
the people collectively & efficiently on their immediate community residents without disregard of their
and long-term problems, and mobilizing the people to being role model
» avoid raising the consciousness of the community
develop their capability and readiness to respond & residents; adopt a low-key profile
take action on their immediate needs towards solving
their long-term problems 3. Organization-Building Phase
• Entails the formation of more formal structures
Principles of COPAR and the inclusion of more formal procedures of
People, especially the most oppressed, exploited and planning, implementing, and evaluating
deprived sectors are open to change, have the capacity community-wide activities
• Conduct of trainings for the organized leaders or
to change, and are able to bring about change. groups to develop their skills in managing their
■ COPAR should be based on the interests of the own concerns/programs
poorest sectors of society
4. Sustenance and Strengthening Phase
■ COPAR should lead to self-reliant community and • Occurs when the community organization has
society already been established and the community
members are already actively participating in
Processes/Methods Used community-wide undertakings
■ A Progressive Cycle of Action - Reflection - Action • The different committees set-up in the
organization-building phase are already expected
-begins with the already existing practice, to be functioning by way of planning,
experience, and concrete conditions of the implementing and evaluating their own programs,
people, sums practice up into a body of theory, with the overall guidance from the community-
puts theory to practice…and the cycle repeats, wide organization
constantly modifying for the better. • Strategies:
■ Consciousness-raising through learning by » Education and training
experience. Related to A-R-A cycle. » Networking and linkages
» Conduct of mobilization on health
■ COPAR is Participatory and Mass-based because and development concerns
it is primarily directed towards and biased in favor » Developing secondary leaders
of the poor, the powerless and the oppressed and
seeks to empower the masses to participate in the
changing of their conditions.