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Course Name


Course Code

This course focuses on the care of population groups and community as
clients utilizing concepts and principles in community health development.
It also describes problems, trends and issues in the Philippine and global
health care systems affecting community health nursing practice.

Course Description

Course Credit
Contact Hours/Semester
Course Objectives:

Course Outline

3 units lecture, 2 units RLE (0.5 skills lab, 1.5 clinicals)

54 lecture hours; 102 RLE hours
NCM 100, Theoretical Foundations of Nursing, Health Assessment
2nd year, 1st Semester
At the end of the course, the student will be able to:
1. Apply concepts and principles of community health development in
the care of communities and population groups.
2. Utilize the Nursing process in the care of communities and
population groups.
a. Assess the health status of communities and population groups
to identify existing and potential problems.
b. Plan relevant and comprehensive interventions and programs
based on identified priority problems.
c. Implement appropriate plan of care to improve the health status
of communities and population group
d. Evaluate the progress and outcomes of community health
nursing interventions and programs.
3. Ensure a well-organized recording and reporting system
4. Share leadership/relate effectively with others in work situations
related to nursing and health
IOverview of Community Health Nursing
a. Community health Nursing as a field of nursing Practice
The hallmark of community health nursing is that it is
CHN is a synthesis of nursing and public health practice
1. Emphasis on the importance of the greatest good for the greatest
2. Assessing health needs planning, implementing and evaluating
the impact of health services on population groups.
3. Priority of health-promotive and disease-preventive strategies
over curative interventions.
4. Tools for measuring and analyzing community health problems;
5. Application of principles of management and organization in the
delivery of health services to the community.
Basic concepts and principles of community health nursing

1. The family is the unit of care, the community is the patient and
there are four levels of clientele in community health nursing.
2. The goal of improving community health is realized through
multi-disciplinary effort.
3. The community health nurse works with and not for the
individual patient, family, group or community. The latter are
active partners, not passive recipients of care.
4. The practice of community health nursing is affected by changes
in society in general and by developments in the health field in
5. Community health nursing is part of the community health
system, which in turn is part of the larger human services
Roles of the nurse in caring for communities and population
Brief history of community health/public health nursing
practice in the Philippines.
IICommunity health and Development Concepts, Principles and
a. Primary health care approach
Definition, PHC as a philosophy, approach, structure and
Legal basis of PHC in the Philippines
Components of PHC
b. Health promotion
Concept of health promotion (as embodied in the Ottawa
Charter, November 1986)
Health promotion strategies:
1. Build healthy public policy
2. Create supportive environments.
3. Strengthen community action.
4. Develop personal skills.
5. Reorient health services.
Examples of Theories/Models of Health Promotion: Pender,
Bandura, Green
c. Community Organizing towards community participation in
i. Definition of Community Organizing
1. CO characteristics
2. Process
3. Phases
4. Goal
ii. Community participation in health levels of community participation,
factors affecting community participation.
d. Capacity building for sustainable community health

development towards community competence

i. Concept of a sustainable community health development;
integrated, community-based comprehensive
ii. Capacity building strategies: health education, competencybased training for community health workers, supervision of
lower level health workers.
e. Partnership Building and Collaboration
Linkage Building
Multi-sectoral collaboration
Interdisciplinary collaboration
III. The Community Health Nursing Process
A. Assessment of Community Health Needs
Components of community needs assessment
1. Health status
2. Health resources
3. Health action potential
Community Diagnosis
1. Definition
2. Types of community diagnosis: Comprehensive, problem
oriented or focused
3. Steps in conducting the Community diagnosis
Tools used in community diagnosis: demography, vital and
health statistics, epidemiology
1. Demography
a. Definition and uses of demography
b. Components of demography
Describing population size
Describing population composition
Describing spatial distribution
c. Sources of demographic data
2. Vital Health Statistics
a. Definition and uses of vital and health statistics
b. Common vital and health statistical indicators
Fertility rates
Mortality rates
Morbidity rates
3. Epidemiology
a. Definition and uses of epidemiology
b. Epidemiologic concepts and principles
Multiple causation Theory or Ecologic
concept of disease
1. Agent-Host-Environment

2. Models: web, wheel and triad

Natural history of disease
Levels of disease prevention
Concept of causality and association
c. Epidemiologic approach focusing on:
Descriptive epidemiology
Analytical epidemiology
B. Planning of Community Health Nursing Services
Principles in Community Health Planning
Bases for developing a community health plan
1. Health status
2. Health resources
3. Health action potential
Steps in making a plan: the planning cycle
Context in developing the community health plan
1. Philippine health care delivery system
a. Executive Order 102 (The Department of Health)
b. RA 7160 (Local Health System)
c. Levels of Health Care and Referral Systems
2. Global Health Situation (Millennium Development Goals)
3. National Health situation (Fourmula one)
4. Primary Health Care as an approach to health care
IV. Implementing the community health nursing services
a. Components of program implementation
Coordinating the health program
Monitoring health program
Supervising the program staff
b. National Health Programs of the DOH
Family Health Services
1. Maternal health
2. Family Planning
3. Child Health
Infant and Young child feeding
Expanded program on immunization
Integrated management of illness
4. Nutrition program
5. Oral health program
6. Essential health packages for the adolescent, adult men
and women and older persons
Control of non-communicable diseases
1. Integrated Community-based Non-communicable
Disease Prevention Program
2. Programs for the prevention of other non-communicable

a. National prevention of Blindness
b. Mental Health and Mental Disorders
c. Renal Disease Control program
d. Community-Based Rehabilitation Program
Control of Communicable Diseases
1. National TB Program-Directly Observed Treatment, Short
Course (NTP-DOTS)
2. National Leprosy Control Program
3. Schistosomiasis Control Program
4. Filariasis Control program
5. Malaria Control Program
6. Rabies Control Program
7. Dengue Control Program
8. Sexually-Transmitted Infections and AIDS Control
Environmental Health
1. Water Supply Sanitation
2. Proper Excreta Disposal
3. Solid Waste Management
4. Vector Control
5. Food Sanitation
6. Air Pollution
7. Proper Housing
c. Specialized Fields of Community health Nursing
School health Nursing
Occupational Health Nursing
Community mental health Nursing
V. Evaluating Community Health Nursing Services
a. Definition of Evaluation
Types of evaluation: quantitative, qualitative
Aspects of evaluation: process, impact and
Methods and tools of evaluation
Evaluation indicators
b. Quality Assurance: Sentrong Sigla Movement
VI. Recording and Reporting
a. Family Health Service Information System
b. Components of FSHIS
Family Treatment Record
Target Client List
Reporting forms
Output Reports

Guide for RLE

Equipment and Materials

(these could be found in
nursing skills lab and in the

Provide opportunity to practice bag technique and other nursing

Provide for actual care of individual, family, population group and
community as client. Requires competencies with emphasis on
health promotion and disease prevention
CHN bag complete with relevant equipment and supplies


The hallmark of community health nursing is that it is population or aggregate-focused
CHN is a synthesis of nursing and public health practice
1. Emphasis on the importance of the greatest good for the greatest number
2. Assessing health needs planning, implementing and evaluating the impact of health
services on population groups.
3. Priority of health-promotive and disease preventive strategies over curative interventions
4. Tools for measuring and analyzing community health problems; and analyzing community
health problems; and
5. Application of principles of management and organization in the delivery of health services
to the community.

Basic concepts and principles of community health nursing
The family is the unit of care; the community is the patient and there are four levels of
clientele in community health nursing
The goal of improving community health is realized through multidisciplinary effort.
The community health nurse works with and not for the individual patient, family, group or
community. The latter are active partners, not passive recipients of care.
The practice of community health nursing is affected by changes in society in general and
by developments in the health field in particular.
Community health nursing is part of the community health system, which in turn is part of
the larger human services system.

Roles of the nurse in caring for communities and population groups.


Brief history of community health/public health nursing practice in the


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
Derived from a Latin word comunicas which means a group of people.
In recent nursing Literature, community has defines as a collection of people who interact with
another and whose common interest or characteristics form the basis for a sense of unity or
belonging.(Allender et al., 2009)

A group of people who share something in common and interact with one another and may share a
geographic boundary (Lundy and Janes 2009)
A group of people who share common interest , who interact with each other, and who functions
collectively within a defined social structure to address common concerns (Clark, 2008)
A locality based entity. Composed of systems of formal organizations reflecting societys
institutions, informal groups and aggregates (Shuster and Goeppinger, 2008)
Maurer and Smith (2009) further addressed the concept of community and identified four defining
attributes: (1) people (2) place, (3) interaction (4) common characteristics, interests, or goals.
Maurer and Smith (2009) noted that there are two main types of communities: geopolitical
communities and phenomenological communities.
Geopolitical communities are defined or formed by both natural and manmade boundaries and
include barangays, municipalities, cities, provinces, regions and nations. It may also be called
territorial communities.
Phenomenological communities refer to the relational, interactive groups, in which the place or
setting is more abstract, and people share a group of perspective or identity based on culture,
values, history, interests and goals. Examples are schools, colleges, and universities; churches, and
mosques; and various groups and organizations.
Population is typically used to denote a group of people having common personal and
environmental characteristics. It can also refer to all of the people in a defined community.
Aggregates are subgroups or subpopulations that have some common characteristics or concerns
(Clark 2008)

WHO defined as a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity.
Determinants of Health and Disease
The health status of community is associated with a number of factors such as health care access,
economic conditions, social and environmental issues, and cultural practices.
WHO cites the social and economic environment, physical environment and the persons
individual characteristics and behaviors as 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 the poorest people, the greater the differences in
2. Education- low education levels are linked with poor health. More stress and lower selfconfidence.
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.
8. Personal behavior and coping skills- balanced eating, keeping active, smoking, drinking and
how we deal with lifes stresses and challenges all affect health.
9. Health services- access and use of services that prevent and treat disease influences health.
10. Gender- men and women suffer from different type of diseases at different ages.
Community Health
Part of paramedical and medical intervention/approach which is concerned on the health of the
whole population

1. Health promotion
2. Disease prevention
3. Management of factors affecting health
Mission of CHN
Health Promotion
Health Protection
Health Balance
Disease prevention
Social Justice
Philosophy of CHN

The philosophy of CHN is based on the worth and dignity on the worth and dignity of man.(Dr.
M. Shetland)

Basic Principles of CHN

1. The community is the patient in CHN, the family is the unit of care and there are four levels of
clientele: individual, family, population group (those who share common characteristics,
developmental stages and common exposure to health problems e.g. children, elderly), and the
2. In CHN, the client is considered as an ACTIVE partner NOT PASSIVE recipient of care
3. CHN practice is affected by developments in health technology, in particular, changes in society, in
4. The goal of CHN is achieved through multi-sectoral efforts
5. CHN is a part of health care system and the larger human services system.

Community Health Nursing Definition

The utilization of the nursing process in the different levels of clientele-individuals, families,
population groups and communities, concerned with the promotion of health, prevention of
disease and disability and rehabilitation. ( 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)
Special field of nursing that combines the skills of nursing, public health and some phases of social
assistance and functions as part of the total public health program for the promotion of health, the
improvement of the conditions in the social and physical environment, rehabilitation of illness and
disability ( WHO Expert Committee of Nursing)

A learned practice discipline with the ultimate goal of contributing as individuals and in
collaboration with others to the promotion of the clients optimum level of functioning thru
teaching and delivery of care (Jacobson)
Nursing practice in a wide variety of community services and consumer advocate areas, and in a
variety of roles, at times including independent nursing is certainly not
confined to public health nursing agencies.

IVDr. Ruth B. Freeman

A service rendered by a professional nurse with communities, groups, families, individuals at
home, in health centers, in clinics, in schools, in places of work for the promotion of health,
prevention of illness, care of the sick at home and rehabilitation. (DR. Ruth B. Freeman)
VAmerican Nurses Association (ANA)
The synthesis of nursing practice and public health practice applied to promoting and preserving
the health of population









Standards in CHN
Applies theoretical concepts as basis for decisions in practice
Data Collection
Gathers comprehensive, accurate data systematically
Analyzes collected data to determine the needs/ health problems of IFC
At each level of prevention, develops plans that specify nursing actions unique to needs of
Guided by the plan, intervenes to promote, maintain or restore health, prevent illness and
institute rehabilitation
Evaluates responses of clients to interventions to note progress toward goal achievement,
revise data base, diagnoses and plan
Quality Assurance and Professional Development
Participates in peer review and other means of evaluation to assure quality of nursing
Assumes professional development
Contributes to development of others
Interdisciplinary Collaboration
Collaborates with other members of the health team, professionals and community
representatives in assessing, planning, implementing and evaluating programs for community health
Indulges in research to contribute to theory and practice in community health nursing

Community based nursing

Application of the nursing process in caring for individuals, families, and groups where they live,
work or go to school as they move through the health care system. (McEwen and Pullis 2008)
Community based nursing is 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
Difference between Community Health Nursing and Community-based nursing (Zotti et al, 1996)

Community health nursing emphasizes preservation and protection of health while community
based nursing emphasizes managing acute or chronic conditions.
In community health nursing, the primary client is the community; in community-based nursing,
the primary clients are the individual and the family.
The services in community health nursing are both direct and indirect while community based
nursing are largely direct.
Distinguishing Features of Community health Nursing Practice
In addition to its preventive approach to health, community health nursing is characterized by its
being population-or aggregate-focused, its developmental nature, and the existence of a
prepayment mechanism for consumers of community health nursing services. Also, unlike nurses
who work in hospital settings, community health nurses care for different levels of clientele.

Population-focused approach and Community health Nursing Interventions

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)
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 and
5. Intervenes with communities, systems, individuals, and families.
Community health nurses may be responsible for a specific subpopulation in the community
(e.g., a school nurse may be responsible for students enrolled in an elementary school),
population-focused practice is concerned with many distinct and overlapping community subpopulations. The goal of population-focused nursing is to promote healthy communities.
Population- focused community health nurses would not have exclusive interest in one or two
sub-populations but would focus on the many sub-populations that make up the entire
community. A population focus involves concern for those who do and for those who do not,
receive health services.
Community health nursing practice requires the following types of data for scientific approach
and population focus: (1) the epidemiology, or body of knowledge, of a particular problem and its
solution and (2) information about the community

Information useful for population focus

Type of information
Demographic data
Age, gender, race/ethnicity,
Vital statistics data (national,
socio-economic status, education
regional, local); census
Groups at high risk
Health status and health
Health statistics (morbidity,
indicators of various
mortality, natality); disease
subpopulations in the community
statistics (incidence and
(e.g., children, elders, those with
Services/providers available
Official (public) health
City directories, phone books,
departments, health care
local or regional social workers,
providers for low-income
lists of low income providers,
individuals and families,
local community health nurses
community service agencies and
(e.g., school health nurses)

organizations (e.g., red cross)

Levels of Clientele of the Community health Nurse

Community health nurses focus on the care of several levels of clientele: the individual, the family,
the group/aggregate, and the community as a whole in many settings, including homes, clinics and
The Intervention Wheel
The Public Health Intervention Model was initially proposed in the late 1990s by nurses from the
Minnesota Department of Health to describe the breadth and scope of public health nursing
practice. This model was later revised and termed Intervention Wheel, and it has become
increasingly recognized as a framework for community and public health nursing practice.
The intervention Wheel contains 3 important elements
1. It is population based
2. It contains 3 levels of practice (community, systems and individual/family)
3. It identifies and defines 17 public health interventions are directed at improving population
Public Health Interventions and Definitions
Public Health Interventions
Describes and monitors health events through ongoing and
systematic collection, analysis, and interpretation of health data for
the purpose of planning, implementing, and evaluating public health
Disease and other health event Systematically gathers and analyzes data regarding threats to the
health of populations, ascertains the source of the threat, identifies
cases and others at risk, and determines control measures.
Locates populations of interest at risk and provides information
about the nature of the concern, what can be done about it, and how
services can be obtained.
Identifies individuals with unrecognized health risk factors or
asymptomatic disease conditions.
Locates individuals and families with identifies risk factors and
Case finding
connects them with resources
Assists individuals and families, groups, organizations, and/or
Referral and follow-up
communities to identify and access necessary resources to prevent
or resolve problems or concerns.
Optimizes self-care capabilities of individuals and families and the
Case Management
capacity systems and communities to coordinate and provide
Are direct care tasks that a registered professional nurse carries out
Delegated Functions
under the authority of a health care practitioner as allowed by law.
Communicates facts, ideas, and skills that change knowledge,
Health teaching
attitudes, values, beliefs, behaviors, and practices of individuals,
families, systems, and or/communities.
Establishes an interpersonal relationship with a community, a
system, and a family or individual, with the intention of increasing or
enhancing their capacity for self-care and coping.
Seeks information and generates optional solutions to perceived


Coalition building
Community organizing


Social marketing

Policy development and


problems or issues through interactive problem solving with a

community system and family or individual.
Commits two or more persons or an organization to achieve a
common goal through enhancing the capacity of one or more of the
embers to promote and protect health.
Promotes and develops alliances among organizations or
constituencies for a common purpose
Helps community to identify common problems or goals, mobilize
resources, and develop and implement strategies for realizing the
goals they collectively have set.
Pleads someones cause or act on someones behalf, with a focus on
developing the community, system, ad individual or familys capacity
to plead their own cause or act on their own behalf.
Utilizes commercial marketing principles and technologies for
programs designed to influence the knowledge, attitudes, values,
beliefs, behaviors, and practices of the population of interest
Places health issues on decision makers agendas, acquires a plan of
resolution, and determines needed resources, resulting in laws,
rules, regulations, ordinances, and policies. Policy enforcement
compels others to comply with laws, rules, regulations, ordinances,
and policies.

Overview of Public Health Nursing in the Philippines

Public health nursing was coined by Lillian Wald when she was the director of the Henry Street
Settlement in New York City to denote a service that was available to all people. However, as
federal state and local governments increased their involvement in the delivery of health services,
the term public health nursing became associated with public or government agencies and in
turn with the care of the poor people.

Public Health definition



Charles Edward A. Winslow

Public Health is directed towards assisting every citizen to realize his birth rights and longevity.
The science and art of preventing disease, prolonging life and efficiency through organized
community effort for: The sanitation of the environment; control of communicable infections;
education of the individual in personal hygiene; organization of medical and nursing services for
the early diagnosis and preventive treatment of disease and the development of a social machinery
to ensure everyone a standard of living, adequate for maintenance of health to enable every citizen
to realize his birth right of health and longevity
Dr. Ruth Freeman
Public Health Nursing may be defined as a 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 mobilization of the public for health action.
American Nurses Association (ANA)
The practice of promoting and protecting the health of populations using knowledge from nursing,
social, and public health sciences (1996)
The ANA (2007) elaborated by explaining that public health nursing practice is populationfocused, with the goals of promoting health and preventing disease and disability for all people
through the creation of conditions in which people can be healthy.
WHO definition
The art of applying science in the context of politics so as to reduce inequalities in health while
ensuring the best health for the greatest number.
The World Health Organization Expert Committee of Nursing defines public health nursing as a
special field of nursing that combines the skills of nursing, public health and some phases of
social assistance and functions as part of the total public health programme for the promotion of
health, the improvement of the conditions in the social and physical environment, rehabilitation of
illness and disability


Public health nursing refers to the practice of nursing in national and local government health
departments (which include health centers and rural health units) and public schools. It is community
health nursing practiced in the public sector.
Public Health Nurses (PHNs) refer to the nurses in the local/national health departments or public
schools whether their official title is Public health Nurse or Nurse or school nurse.
Core Business of Public health
Disease control
Injury prevention
Health protection
Health Public Policy including those in relation to environmental hazards such as in the workplace,
housing, food, water, etc.
Promotion of health and equitable health gain
Essential Public Health Functions
Health situation monitoring and analysis
Epidemiological surveillance/Disease prevention and control
Development of policies and planning in public health
Strategic management of health systems and services for population health gain
Regulation and enforcement to protect public health
Human resources development and planning in public health
Health promotion, social participation and empowerment
Ensuring the quality of personal and population based health services
Research, development and implementation of innovative public health solutions.
Public health nurses are found I various health settings and occupying various positions in the
hierarchy. They are assigned in rural health units, city health centers, provincial health offices,
regional health offices, and even in the national office of the Department of Health. They are also
assigned in public schools and in the offices of government agencies providing health care service.

They occupy a range of positions from Public Health Nurse I to Nurse Program Supervisors to
Chief Nurse in public health settings.
The Public Health Nurse uses various tools and procedures necessary for her to properly
practice her profession and deliver basic health service. She uses nursing process in her practice
and is adept in documenting and reporting accomplishments through record and reports. She is
also technically competent in various nursing procedures conducted in settings where she is

QUALIFICATIONS of Public Health Nurse

1. Is a graduate of BSN and a registered nurse (RN)
2. Has the following personal qualities and professional competencies
Good physical and mental health
Interest and willingness to work in the community
Capacity and ability to:
Relate the practice with ongoing community health and health related activities
Work cooperatively with other disciplines and members of the community
Accept and take actions needed to improve self and service
Analyze combination of factors and conditions that influence health of populations
Apply nursing process in meeting the health and nursing needs of the community
Mobilize resources in the community
With leadership potential
Resourcefulness and creativity
Honesty and integrity
Active membership to professional nursing organizations
The functions and activities of the PHN which are related to management training, supervision, provision
of nursing care, health promotion and education and coordination are consistent with the nursing law (RA
1. The PHN, in coordination with the faculty of colleges of nursing, participates in teaching, guidance
and supervision of students in nursing and midwifery for their related learning experiences (RLE) in
the community setting.
2. The PHN participates in the conduct of research and utilizes research findings in his/her nursing
The PHN supervises midwives within her catchment area in accordance with the agencys policy
and in a manner that improves performance and promotes job satisfaction.
a. The PHN formulates a supervisory plan
b. The HN conducts supervisory visits to implement the supervisory plan.
c. The PHN regularly monitors and evaluates midwives and nursing auxiliaries performance in
the implementation of public health programs
d. The PHN initiates and participates in activities to promote his or her supervisees/ personal and
professional growth.
e. The PHN initiates and participates in developing policies and guidelines that promote good
performance in nursing and midwifery services.
a. The PHN establishes linkages and collaborative relationship with other health professionals,
government agencies, the private sector (businesses) non-government organizations and
peoples organizations to address the communitys health problems.


b. The PHN collaborates with other health care providers, professionals, and community
representatives in assessing, planning, implementing and evaluating programs for community
a. The PHN establishes a working relationship to help ensure good quality data and to facilitate
on enhance partnership in addressing identified health needs and problems.
b. The PHN systematically collects data that are appropriate and accurate
c. The PHN recognizes the broad impact of certain factors on the clients health and nursing
problems such as political climate, the clients and/or the agencys financial capability, clients
values and culture, and their readiness or willingness to do something about their problems.
d. The PHN analyzes data collected about the community, family and individual to determine the
e. The PH formulates a nursing/community diagnosis
f. The PHN develops jointly with the client a nursing care plan or program plan for the priority
nursing problem.
g. The PHN implements the nursing care plan/program plan to promote, maintain, or restore
health, to prevent illness, to effect rehabilitation and to improve the capability of clients.
h. The PHN evaluates the responses of his/her clients to interventions in order to revise data
base, diagnoses and plan, and to formulate recommendations.
a. The PHN recognizes the role of healthy lifestyle in the prevention of a number of health
problems and integrates healthy lifestyle in the different health programs
b. The PHN plans, conducts, and evaluates health promotion and health education activities
c. The PHN demonstrates knowledge and skills on
How to advocate for healthy public policy
Creating supportive environments
Strengthening community action
. Developing clients personal skills.
d. The PHN actively works to build capacity for health promotion among the midwives, volunteer
health workers and community partners



Clinician, who is a health care provider, taking care of the sick people at home or in the RHU
Health Educator, who aims towards health promotion and illness prevention through
dissemination of correct information; educating people
Facilitator, who establishes multi-sectoral linkages by referral system
Supervisor, who monitors and supervises the performance of midwives
Health Advocator, who speaks on behalf of the client
Advocator, who act on behalf of the client
Collaborator, who working with other health team member

*In the event that the Municipal Health Officer (MHO) is unable to perform his duties/functions or is not
available, the Public Health Nurse will take charge of the MHOs responsibilities.
Other Specific Responsibilities of a Nurse, spelled by the implementing rules and Regulations of RA
7164 (Philippine Nursing Act of 1991) includes:
Supervision and care of women during pregnancy, labor and puerperium
Performance of internal examination and delivery of babies

Suturing lacerations in the absence of a physician

Provision of first aid measures and emergency care
Recommending herbal and symptomatic medsetc.

In the care of the families:

Provision of primary health care services
Developmental/Utilization of family nursing care plan in the provision of care
In the care of the communities:
Community organizing mobilization, community development and people empowerment
Case finding and epidemiological investigation
Program planning, implementation and evaluation
Influencing executive and legislative individuals or bodies concerning health and development
Responsibilities of CHN
be a part in developing an overall health plan, its implementation and evaluation for communities
provide quality nursing services to the three levels of clientele
maintain coordination/linkages with other health team members, NGO/government agencies in
the provision of public health services
conduct researches relevant to CHN services to improve provision of health care
provide opportunities for professional growth and continuing education for staff development

Brief History of Community Health/Public Health

Nursing Practice in the Philippines
The Fajardo Act (Act No. 2156) created Sanitary Divisions. The President of the Sanitary Divisions (forerunners of the
present Municipal Health Officers) took charge of two or three municipalities. Where there were no physicians
available male nurses were assigned to perform the duties of the President, Sanitary Division.
In the same year the Philippines General Hospital, then under the Bureau of Health sent Four Nurses to Cebu to take
care of mothers and their babies. The St. Pauls Hospital School of Nursing in Intramuros, also assigned two nurses to
do home visiting in Manila and gave nursing care to mothers and newborn babies from the outpatient obstetrical
service of the Philippines General Hospital.
School nursing was rendered by a nurse employed by the nurse employed by the Bureau of Health in Tacloban,
Leyte. In the same year, Reorganization Act No. 2462 created the Office of General Inspection. The Office of District
Nursing was organized under this office. It was headed by a lady Physician, Dr. Rosario Pastor who was also a nurse.
This Office was created due to increasing demand for nurse to work outside the hospital, and the need for the
direction, supervision and guidance of public health nurses.
Two graduate Filipino nurses, Mrs. Casilang Eustaquio and Mrs. Matilde Azurin were employed for Maternal and
Child Health and Sanitation in Manila under and American nurse, Mrs. G. D. Schudder.
Miss Perlita Clark took charge of the public health nursing work. Her staff was composed of one American nurse
supervisor, one American dietitian, 36 Filipino nurses working in the provinces and one nurse and one dietitian
assigned to Sanitary Divisions.
Four graduate nurses paid by the city of Manila were employed to work in the City Schools. Provinces that could
afford to carry out school health services were encouraged to employ a district nurse.
The Office of Miss Clark was abolished due to lack of funds.



The first Filipino nurse supervisor under the Bureau of Health, Miss Carmen del Rosario was appointed.
She succeeded Miss Mabel Dabbs.
She had a staff of 84 public health nurses assigned in five health stations. There was a gradual increase of
public health nurses and expansion of services.
Two government Schools of Nursing were established: Zamboanga General Hospital School of Nursing in
Mindanao and Baguio General Hospital in Northern Luzon. These schools were primarily intended to train
non-Christian women and prepare them to render service among their people. In later years, four more
government schools of Nursing were established: one in southern Luzon (Quezon Province) and three in
the Visayan Islands of Cebu, Bohol and Leyte.
July 1, 1926
Miss Carmen Leogardo resigned and Miss Genara S. Manongdo, a ranking supervisor of the American Red
Cross, Philippine Chapter was appointed in her place.
The office of District Nursing under Office of General Inspection, Philippine Health Service was abolished
and supplanted by the section of public health nursing. Mrs. Genara de Guzman acted training as
consultant to the director of Health on nursing matters.
The first convention of nurses was held by nurses followed by yearly conventions until the advent of World
War II. Pre-service training was initiated as pre-requisite for appointment.
The Section of Public Health Nursing was converted into Section of Nursing due to pressing need for
guidance not only in public nursing services but also in Hospital nursing and nursing education. The
Section of Nursing was transferred from the Office of General Services to the Division of Administration.
This office covered the supervision and guidance of nurses in the provincial hospitals and the two
government schools of nursing.
Reorganization Act No. 4007 transferred the Division of Maternal and Child Health of the Office of Public
Welfare Commission to the Bureau of Health. Mrs. Soledad A. Buenafe, former Assistant Superintendent of
Nurses of the Public Welfare Commission was appointed as Assistant Chief Nurse of the section of
Nursing, Bureau of Health.
Activities and personnel including six public health members of the Metropolitan Division, Bureau of
Health were transferred to the new department. Dr. Mariano Icasiano became the first City Health Officer
of Manila. An Office of nursing was organized with Mrs. Vicenta C. Ponce as Chief Nurse and Mrs. Rosario
A. Ordiz as Assistant Chief Nurse. They occupied these positions until their retirement.
December 8, 1941
When World War II broke out, public health nurses in Manila were assigned to devastated areas to attend
to the sick and the wounded.
A group of public health nurses, physicians and administrators from the Manila Health Department went to
the internment camp in Capas, Tarlac to receive sick prisoners of war released by the Japanese army. They
were confined at San Lazaro Hospital and Sixty-eight National Public Health Nurses were assigned to help
the Hospital staff take care of them.
July 1942
Thirty-one nurses who were taken prisoners of war by the Japanese army and confined at the Bilibid Prison
in Manila were released to the then Director of the Bureau of Health, Dr. Eusebio Aguilar who acted as
their guarantor.
Many public health nurses joined the guerillas or went to hide in the mountains during World War II.
February 1946

Post war records of the Bureau of Health showed that there were 308 public health nurses and 38
supervisors compared to pre-war when there were 556 public health nurses and 38 supervisors. In the
same year Mrs. Genera M. de Guzman, Technical Assistant in Nursing of the Department of Health and
concurrent President of the Filipino Nurses Association recommended the creation of a Nursing Office in
the Department of Health.
October 7, 1947
Executive Order No. 94 reorganized government offices and created the division of nursing under the
office of the Secretary of Health. This was implemented on December 16, 1947. Mrs. Genara de Guzman
was appointed as Chief of the Division, with three Assistants: Miss Annie Sand for Nursing Education: Mrs.
Magdalena C. Valenzuela for Public Health Nursing and Mrs. Patrocinio J. Montellano for staff Education.
The Nursing Division was placed directly under the Secretary of Health so that nursing services can be
availed of by the different bureaus and units to help carry out their health programs.
At the Bureau of Health, the Section of Nursing Supervision took over the functions of the former Section
of Nursing. Mrs. Soledad Buenafe was appointed Chief and Miss Marcela Gabatin, Assistant Chief.
The newly created Section of Puericulture Center of the Bureau of Hospitals had Mrs. Teresa Malgapo as
The first training Center of the Bureau of Health was organized in cooperation with the Pasay City Health
Department. This was housed at the Tabon Health Center located in a marginalized part of the city. It was
later renamed as Donya Marta Health Center. The original training staff of the Center had Dr. Trinidad A.
Gomez as Center Physician; Miss Marcela Gabatin as Nurse Supervisor; Miss Constancia Tuazon, Mrs.
Bugarin and Miss Ramos as Nurse Instructors. Miss Zenaida Y. Panlilio, National Public Health Nurse,
Bureau of Health, Later joined the staff.
Physicians and nurses undergoing pre-service and in-service training in health/public health nursing as
well as nursing students on affiliation were assigned to the above training center.
The Rural Health Demonstration and Training Center (RHDTC) was established by the Department of
Health through the initiative of Dr. Hilario Lara, Dean, Institute of Hygiene, now College of Public Health,
University of the Philippines. The WHO/UNICEF assisted project used health centers of the Quezon City
Health Department, which were located in the rural areas of the city. The RHDTC was used as a laboratory
for the field experiences of graduate and basic students in medicine, nursing, health education, nutrition,
and social work.
Health workers from other countries also came to observe in the training center. Dr. Amansia S. Mangay
(Mrs. Andres Angara), a Doctor of Public Health graduate from Harvard was chosen to be in Chief of the
RHDTC. Dr. Antonio N. Acosta former Physician of the Manila Health Department was Medical Training
The training staffs of RHDTC were nurses and had a major role in the organizationand implementation of
training activities. The first Supervising Training Nurse was Miss Marta Obana, with Miss Jean Bactat, Mrs.
Mary Velono, and Mrs. Natividad B. Asuque as Nurse Instructors.
The Office of Health Education and Personnel Training (forerunner of Health Manpower Development and
Training Service) was established with Dr. Trinidad Gomez as Chief. Four nurse instructors were recruited,
two from the Manila Health Department, Mrs. Venancia Cabanos and Mrs. Damasa Torrejon and two from
the Bureau of Health, Miss Zenaida y. Panlilio and Miss Leonora M. Liwanag, (the first graduates of the
Bachelor of Science in Nursing Degree from the University of the Philippines, College of Nursing, to join
the Bureau of Health).


Philippine Congress approved Republic Act No. 1082 or the Rural Health Law. It created the first 81 Rural
Health Units. Each unit had a physician, a public health nurse, a midwife, a sanitary inspector and a clerk
driver. They were provided with transportation (jeep) by the UNICEF.
Among the first public health nurses to undergo pre-service training prior to assignment in the Rural
Health Units were two graduates of Class 1952 of the Philippine General Hospital School of Nursing, Miss
Florida B. Ramos (Mrs. Martinez) and Miss Lydia Amurao (Mrs. Cabigao)
Republic Act 1891 was approved amending Sections Two, Three, Four, Seven and Eight of R.A. 1082
strengthening Health and Dental Services in the Rural Areas and Providing Funds Thereto This Second
Rural Health Act created 8 categories of rural health units based on population. This resulted in additional
number of positions for health workers including public health nurses and midwives.
Republic Act 977 passed by Congress in 1954 was implemented. This abolished the Division of Nursing.
However, it created nursing positions at different levels in the health organization. Miss Annie Sand was
appointed Nursing Consultant under the Office of the Secretary of Health.
Two nurses in the former Bureau of Hospitals worked closely with the Nursing Consultant. They were Miss
Rosita Furia for Hospital Nursing Service, and Miss Eva Obsequio for Nursing Education, Mrs. Rosita
Villanueva and Mrs. Juanita P. Hernando were appointed Nursing Program Supervisors of the Bureau of
Hospitals vice Miss Furia amd Miss Obsequio when they retired.
The Department of Health National League of Nurses, Inc. was founded by Miss Annie San in 1961. She
became its first President and Adviser.
The Reorganization Act with implementing details embodied in Executive Order 288, series of 1959 de
centralized and integrated health services. It created 8 regional Health Offices in the Country, which were
later increased to eleven and eventually seventeen.
At the Regional level two positions for nurses were created: Regional Nurse Supervisor and Regional Public
Health Nurse. These Nurses had the same salary grades and performed the same functions and
responsibilities. In every Region, there were 3 to 4 Regional Nurses Supervisors and 1 to 2 Regional Public
Health Nurses. They were assigned to specific provinces and cities and supervised both hospital and
public health nurses. One of them was designated as coordinator. Simultaneously, each Regional Health
Office had a Regional Training Center, creating positions for Regional Training Nurses and Nurse
Instructors who took charge of training activities.
The Supervising Public Health Nurses (SPHN) at the Provincial Health once supervised the Public Health
Nurses assigned at the Rural Health Units as well as the Chief Nurses of the District hospitals. A small
province ha one SPHN and big provinces had two SPHNs.
The reorganization of 1959 also merged two Bureaus in the Department of Health. The Bureau of Health
(in charge of preventive programs Maternal and Child Health, Dental Health, Industrial or Occupational
Health) was merged with the Bureau of Hospitals (Curative programs and regulatory/licensing functions)
to form the bureau of Health and Medical Services.
In the merged Bureau of Health and Medical Services. Nursing Program Supervisors were appointed for
the different programs. In the Maternal and Child Health Division, the nurses were Miss Saturnina Latorre,
Mrs. Fe Bacalso and later Mrs. Rosario Zaraspe, Mrs. Isabel Pascua and Mrs. Emilia Briones. They
monitored MCH programs and activities in the regions. They also conducted training activities for the
Maternal and Child Health Service. In the Occupational Health Division, Mrs. Felisa V. Chanco was the
nurse in charge of Occupational Health Nursing.

In the Bureau of Disease Control, Mrs. Zenaida Panlilio-Nisce was appointed as Nursing Program
Supervisor and served as consultant on the nursing aspects of the 4 special diseases: TB, Leprosy,
Venereal Disease, Cancer, Filariasis, and, Mental Health. She was involved in program planning,
monitoring, evaluation, and research.
At the Office of Health Education and Personnel Training, the nurses were Mrs. Josefina A. Mendoza,
Supervising Nurse Instructor, Miss Carmen Panganiban, Miss Virginia Orais and later, Mrs. Constancia
Asinas. Nurse Instructors were involved in staff development and training of foreign and local health
workers. Their positions were later reclassified as Department Training Nurses.
November 1971
Mrs. Josefina A. Mendoza, Supervising Nurse Instructor, Office of Health Education and Personnel
Training, succeeded Miss Annie Sand as Nursing Consultant. A few years later, Mrs. Nelida K. Castillo,
former Nurse Instructor at San LAzaro Hospital and counterpart to Miss Helen Fillmore, WHO consultant
on Pediatric Nursing was appointed Nursing Program Supervisor, Office of the secretary of Health.
The Project Management Staff was organized as part of Population Loan II of the Philippine Government
with Dr. Francisco Aguilar as Project Manager. Experts on Different fields of public health were recruited
and Mrs. Nelida Castillo joined the PMS staff. Her position as Nursing Program Supervisor, Office of the
Secretary of Health was taken over by Mrs. Zenaida Nisce, Nursing Program Supervisor, Bureau of Disease
Control. Miss Julita Yabes, faculty member of the Institute of Hygiene (now College of Public Health)
University of the Philippines served as consultant on nursing matters in the Project Management Staff.
As a result of the restructuring of the health care delivery system based on findings of the Operations
Research (WHO assisted) conducted in the province of Rizal in the early 70s, the functions of the health
team members (Municipal Health Officer, Public Health Nurse, Rural Health Midwife, and Rural Sanitary
Inspector) were redefined. The roles of the public health nurse and the midwife were expanded. Two
thousand midwives were recruited and trained to serve in the rural areas.
The Nursing Consultant and Nursing Program Supervisor of the Office of the Secretary of Health were
involved in the Rural Health Practice Program which required medical and nursing graduates to serve for
two months in the rural areas of the country before their license could be issued by the Professional
Regulation Commission. When the number of nursing graduates reached over 12,000 per year, the
program was stopped. By then, the objectives of the program that health services be made available in the
rural areas of the country, and that the young medical and nursing graduates develop a liking for working in
these remote undeserved areas were partially attained.
During the incumbency of President Ferdinand Marcos, Mrs. Josefina Mendoza as Nursing Consultant
strongly repeatedly recommended the creation of a Bureau of Nursing but unfortunately, the government
was in the midst of streamlining its organization. The envisioned Bureau of Nursing did not materialize
even if the President endorsed it to
Mr. Armand Fabella who was in charge of the government
Nonetheless, nursing was represented in the monthly staff meetings of the Department of Health.
Communications and problems on nursing matters were referred to the Nursing Consultant. She and the
other nurses at the Central Office represented the Department of Health at regional, national and
international nursing conferences and seminars.
The reorganization of the Department of Health during this period placed the position of Nursing
Consultant at the Bureau of Health and Medical Services. It was later abolished when Mrs. Mendoza

retired. Mrs. Zenaida Nisce remained as Nursing Program Supervisor of the Office of the Secretary of
Health. In addition, to her duties she was made Secretary, Task force on Mental Health.
The other nursing positions at the Central Office were at the National Family Planning Service (NFPS).
Among these nurses were Miss Leonora Liwanag, Miss Virginia Orais, Mrs. Vilma Paner, Mrs. Sarah Austria
and Mrs. Leticia Daga. Mrs. Nelia Hizon joined the NFPS when Miss Liwanag retired.
Executive Order No. 119 reorganized the Department of Health and created several offices and services
with the Department of Health.
The number of positions of Nursing Program Supervisors (Nurse VI) was increased as there were three or
more appointed in each service. In the Maternal and Child Health Services Mrs. Emilia Briones and Mrs.
Ana Mallari were first appointed followed by Mrs. Patria Billones, Mrs. Nilda Silvera and Mrs. Vicenta Borja.
Mrs. Azucena Alcantara and Mrs. Lucila Agripa later joined them. Aside from the usual services for
mothers and children, these nurses were involved in the following programs: Expanded Program on
Immunization, Control of Diarrheal Diseases and Control of Acute Respiratory Infections.
In the non-communicable Disease Control Service (NCDCS), the first two Nursing Program Supervisors
(Nurse VI) were Mrs. Gloria Temelo and Miss Gilda Estipona who were the cardiovascular and cancer
control programs respectively. In 1989, Mrs. Carmen Buencamino joined the Occupational Health Division
as Nurse VI. When these three nurses retired one after another, their positions were taken over by Miss
Ma. Thelma. Bermudez, Miss Frances Prescilla Cuevas and Mrs. Ma. Theresa Mendoza. They were
involved in the development of public health programs for the prevention and control of cardiovascular
diseases, cancer, diabetes and disabilities such as blindness and deafness, osteoporosis, asthma and
smoking control.
The three nurses at the Communicable Disease Control Service, Mrs. Zenaida P. Nisce, Mrs. Carolina A.
Ruzol and Mrs. Zenaida Recidoro participated in the planning, training, monitoring, supervision and
evaluation of diseases as leprosy sexually transmitted diseases, rabies, and filariasis and dengue
hemorrhagic fever. At the Community Health Service, The Nursing Program Supervisor was Mrs.
Patrocinio Ferrera. She was involved in the planning and monitoring of primary health care activities in the
different regions. At the Department of Health Administrative Service there were four Public Health Nurses
and one Senior Public Health Nurse assigned at the Medical Examination Division and Infirmary (MEDI)
formerly called Physical Examination Division.
January 1999
Department Order No. 29 designated Mrs. Nelia F. Hizon, Nurse VI, and then President of the National
League of Philippine Government Nurses, as nursing adviser. She was detailed at the Office of Public
Health Services. As nursing Adviser, matters affecting nurses and nursing are referred to her.
May 24, 1999
Executive Order No. 102 was signed by President Joseph Ejercito Estrada redirecting the functions and
operations of the Department of Health.
Based on this Executive Order, most of the nursing positions T THE Central Office were either transferred
or devolved to other offices and service.
The development of the Rationalization Plan to streamline the bureaucracy further was started and is in
the last stages of finalization.



In order for the public health nurse to fully appreciate the public health system in this country, it is
important to have an understanding of the development of the government agency mandated to protect
the health of the people. The following historical account on the institutional development of the
Department of Health was referenced from the souvenir Program during the 100 th year anniversary of DOH.
Pre-Spanish and Spanish Periods (before 1898)
Traditional health care practices especially the use of herbs and rituals for healing were widely practiced
during these periods. The western concept of public health services in the country is traced to the first
dispensary for indigent patients of Manila ran by a Franciscan Friar that was began in 1577. In 1876,
Medicos Titulares, equivalent to provincial health officers were already existing. In 1888, a Superior Board
of Health and Charity was created by the Spaniards which established a hospital system and a board of
vaccination, among others.
June 23, 1898
Shortly after the proclamation of the Philippine independence from Spain, the Department of Public
Works, Education and Hygiene was created by virtue of a decree signed by President Emilio Aguinaldo.
However, this was short lived because the American took over and started a military and subsequently a
civil government in the islands.
September 29, 1898
With the primary objective of protecting the health of the American soldiers, General Orders No. 15
established in the Board of Health for the City of Manila.
July 1, 1901
Because it was realized that it was impossible to protect the American soldiers without protecting the
natives, a Board of Health for the Philippine Islands was created through Act No. 157. This also functioned
as the local health board of Manila. It truly became an Insular Board of Health when Act Nos. 307, 308
dated December 2, 1901, established the Provincial and Municipal Boards respectively completing the
health organization in accordance with the territorial division of the islands.
October 26, 1905
The Insular Board of Health proved to be inefficient operationally so it was abolished and was replaced by
the Bureau of Health under the Department of Interior through Act No. 1407. Act No. 1487 in 1906
replaced the provincial boards of health with district health officers
Act No. 2156 also known as the Fajardo Act, Consolidated the municipalities into sanitary divisions and
established what is known as the Health Fund for travel and salaries.
Act No. 2468 transformed the Bureau of Health into a commissioned service called the Philippine Health
Service. This introduced a systematic organization of personnel with corresponding civil service grades,
and a secure system of civil service entrance and promotion described as the semi-military system of
public health administration.
August 2, 1916
The passage of the Jones Law also known as the Philippine Autonomy Act, provided the highlight in the
struggle of the Filipinos for independence from the American rule. The establishment of an elective
Philippine Senate completed an all Filipino Philippine Assembly that formed a bicameral system of
government. This ushered in a major reorganization which culminated in the Administrative Code of 1917
(Act 2711), which included the Public Health Law of 1917.
Because of the need to better coordinate public health and welfare services, Act No. 4007 known as the
Reorganization Act of 1932, reverted back the Philippine Service into the Bureau of Health, combined the
Bureau of Public Welfare under the Office of the Commissioner of Health and Public Welfare.
The Philippine Commonwealth and the Japanese Occupation (1935-1945)
May 31, 1939

Commonwealth Act No. 430 created the Department of Public Health and Welfare, but the full
implementation was only completed through Executive Order No. 317, January 7, 1941. Dr. Jose Fabella
became the First Department Secretary of Health and Public Welfare in 1914.
During the period of the Japanese occupation, various reorganizations and issuances for the health and
welfare of the people were instituted and lasted until the Americans came in 1945 and liberated the
October 4, 1947
Executive Order No. 94 provided for the post war reorganization of the Department of Health and Public
Welfare. The resulted in the split of the Department with the transfer of the Bureau of Public Welfare
(which became the Social Welfare Administration) and the Philippine General Hospital to the Office of the
President. Another split was created between the curative and preventive services through the creation of
the Bureau of Health. This order also established the Nursing Service Division under the Office of the
January 1, 1951
The Office of the President of the Sanitary District was converted into a Rural Health Unit, carrying out 7
basic health services: maternal and child health, environmental health, communicable disease control,
vital statistics, medical selected provinces. The impact to the community was so strong, it directly resulted
in the passage of the Rural Health Act of 1954 (RA 1082). This Act created more rural health units and
created posts for municipal health officers, among other provisions.
February 20, 1958
Executive Order No. 288 provided for what is described as the most sweeping reorganization in the
history of the Department at that period. This came about in an effort to decentralize governance of health
services. An office of the Regional Health Director was created in 8 regions and all health services were
decentralized to the regional, provincial and municipal levels. Bureaus were limited to staff functions such
as policy making and development of procedures. RHUs were made in integral part of the public health
care delivery system.
The Restructured Health Care Delivery System was conceptualized. It classified health services into
primary, secondary and tertiary levels of care. This further expanded the reach of the rural health units.
Under this concept the public health nurse to population ratio 1:20,000. The expanded role of the public
health nurse were highlighted.
June 2, 1978
With the proclamation of martial law in the country, President Decree 1397 renamed the Department of
Health to the Ministry of Health. Secretary Gatmaitan became the first Minister of Health.
December 2, 1982
Executive Order No. 851 signed by the President Ferdinand E. Marcos reorganized the Ministry of Health
as an integrated health care delivery system through the creation of the Integrated Provincial Health Office
which combines public health and hospital operations under the Provincial Health Officers.
April 13, 1987
Executive Order No. 119, Reorganizing the Ministry of Health by President Corazon C. Aquino saw a
major change in the structure of the ministry. It transformed the Ministry of Health back to the Department
of Health.
EO 119 clustered agencies and programs under the Office for Public Health Services. Office for Hospital
and Facilities Services, Office for Standards and Regulations and Office of management Services. The Field
Offices were composed of the Regional health Offices and National Health Facilities. The later was
composed of National Medical Centers, the Special Research Centers and Hospital. Five deputy minister
positions were also created.
October 10, 1991

Republic Act 7160 known as the Local Government Code provided for the decentralization of the entire
government. This brought about a major shift in the role and functions of the Department of Health. Under
this law, all structures, personnel and budgetary allocations from the provincial health level down to the
barangays were devolved to the local government units (LGUs) to facilitate health service delivery. As
such, delivery of basic health services is now the responsibility of the LGUs. The Department of Health
changed its role from one of implementation to one of governance.
May 24, 1999
Executive Order No. 102 Redirecting the Functions and Operations of the Department of Health by
President Joseph E. Estrada granted the DOH to proceed with its Rationalization and Streamlining Plan
which prescribed the current organizational, staffing and resource structure consistent with its new
mandate, roles and functions post devolution.
The shift in policy and functions is indicated in the de-emphasis from direct service provision and program
implementation, to an emphasis on policy formulation, standard setting and quality assurance, technical
leadership and resource assistance. The shift in policy direction of the DOH is shown in its new role as the
national authority on health providing technical and other resource assistance to concerned groups.
EO102 mandates the Department of Health to provide assistance to local government units, peoples
organization, and other members of civic society in effectively implementing programs, projects and
services that will promote the health and well-being of every Filipino; prevent and control diseases among
population at risks; protect individuals, families and communities exposed to hazards and risks that could
affect their health; and treat, manage and rehabilitate individuals affected by diseases and disability.
Development of the Health Sector reform Agenda which describes the major strategies, organizational and
policy changes and public investments needed to improve the way health care is delivered, regulated and
2005 ongoing
Development of a plan to rationalize the bureaucracy in an attempt to scale down including the
Department of Health.
Roles and Functions of DOH
The Department of Health, in its new role as the national authority on health providing technical and other
resource assistance to concerned groups as mandated by Executive Order 102 has identified the following
general functions under its three specific roles in the health sector:
1. Leadership in Health
Serve as the national policy and regulatory institution from which the local government units, nongovernment organizations and other members of the health sector involved in social welfare and
development will anchor their thrusts and directions for health.
Provide leadership in the formulation, monitoring and evaluation of national health policies, plans
and programs. The DOH shall spearhead sectoral planning and policy formulation and assessment
at the national and regional levels.
Serve as advocate in the adoption of health policies, plans and programs to address national and
sector concerns.
2. Enabler and Capacity Builder
Innovate new strategies in health to improve the effectiveness of health programs, initiate public
discussion on health issues undertaking and disseminate policy research outputs to ensure
informed public participation in policy decision-making.
Exercise oversight functions and monitoring and evaluation of national health plans, programs and

Ensure the highest achievable standards of quality health care, health promotion and health
3. Administrator of Specific Services
Manage selected national health facilities and hospitals with modern and advanced facilities that
shall serve as national referral centers (i.e., special hospitals); and, selected health facilities at subnational levels that are referral centers for health systems (i.e., tertiary and special hospital
reference laboratories, training centers, centers for health promotion, centers for disease control
and prevention, regulatory offices, among others).
Administer direct services for emergent health concerns that require new complicated
technologies that it deems necessary for public welfare; administer special components of specific
programs like tuberculosis, schistosomiasis, HIV-AIDS, in as much as it will benefit and affect large
segments of the population.
Administer health emergency response services, including referral and networking system for
trauma, injuries and catastrophic events, in cases of epidemic and other widespread public danger,
upon the direction of the President and in consultation with concerned LGU.
The DOH is the leader, staunch advocate and model in promoting Health for All in the Philippines.
Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor and shall
lead the quest for excellence in health.
The DOH shall do this by seeking all ways to establish performance standards for health human resources;
health facilities and institutions; health products and health services that will produce the best health
systems for the country. This, in pursuit of its constitutional mandate to safeguard and promote health for
all Filipino regardless of creed, status or gender with special consideration for the poor and the vulnerable
who will require more assistance.
Goal: Health Sector Reform Agenda (HSRA)
Health Sector reform is the overriding goal of the DOH. Support mechanisms will be through sound
organizational development, strong policies, systems and procedures, capable human resources and
adequate financial resources.
Rationale for Health Sector Reform
Although there has been a significant improvement in the health status of Filipinos for the last 50 years, the
following conditions are still seen among the population.
Slowing down in the reduction in the infant Mortality Rate (MR) and the Maternal Mortality Rate
Persistence of large variations in health status across population groups and geographic areas.
High burden from infectious diseases.
Rising burned from chronic and degenerative diseases.
Unattended emerging health risks from environmental and work related factors.
Burden of disease is heaviest on the poor.
The reason why the above conditions are still seen among the population can be explained by the
following factors:
Inappropriate health delivery system as shown by an inefficient and poorly targeted hospital
system, ineffective mechanism for providing public health programs on top of health human
resources maldistribution.
Inadequate regulatory mechanisms for health services resulting to poor quality of health care, high
cost of privately provided health services, high cost of drugs and presence of low quality of drugs in
the market.

Poor health care financing and inefficient sourcing or generation of funds for healthcare.
The following are the implications of the above situation:
There is poor coverage of public health and primary care services.
There is inequitable access (physical and financial) to personal health care services.
There is low quality and high cost of both public and personal health care.
In order to address the problem in the way the Philippines health care system delivers and pays for health
services, interrelated reforms in five areas have been identified as critical in transforming the health system
into one that ensures the delivery of cost effective services, universal access to essential services and
adequate and efficient financing.
Areas that needed to be reformed are on health financing, health regulation, local health systems, public
health systems, public health programs and hospital systems.
Framework for Implementation of HSRA: FOURmula ONE for Health.
This is adopted as the implementation framework for health sector reforms under the current
administration. It intends to implement critical interventions as a single package backed by effective
management infrastructure and financing arrangements following a sectorwide approach.
Goal of FOURmula ONE for Health
1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing
The four elements of the strategy are:
1. Health financing the goal of this health reform area is to foster greater, better and sustained
investments in health. The Philippine Health Insurance Corporation, through the National Health
Insurance Program and the Department of Health through sectorwide policy support will lead this
component jointly.
2. Health regulation the goal is to ensure the quality and affordability of health good and services.
3. Health service delivery the goal is to improve and ensure the accessibility and availability of
basic and essential health care in both public and private facilities and services.
4. Good governance the goal is to enhance health system performance at the national and local
A key feature of the FOURmula ONE for Health implementation strategy is the engagement of the National
Health Insurance Program (NHIP) as the main lever to effect desired changes and outcomes in each of the
four implementation components. The NHIP supports each of the elements in terms of:
Financing, as it reduces the financial burden placed on Filipinos by health care costs;
Governance, as it is a prudent purchaser of health care thereby influencing the health care market
and related institutions;
Regulation, as the NHIPs role in accreditation and payments based on quality acts as a driver for
improved performance in the health sector; and,
Service delivery, as the NHIP demands fair compensation for the costs of care directed at
providing essential goods and services in health.
Roadmap for All Stakeholders in Health:
National Objectives for Health 2005 to 2010
The NOH 2005-2010 provides the road map for stakeholders in health and health-related sectors to
intensify and harmonize their efforts to attain its time honored vision of health for all Filipinos and
continue its avowed mission to ensure accessibility and quality of health care to improve the quality of life
of all Filipinos, especially the poor.
The NOH sets the targets and critical indicators, current strategies based on field experiences, and laying
down new avenues for improved interventions. It provides concrete handle that would guide policy
makers, program managers, local government, executives, development partners, civil society and the
communities in making crucial decisions for health.

Building on the initiatives under Health Sector Reform Agenda and as set forth in the NOH 1999-2004, an
implementation is defined through FOURmula ONE for health which strategically focuses on interventions
that create the most impact and generates buy-in from all partners. FOURmula ONE for Health is an
overarching philosophy to achieve the end goals of better health care financing. It is directed towards
ensuring accessible, affordable quality health care especially for the more disadvantaged and vulnerable
sectors of the population.
Objectives of the Health Sector
a. Improve the general health status of the population
b. Reduce morbidity and mortality from certain diseases
c. Eliminate certain diseases as public health problems
d. Promote healthy lifestyle and environmental health
e. Protect vulnerable groups with special health and nutrition needs
f. Strengthen national and local health systems to ensure better health service delivery
g. Pursue public health and hospital reforms
h. Reduce the cost and ensure the quality and safety of essential drugs.
i. Institute health regulatory reforms to ensure quality and safety of health good and services.
j. Strengthen health governance and management support systems
k. Institute safety nets for the vulnerable and marginalized groups
l. Expand the coverage of social health insurance
m. Mobilize more resources for health
n. Improve efficiency in the allocation, production and utilization of resources for health


Health Care for all Filipinos
Administrative order no.2010 -0036(December 16,2010)
Overall Goal:
The implementation of Universal Health Care shall be directed towards ensuring the achievement of the
health system goals of better health outcomes, sustained health financing and responsive health system by
ensuring that all Filipinos, especially the disadvantaged group in the spirit of solidarity, have equitable
access to affordable health care.
General Objective:
Universal Health Care is an approach that seeks to improve, streamline, and scale up the reform strategies
in HSRA and Fl in order to address inequities in health outcomes by ensuring that all Filipinos, especially
those belonging to the lowest two income quintiles, have equitable access to quality health care.
This approach shall strengthen the National Health Insurance Program (NHIP) as the prime mover in
improving financial risk protection, generating resources to modernize and sustain health facilities, and
improve the provision of public health services to achieve the Millennium Development Goals (MDGs).
A, The Aquino Health Agenda (AHA) is a focused approach to health reform implementation in the
context of HSRA and F1, ensuring that all Filipinos especially the poor receive the benefits of health
reform. AHA shall be attained by pursuing three strategic thrusts:
l. Financial risk protection through expansion in NHIP enrollment and benefit delivery - the poor
are to be protected from the financial impacts of health care use by improving the benefit delivery ratio of
the NHIP;
2. Improved access to quality hospitals and health care facilities government owned and operated
hospitals and health facilities will be upgraded to expand capacity and provide quality services to help
attain MDGs, attend to traumatic injuries and other types of emergencies, and manage non-communicable
diseases and their complications; and

3. Attainment of the health-related MDGs - public health programs shall be focused on reducing
maternal and child mortality, morbidity and mortality from TB and malaria, and the prevalence of
HIV/AIDS, in addition to being prepared for emerging disease trends, and prevention and control of noncommunicable diseases.
B. The six (6) strategic instruments shall be optimized to achieve the AHA strategic thrusts:
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 socio-economic 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. Govemance 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 capable of meeting their health needs at 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
A. Financial risk protection through improvements in NHIP benefit delivery shall be achieved by:
1. Redirecting Phil-Health operations towards the improvement of the national and regional benefit
delivery ratios;
2. Expanding enrolment of the poor in the NHIP to improve population coverage;
3. Promoting the availment of quality outpatient and inpatient services at accredited facilities through
reformed capitation and no balance billing arrangements for sponsored members, respectively;
4. Increasing the support value of health insurance through the use of information technology upgrades to
accelerate Phil-Health claims processing, etc.; and
5. A continuing study to determine the segments of the population to be covered for specific range of
services and the proportion of the total cost to be covered/supported
B. Improved access to quality hospitals and other health care facilities shall be achieved by:
1. A targeted health facility enhancement program that shall leverage funds for improved facility
preparedness to adequately manage the most common causes of mortality and morbidity, including
2. Provision of financial mechanisms drawing from public-private partnerships to support the immediate
repair, rehabilitation and construction of selected priority health facilities;
3. Fiscal autonomy and income retention schemes for government hospitals and health facilities;
4. Unified and streamlined DOH licensure and Phil-Health accreditation for hospitals and health facilities;
5. Regional clustering and referral networks of health facilities based on their catchment areas to address
the current fragmentation of health services in some regions as an aftermath of the devolution of local
health services.
C. Health-related MDGs shall be attained by:
1. Deploying Community Health Teams that shall actively assist families in assessing and acting on their
health needs;
2. Utilizing the life cycle approach in providing needed services, namely family planning; ante-natal care;
delivery in health facilities; essential newborn and immediate postpartum care and the Garantisadong
Pambata package for children 0-14 years of age;
3. Aggressively promoting healthy lifestyle changes to reduce non-communicable diseases;

4. Ensuring public health measures to prevent and control of communicable diseases, and adequate
surveillance and preparedness for emerging and reemerging diseases: and
5. Harnessing the strengths of inter-agency and inter-sectoral cooperation to health especially with the
Department of Education and Department of Social Welfare and the Department of Interior and Local
FOURmula One for health (2005-2010)
Health Sector Reform Agenda (1999-2004)


Primary health Care (PHC)
Is essential health care made universally accessible to individuals and families in the community by
means acceptable to them through their full participation at a cost that the community and country
can afford, in the spirit of self-reliance and self-determination.
PHC was declared during the first International Conference on PHC held in Alma Ata, USSR on
September 6-12, 1978 by WHO
The goal was Health for all by the Year 2000. This was adopted in the Philippines through Letter
of Instruction (LOI) 949 signed by President Marcos in October 19, 1979 and has underlying
theme of Health in the Hands of the people by 2020.
The concept of PHC is characterized by partnership and empowerment of the people that shall
permeate as the core strategy in the effective provision of essential health services that are
community based, accessible, acceptable and sustainable at a cost which the community and the
government can afford.
It is a strategy, which focuses responsibility for health on the individual, his family and the
community. It includes the full participation and active involvement of the community towards the
development of self-reliant people, capable of achieving an acceptable level of health and wellbeing. It also recognizes the interrelationship between health and the overall political, sociocultural and economic development of society.
The Alma Ata Conference made the following declarations:
1. Health is a basic fundamental right
2. There exists 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 a responsibility for the health of their people
Four Cornerstones/Pillars in primary Health Care
1. Active community participation
2. Intra and inter-sectoral linkages
3. Use of appropriate technology
4. Support mechanism made available
The WHO has identified five key elements to achieving the goal of health for all
1. Reducing exclusion and social disparities in health (universal coverage)
2. Organizing health services around peoples needs and expectations (health service reforms)
3. Integrating health into all sectors (public policy reforms)
4. Pursuing collaborative models of policy dialogue (leadership reforms)

Increasing stakeholder participation

KEY Principles of Primary health Care
1. Accessibility, Affordability, Acceptability and Availability
a. Accessibility- usually refers to the physical distance of a health facility or the travel time
required for people to get the needed or desired health services. This requires the existence of
a facility within reasonable distance from the catchment population or the people it is meant to
b. Affordability- is not only in consideration of the individual or familys capacity to pay for basic
health services. Particularly for public health services, it is also a matter of whether the
community or government can afford these services.
c. Acceptability- means that the health care offered is in consonance with the prevailing culture
and traditions of the population
d. Availability- is a question whether the basic health services required by the people are offered
in the health care facilities or is provided on a regular and organized manner.
2. Support mechanisms
The resources for essential health services come from the three major entities: the people
themselves; the government, and the private sector like NGOs and socio-civic and faith
3. Multi-sectoral approach
As health and disease are outcomes of multiple interrelated factors, PHC requires
communication, cooperation and collaboration within and among various sectors.
a. Intra-sectoral linkages
Refer to communication, cooperation, and collaboration within the health sector; among
the members of the health team and among health agencies
For example, a pregnant woman who had pre-natal checkups in the BHS or rural health
unit (RHU) has been identified as high risk. She would be referred to appropriate hospital
for childbirth. In the spirit of the two-way referral system, the same mother once
discharged from the hospital is referred back to the RHU for follow-up home care.
b. Inter-sectoral linkages
Encompass the communication, cooperation, and collaboration between the health
sector and other sectors of society like education, public works agriculture, and
local government officials.
A concrete example is the Rabies Prevention and Control Program. The DOH
provides immunization for victims of animal bites, The Department of Agriculture
(DA) provides outreach rabies immunization for dogs while the DepEd and LGUs
are in charge of information campaign in school and communities.
4. Community participation
Health is achieved through self-reliance and self-determination, and those individuals,
families, and communities are not considered as recipients of care but active participants
in achieving their health goals.
Community participation is an educational and empowering process in which people, in
partnership with those who are able to assist them, identify the problems and the needs
and increasingly assume responsibilities themselves to plan, manage, control and asses the
collective actions that are proved necessary.
5. Equitable distribution of health resources
PHC advocates for care that community-based and preventive in orientation. It calls for an
inventory and analysis of health resources, facilities and manpower.
Examples are Doctor to the Barrios Program (DTTB) and Nurses Deployment program
(NDP). The DTTB volunteers are fielded to manage the RHU or health centers in unserved,
economically depressed municipalities for 2 years. These volunteers are offered

competitive compensation by the DOH and the LGU. NDP volunteers are deployed to
unserved, economically depressed municipalities to address the inadequate nursing
workforce in rural communities and health facilities.
6. Appropriate technology
Refers to the technology that is suitable to the community that will use it. To better capture
its essence, the terms peoples technology and indigenous technology are also used in
reference to appropriate technology.
Criteria for appropriate health technology
1. Safety- this means that the technology results in minimal risk for the user and that the
intended positive outcomes of the use of a technology far outweigh its unintended negative
Example the pertussis vaccine, is not recommended to be given to a child who is 7
years or older because at this age, the vaccine is already more hazardous that the
disease itself.
2. Effectiveness- the technology should accomplish what it is meant to accomplish.
For example, the medicinal herbs endorsed by the DOH have been tested and have
been clinically proven to have medicinal value in the relief and treatment of
3. Affordability- measures for health promotion and disease prevention are cost-effective in
comparison to treatment of diseases. Prevalent childhood conditions such as cough and
colds, diarrhea and fever often require home management only. These cost effective
interventions require an educated community.
4. Simplicity- the technology that requires readily available simple materials and that
involves a simpler process in its use can be more easily adopted by the people in the
community when and where applicable.
For example, oral rehydration for management of diarrhea is a simple technology
that can be administered at home.
5. Acceptability- technology is effective only when it is used by those who need it. Thus,
culture is an important consideration in determining the appropriateness of a technology.
In addition, education regarding a particular technology is essential for its adoption.
6. Feasibility and reliability- the technology must be easy to apply considering the peoples
natural settings like the home, school, workplace, and community. Supplies must be
constantly available.
For example, compared to chest X0ray, sputum examination is feasible in more
7. Ecological effects- effects on ecology are an important consideration in choosing or
rejecting a particular technology.
For example, the DOH Administrative order no. 21 s 2008 mandated the gradual
phase out of mercury in all Philippines health care facilities and institutions.
8. Potential to contribute to individual and community development- appropriate
technology promotes self-sufficiency on the part of those using it.

PHC: Seven principles and Strategies (DOH)

1. Accessibility, availability and acceptability of health services
Delivery of health services directed to where the people are accessible to the community
Use of indigenous volunteer workers as health care providers (1:10-20 ratio)

Use of traditional (herbal) medicine together with essential drugs

2. Provision of quality basic and essential health services
Competency-based training design and curriculum (based on community needs and
priorities, task analysis of community health workers (CHW)
Attitudes, knowledge and skills developed on promotive, preventive, curtive and
rehabilitative health care
Regular monitoring and periodic monitoring of CHW performance by community and
health staff.
3. Community participation
Awareness building and consciousness raising on health and health related issues.
Planning, implementation, monitoring and evaluation done through small group meetings
(10-12 households)
Selection of CHWs by the community
Community building and organizing
4. Self-reliance
Community generates support for the health program.
Use of local resources
Training of the community in leadership and management skills.
Incorporation of income generating projects, cooperatives and business
5. Recognition of interrelationship between health and the government
Convergence of health, food, nutrition, water, sanitation and population services
Integration of PHC into national, regional, provincial, municipal and Barangay development
Coordination of activities with economic planning, education, agriculture, industry,
housing, public works, communication and social services.
6. Social mobilization
Establishment of an effective health referral system
Multi-sectoral and interdisciplinary linkages.
Information, education and communication support using multimedia
Collaboration between government and non-government organization.
7. Decentralization
Reallocation of budgetary resources
Reorientation of health professionals on PHC
Advocacy for political will and support from national leadership down to the barangay level.
Elements/Components of PHC
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 diseases
S- Safe water and sanitation
1. Reorientation and re-organization of the national health care system with the establishment of
functional support mechanism in support of the mandate of devolution under the Local
government Code of 1991
2. Effective preparation and enabling process for health action at all levels

3. Mobilization of all the people to know their communities and identifying their basic health needs
with the end in view of proving appropriate solutions (including legal measures)
4. Development and utilization of appropriate technology focusing on local indigenous resources
available in and acceptable to the community.
5. Organization of communities arising from their expressed needs which they have decided to
address and that this continually evolving in pursuit of their own development
6. Increase opportunities for community participation in local level planning, management,
monitoring and evaluation within the context of regional and national objectives
7. Development of intra-sectoral linkages with other government and private agencies so that
programs of the health sector is closely linked with those of other socio-economic sectors at the
national, intermediate and community levels.
8. Emphasizing partnership so threat the health workers and the community leaders/members view
each other as partners rather than merely providers and receiver of health care respectively.
RA 8423 or the Traditional and Alternative Medicine At of 1997 were signed into law through the
efforts of Secretary of Health Juan Flavier.
This created the Philippine Institute of Traditional and Alternative Health Care, which is tasked to
promote and advocate the use of traditional and alternative health care modalities through
scientific research and product development.

Medicinal plants
(Vitex Negundo)

Yerba Buena

The 10 medicinal plants endorsed by DOH

Asthma, cough and fever,
Decoction-boils raw fruits or leaves for
15-20 min.
dysentery, colds and pain
Decoction-boil a handful of leaves and
flower to produce a glass, three times a
Skin diseases (dermatitis,
Decoction-Wash and clean the
scabies, ulcer, eczema &
skin/wound with the prepared
decoction of leaves.
Poultice- crush leaves then apply on
Rheumatism, sprain,
Poultice- pound the leaves and apply
contusions, insect bites
on the affected area
Aromatic bath
Decoction- for sick and newly delivered
Pain (headache,
Decoction-chopped leaves are boiled in
2 glasses for 15 minutes. Drink one part
(of 2 parts) every three hours.
Rheumatism, arthritis, and
Crush leaves and squeezes sap.
Massage sap on painful parts with
Cough and colds
Infusion- soaks 10 fresh leaves in a
glass of hot water. Drink as tea
Swollen gums
Steep 6 g of fresh leaves ina glass of
boiling water for 30 minutes. Use

solution as gargle.



Menstrual and gas pain

Nausea and fainting

Insect bites



Tsaang Gubat
(Carmona retusa)

Diarrhea, stomachache

(Quisqualis indica)


(Psidium guajava L)

For washing wounds

As gargle and for

(cassia, alata L)


Anti-fungal (tinea flava,

ringworm, athletes foot,
& scabies)
Lowers blood uric acid

Soak a piece of cotton in the squeezed

sap and insert this in aching tooth
Note: gargle with salt solution before
inserting cotton
Infusion- soaks a handful of leaves in a
glass of boiling water. Drink infusion
(induces menstrual flow and sweating)
Crush leaves and apply to nostrils of
Crush leaves (paste-like) and apply juice
on affected area
Decoction- boils plant alone or with
eucalyptus in water. Use as wash on
affected area
Decoction- chopped leaves are boiled
leaves for 15 minutes until a glassful
remains. Drink one part three times a
Note: not a medicine for kidney
Decoction chopped leaves are boiled
in 2 glasses of water for 15 minutes until
1 glass remains. Coll and filter/strain
The seeds are taken 2 hours after
supper. If no worms are expelled, the
dose may be repeated after one week.
Not to be given to children below 4 years
Dose: adult (8-10 seeds), 7-12 y/o (6-7),
6-8 y/o (5-6), and 4-5 y/o (4-5)
May be used twice a day
May be taken 3-4 times a day
Chopped guava leaves are boiled for
15minutes (low fire, dont cover
pot). Warm decoction is used for
Freshly pounded leaves are used for
Fresh matured leaves are pounded.
Apply as soap to the affected area 12 times a day
One and a half cup leaves are boiled



(rheumatism and gout)

in 2 glasses of water.

Lower cholesterol,

Lower blood sugar levels

Diabetes mellitus (mild
non-insulin dependent)

May be fried, roasted, soaked in

vinegar for 30 minutes, or blanched
in boiled water for 15 minutes
Chopped 6 tablespoons are boiled in
2 glasses of water for 15minutes
under low fire (dont cover pot).
Take 1/3 cup three times a day after
cup of blanched/steamed leaves
can be eaten 2x/day


A method of healing and health promotion that uses the application of
pressure on acupuncture points without puncturing the skin
A method of healing using special needles to puncture and stimulate
specific anatomical points on the body
The art and science of the sense of smell whereby essential aromatic
oils are combined and then applied to the body in some form of
A discipline of the healing arts concerned with the pathogenesis,
diagnosis, therapy, and prophylaxis of functional disturbances,
pathomechanical states, pain syndromes, and neurophysiological
effects related to the static and dynamics of the locomotor system,
especially of the spine and pelvis.
Finished, labeled, medicinal products that contain as active ingredients
aerial or underground parts of the plant or other materials or
combination thereof, either in the crude state or as plant preparations
A method wherein the superficial soft parts of the body are rubbed,
stroked, kneaded, or tapped for remedial, aesthetic, hygienic, or limited
Nutritional therapy
The use of food as medicine and to improve health by enhancing the
nutritional value of food components that reduces the risk of a disease.
It is synonymous with nutritional healing
Pranic healing
A holistic approach of healing that follows the principle of balancing
The application of therapeutic pressure on the bodys reflex points to
enhance the bodys reflex points to enhance the bodys natural healing
mechanisms and balance body functions. It is based on the principle
that internal glands and organs can be influenced by properly applying
pressure to the corresponding reflex area on the body.



Focus client
Focus of care
Decision-making process
Setting for services


Family and community

Promotive and preventive through
community participation
Community centered/consultativeparticipative
Rural-based satellite clinics,
community health centers, health
posts that are accessible to all
Development and preventive care

Curative, provided by health
Health worker driven
Reliance on health professionals
to restore/regain health
Mostly urban-based; hospitals,
Absence of disease

Levels of health care and referral system

1. Primary level of care
Primary care is developed to the cities and the municipalities. It is health care provided by center
physicians, public health nurses, rural health midwives, barangay health workers, traditional healers
and others at the barangay health stations and rural health units. The primary health facility is usually
the first contact between the community members and the other levels of health facility.
2. Secondary level of care
Secondary care is given by physicians with basic health training. This is usually given in health facilities
either privately owned or government operated such as infirmaries, municipal and district hospitals
and out-patient departments of provincial hospitals. This serve as a referral center for the primary
health facilities. Secondary facilities are capable of performing minor surgeries and perform some
simple laboratory examinations.
3. Tertiary level of care
Tertiary care is rendered by specialists in health facilities including medical centers as well as regional
and provincial hospitals, and specialized hospitals such as the Philippine Health Center. The tertiary
health facility is the referral center for the secondary care facilities. Complicated cases and intensive
care requires tertiary care and all these can be provided by the tertiary care facility.
Philippine Health Care Delivery System
Barangay Health Station
Emergency/District Hospital
Regional Health Services;
Regional Medical Centers and
Training Hospitals
Rural Health Units, Community
Provincial/City Hospitals;
National Health Services Medical
Hospitals and health center,
Provincial/City Health Service
Centers, Teaching and Training


The Ottawa Charter for Health Promotion is the name of an international agreement signed at the First
International Conference on Health Promotion, organized by the World Health Organization (WHO) and
held in Ottawa, Canada, in November 1986. It launched a series of actions among international
organizations, national governments and local communities to achieve the goal of "Health For All" by the
year 2000 and beyond through better health promotion


The Ottawa charter defines health promotion broadly, as the process of enabling people to
increase control over and to improve their health. To reach a state of complete physical, mental
and social well-being, an individual or group must be able to identify and to realize aspiration; to satisfy
needs, and to change or cope with the environment. Health is, therefore, seen as resource for everyday
life not the objective of living. Health is a positive concept emphasizing social and personal resource,
as well as physical capacities. Therefore, health promotion is not just the responsibility of the health
sector, but goes beyond healthy life-style to well-being.
The first use of the term health promotion occurred in 1945 when Henry E. Sigerist, the great medical
historian defined the four major tasks of medicine as 1) the promotion of health; 2) the prevention
of illness; 3) the restoration of the sick and 4) rehabilitation.
According to him (Henry E. Sigerist), health is promoted by providing a decent standard of living,
good labor condition, education, physical culture, means of rest and recreation . These concepts are
found in the Ottawa charter for health promotion which occurred 40 years later.
IN 1986, THE WHO, HEALTH AND WELFARE Canada and the Canadian public health association
organized an international conference on health promotion. The conference came out with what is now
popularly known as the Ottawa charter for health promotion which was adopted by 212
participants from 38 countries. Since then various charters have been issued on health promotion
but the Ottawa charter remained to be the guiding principle in health promotion efforts currently

Prerequisite for health

The fundamental condition and resources for health are listed below. Improvement in health requires a
secure foundation in these basic prerequisites
A stable eco-system,
Sustainable resources,
Social justice,
Five action areas for health promotion were identified in the charter
1. Building healthy public policy
2. Creating supportive environments
3. Strengthening community action
4. Developing personal skills
5. Re-orienting health care services toward prevention of illness and promotion of health
In order to operationalize the concept of health promotion the charter recommended the following action
1. Build health public policy
Health promotion goes beyond health care. It puts health of the agenda of policy makers in all
sectors and at all levels, directing them to be aware of the health consequence of their decision
and to accept their responsibilities for health.
Health promotion policy combines diverse but complementary approaches including legislation,
fiscal measures, taxation, and organizational change. It is a coordinated action. That leads to
health, income and social policies that foster greater equity. Joint action contributes to ensuring
safer and heals their goods and services, healthier public services, and clears, more enjoyable

Health promotion requires the identification of obstacles to the adoption of health public policies
in non-health sectors, and ways of removing them. The aim must be to make the healthier and
easier choice for policy makers as well.
2. Create supportive environments
Our societies are complex and interrelated. Health cannot be separated from other goals. The
inextricable links and between people and their environment constitutes the basis for a socioecological approach to health. The overall guiding principle for the word, nations, regions, and
communities alike, is the need to encourage reciprocal maintenance-to take care of each other,
our communities and our natural environment. The conservation of natural resources throughout
the word should be emphasized as global responsibility.
Changing patterns of life, work and leisure have a significant impact on health. Work and leisure
should be a source of health for people. The way society organizes work should help create a
society. Health promotion generates living and working condition that is safe, stimulating,
satisfying and enjoyable.
Systematic assessment of health impact of a rapidly changing environment particularly in areas of
technology, works, and energy production urbanization is essential and must be followed by
action to ensure positive benefits to health of the public. The protection of the natural and built
environments and the conservation of natural resource must be addressed in any health
promotion strategy.
3. Strengthen community action
Health promotion works through concrete and effective community action in setting priorities,
making decision, planning strategies and implementing them to achieve better health. At the heart
of this process is the empowerment of communities-their ownership and control of their own
endeavours and destinies.
4. Develop personal skill
Health promotion supports personal and social development through providing information,
education for health, and enhancing life skills. By so doing, it increase the option available to
people to exercise more control over their own health and over their environments and to make
choices conducive to health.
Enabling people to learn throughout life, to prepare themselves for all of its stage and to cope
with chronic illness and injuries is essential. Action is required through educational, professional,
commercial, and voluntary bodies, and within the institution themselves.
5. Reorient Health services
The responsibility for health promotion in health services is shared among individual; community
group, health professional, health service institutions and governments. They must work together
towards a health care system which contributes to the pursuit of health.
The WHO cites the following principles of health promotion:
1. Health promotion involves the population as a whole in the context of their everyday life, rather
than focusing on people at risk from specific diseases.
2. Health promotion is directed toward action on the determinants or cause health. This requires
a close cooperation between sectors beyond health care reflecting the diversity of condition
which influences health.
3. Health promotion combines diverse, but complementary methods or approaches, including
communication, education, legislation, fiscal development and spontaneous local activities
against health hazards.
4. Health promotion aims particularly at effective and concrete public participation. This requires
the further development of problem-defining and decision-making life skills, both individually,
and the promotion of effective participation mechanisms.
5. Health promotion is primarily a societal and political venture and not a medical services,
although health promotion. (WHO health promotion glossary 1990)
The basic strategies for health promotion were prioritized as:

1. Advocate: Health is a resource for social and developmental means, thus the dimensions that
affect these factors must be changed to encourage health.
2. Enable: Health equity must be reached where individuals must become empowered to control the
determinants that affect their health, such that they are able to reach the highest attainable quality
of life.
3. Mediate: Health promotion cannot be achieved by the health sector alone; rather its success will
depend on the collaboration of all sectors of government (social, economic, etc.) as well as
independent organizations (media, industry, etc.)


It is the basis, in part, of several nursing theories that the community health nurse may find useful.
It is the framework of the Community Assessment Tool developed by Maurer and Smith (2009)
The general system theory is applicable to the different levels of community health nurses
clientele: individuals, families, groups or aggregates, and communities.
Viewed as an open system, the client is considered as a set of interacting elements that exchange
energy, matter, or information with the external environment to exist.
The individual is a set of several dimensions physical, psychological, social, and spiritual that is
interdependent and interrelated. The family and the group or aggregate are sets or interrelated
individuals. A geographic community is composed of a set of families.
The family gets inputs of matter (e.g., food, water), energy (e.g., sunlight, electricity) and
information (news on community events, health teachings), which are resources taken from its
environment. Outputs refer to material products, energy and information that results from familys
processing (throughput) of inputs. The health practices and the health status of family members
are example of outputs. Feedbacks is information from the environment directed back to the
system, which allows the system to make the necessary adjustments for better functioning. For
example, the nurses feedback to a mother that her young child is underweight makes the mother
more conscious of her childs nutritional needs, allowing her to take remedial action .
Subsystems, the components of a system, interact to accomplish their own purpose and the
purpose for which the system exists. The family members make up its subsystems. On the other
hand, a suprasystem, such as the community, is a bigger system composed of families who
interrelate with and affect one another, whether purposely or unknowingly, making community
problems complex and multifaceted.


Social learning theory is based on the belief that learning takes place in a social context, that is,
people learn from one another and that leaning is promoted by modeling or observing other
people. It is anchored on the fact that persons are thinking beings with self-regulatory capacities,
capable of making decisions and acting according to expected consequences of their behavior. The
environment affects learning, but learning outcomes depend on the leaners individual

The nurse applies this theory in different ways: by serving as a live model (e.g., demonstrating
infant care procedures), by giving detailed verbal instructions (e.g., teaching a patient how to
collect an early morning sputum specimen), or by using print or multimedia strategies for health

An application of the social learning theory is seen in the following example. The learning process
involved is italicized. Consider the nurse teaching a group of young mothers about giving solid

food in addition to breast milk to infants who are older than 6 months. The nurse facilitates the
mothers learning through (1) catching the mothers attention though different strategies; (2)
promoting retention of learning by demonstrating step-by-step procedure of preparation of solid
food for infants (3) providing the mothers with occasions for the reproduction or imitation of the
procedures of straining,, pureeing, mashing, grinding, and chopping appropriate foods; and (4)
motivating the mothers by explaining the benefits derived from the behavior.



This theory posits a multifaceted causal structure in which self-efficacy beliefs operate together
with goals, outcome expectations, and perceived environmental impediments and facilitators in
the regulation of human motivation, behavior, and well-being.
Belief in ones efficacy to exercise control is a common pathway through which psychosocial
influences affect health functioning. This core belief affects each of the basic processes of personal
changewhether people even consider changing their health habits, whether they mobilize the
motivation and perseverance needed to succeed should they do so, their ability to recover from
setbacks and relapses, and how well they maintain the habit changes they have achieved. Human
health is a social matter, not just an individual one. A comprehensive approach to health promotion
also requires changing the practices of social systems that have widespread effects on human health
Social Cognitive Theory (SCT) is an interpersonal level theory developed by Albert Bandura that
emphasizes the dynamic interaction between people (personal factors), their behavior, and their
This interaction is demonstrated by the construct called Reciprocal Determinism. As seen in the figure
below, personal factors, environmental factors, and behavior continuously interact through influencing
and being influenced by each other.
How to use Reciprocal Determinism: Consider multiple ways to change behavior; for example,
targeting both knowledge and attitudes, and also making a change in the environment.

1. Self-Efficacy

Definition: Confidence or belief in one's ability to perform a given behavior. Self-efficacy is taskspecific, meaning that self-efficacy can increase or decrease based on the specific task at hand,
even in related areas.
Example: A study designed to determine the extent to which positive outcome expectations and
self-efficacy influenced disclosure of HIV seropositivity to sexual partners examined these aspects
of self-efficacy
. How to use it: Break down behavior change into small, measurable steps. Allow intervention
participants to recognize and celebrate small successes along the path to larger behavior change.

2. Outcome Expectations
Definition: Beliefs about the likelihood and value of the consequences of behavioral choices.
Example: A study designed to determine the extent to which positive outcome expectations and
self-efficacy influence disclosure of HIV seropositivity to sexual partners examined these outcome
How to use it: Provide both knowledge-based training and skill-based training to intervention
3. Collective Efficacy
Definition: Confidence or belief in a group's ability to perform actions to bring about desired
change. Collective efficacy is also the willingness of community members to intervene in order to
help others.
Example: A study designed to determine the relationship between neighborhood-level collective
efficacy and BMI in youth examined the degree to which respondents felt their neighborhood
How to use it: Bring people together and mobilize them to action. Develop group activities that
allow individuals to get to know each other better and increase confidence to accomplish the
desired behavior change.
4. Self-Regulation
Definition: Controlling oneself through self-monitoring, goal-setting, feedback, self-reward selfinstruction, and enlistment of social support.
Example: A study designed to explain "leisure time" physical exercise among high school students
measured self-regulation in five domains:
gaining and maintaining social support
planning to overcome barriers
securing reinforcements
How to use it: Build in goal-setting activities throughout the intervention. Work with participants
to create realistic and measurable goals. Also allow time for reflection and evaluation about success
or failure in meeting goals.

5. Facilitation/Behavioral Capability
Definition: Providing tools, resources, or environmental changes that make new behaviors easier
to perform.
Example: The Minnesota Smoking Prevention Program evaluated sixth grade students' behavioral
capability to resist positive images of smoking. This was more clearly defined as one's ability to

identify, evaluate the truthfulness, and reject favorable images of smoking presented through
media and adult modeling.
How to use it: Provide both knowledge-based training and skill-based training to intervention

6. Observational Learning
Definition: Beliefs based on observing similar individuals or role models perform a new behavior.
Example: A church-based intervention, designed to increase physical activity and healthy eating
behaviors, ensured that the church's minister participated in walking clubs. He was seen as a role
model for other participants, because he grew up in the community and was now a well-known
leader. His involvement with the program was key to encouraging church members to change their
How to use it: Provide credible role models who reflect the target population and perform the
desired behavior.
7. Incentive Motivation
Definition: The use and misuse of rewards and punishments to modify behavior.
Example: As part of efforts to increase mammography screening rates, a number of
studies/programs have offered cash prizes, small gifts, as well as coupons for food in
exchange for attendance at screening visits.
How to use it: Determine what kind of incentives would motivate participants to
participate in the intervention. Offer options, as not all participants may be motivated by
the same incentives
8. Moral Disengagement
Definition: Ways of thinking about harmful behaviors and the people who are harmed that
make infliction of suffering acceptable by disengaging self-regulatory moral standards.

Example: Terrorism is an example of destructive conduct which has been made personally
and socially acceptable by the terrorist who portrays their actions as serving a moral
purpose. This self-framing then allows the individual to act on a moral imperative [7].
How to use it: Re-engage self-regulatory moral standards by illuminating possible
dehumanization and diffusion of responsibility onto others


Initially proposed in 1958, the health belief model (HBM) provides the basis for much of the
practice of health education and health promotion today. The HBM was developed by a group of
social psychologists to explain why the public failed to participate in screening for tuberculosis.
Hochbaum and his associates had the same questions that perplex many health professionals
today: why do people who may have a disease reject health screening? Why do individuals
participate in screening if it may lead to the diagnosis of disease? Through their work, this group
found that information alone is rarely enough to motivate one to act. Individuals must know what to
do and how to do it before they can take action. Also, the information must relate in some way to
the individuals needs. One of the most widely used conceptual frameworks in health behavior, the

HBM, has been used to explain behavior change and maintenance of behavior change and to
guide health promotion interventions.

Kurt Lewins works lent itself to the models core dimension. He proposed that behavior is based
on current dynamics confronting individual rather than prior experiences.
The HBM is based on the assumption that the major determinant of preventive health
behavior is disease avoidance. The concept of disease avoidance includes perceived
susceptibility to disease X, perceived seriousness of diseased X, modifying factors, cues to
action, perceived benefits minus perceived barriers to preventative health action, perceived threat
of disease X, and the likelihood of taking a recommended health action. Disease X represents a
particular disorder that a health action may prevent.
For example, a cue to action in the prevention of dengue fever may be provided through an
information campaign, making people in a barangay aware of the occurrence of the disease in the
community. One of the campaign objectives should be to make the people understand that
everyone is susceptible to the disease and that the disease is serious and may be fatal. In situations
such as this, HBM may be applied by the nurse to assist clients in making necessary behavior
modifications precisely by making them conscious of the need for such modification.
A major limitation of the HBM is that it places the burden of action exclusively on the client. It
assumes that only those clients who have distorted or negative perceptions of the specified disease
or recommended health action will fail to act.

Perceived susceptibility
Perceived severity
Perceived benefits

Ones belief regarding the chance of getting a
given condition
Ones belief regarding the seriousness of a
given condition
Ones belief in the ability of an advised action
to reduce the health risk or seriousness of a
given condition

Perceived barriers

Ones belief regarding the tangible and

psychological costs of an advised action

Cues to action

Strategies or conditions in ones environment

that activate readiness to take action
Ones confidence in ones ability to take action
to reduce health risks



Provides a complement to the HBM and provides mechanism for directing attention upstream and
examining opportunities for nursing intervention at the population level.
Nancy Milio outlined six propositions that relate an individuals ability to improve healthful
behavior to a societys ability to provide accessible and socially affirming options for healthy
choices. She noted that the range of variable health choices is critical in shaping a societys
overall health status. In addition; she stated that policy decisions in government and private
organizations shape he range of choices available to individuals. She believed that national-level
policy making was the best way to favorably impact the health of most people rather than

concentrating efforts on imparting information in an effort to change an individual patterns of

Applications for Milios framework in Public Health Nursing (Milio 1976)
Milios proposition summary
Population health examples
Population health deficits result from
Individuals and families living in poverty have poorer health status
deprivation and/or excess of critical
compared with middle and upper class individuals and families.
health resources
Behaviors of populations results from
Positive and negative lifestyle choices (smoking, alcohol use, safe
selection from limited choices; these
sec practices, regular exercise, diet/nutrition, seatbelt use) are
arise from actual and perceived options strongly dependent on culture, socioeconomic status and
available as well as beliefs and
educational level.
expectations resulting from
socialization, education and
Organizational decisions and policies
Health insurance coverage and availability are largely determined
(both governmental and nonand financed by the government through the National health
governmental) dictate many of the
Insurance Corporation (Phil Health) and private insurance (out-ofoptions available to individuals and
pocket expense by patients or provided by employers); the source
populations and influence choices
and funding of insurance influences health provider choices and
Individual choices relate to health
Choices and behaviors of individuals are strongly influenced by
promotion or health damaging
desires, values and beliefs. For example, the use of illegal drugs by
behaviors are influenced by behaviors
adolescents is often dependent on peer pressure and the need for
are influenced by efforts to maximize
acceptance, love and belonging
valued resources.
Alteration in patterns of behavior
Some behaviors such as tobacco use have become difficult to
resulting from decision making of a
maintain in many settings or situations in response to
significant number of people in a
organizational and public policy mandates
population can result in social change
Without concurrent availability of
Addressing persistent health problems (e.g., hypertension is
alternative health-promoting options
hindered because most people are very aware of what causes the
for investment of personal resources,
problem, but are reluctant to make lifestyle changes to prevent or
health education will largely ineffective reverse the condition. Often, new information (e.g., a new diet) or
in changing behavior patterns.
resources (new medication) can assist in attracting attention and
directing positive behavioral changes.


It provides a model for community assessment, health education planning, and evaluation
Green defined health education as any combination of learning experience designed to facilitate
voluntary adoptions behaviors conducive to health. Green et al 1980
The PRECEDEPROCEED model is a costbenefit evaluation framework proposed in 1974 by Dr.
Lawrence W. Green, that can help health program planners, policy makers, and other evaluators
analyze situations and design health programs efficiently.


In this model, predisposing factors refer to peoples characteristics that motivate them toward
health-related behavior (attitudes, beliefs, values). Enabling factors refer to conditions in people and
environment that facilitate or impede health-related behavior (skills, availability, accessibility,
referrals). Reinforcing factors refer to feedback given by support person or groups resulting from the
performance of the health related behaviors (support from family, peers, teachers, employers, health
care provider)

It provides a comprehensive structure for assessing health and quality of life needs, and for designing,
implementing, and evaluating health promotion and other public health programs to meet those
One purpose and guiding principle of the PRECEDEPROCEED model is to direct initial attention to
outcomes, rather than inputs. It guides planners through a process that starts with desired outcomes
and then works backwards in the causal chain to identify a mix of strategies for achieving those
A fundamental assumption of the model is the active participation of its intended audience that is,
that the participants ("consumers") will take an active part in defining their own problems,
establishing their goals, and developing their solutions.
in this framework, health behavior is regarded as being influenced by both individual and
environmental factors, and hence has two distinct parts. First is an "educational diagnosis"
PRECEDE, an acronym for Predisposing, Reinforcing and Enabling Constructs in Educational
Diagnosis and Evaluation. Second is an "ecological diagnosis"
PROCEED, for Policy, Regulatory, and Organizational Constructs in Educational and
Environmental Development. The model is multidimensional and is founded in the social/behavioral
sciences, epidemiology, administration, and education. The systematic use of the framework in a
series of clinical and field trials confirmed the utility and predictive validity of the model as a planning
tool (e.g. Green, Levine, & Deeds)

Phase 1-Social Diagnosis
Phase 2-Epidemiological Behavioral & Environmental Diagnosis
Phase 3-Educational & Ecological Diagnosis
Phase 4-Administrative & Policy Diagnosis

Phase 5-Imlementation
Phase 6-Process Evaluation
Phase 7-Impact Evaluation
Phase 8-Outcome Evaluation

Phase 1 social diagnosis

Defined by community in terms of unemployment, days lost from work or school, family disruption,
and other dimension of their quality of life.
The first stage in the program planning phase deals with identifying and evaluating the social
problems that have an impact on the quality of life of a population of interest . Social assessment is the
"application, through broad participation, of multiple sources of information, both objective and

subjective, designed to expand the mutual understanding of people regarding their aspirations for the
common good".
During this stage, the program planners try to gain an understanding of the social problems that affect
the quality of life of the community and its members, their strengths, weaknesses, and resources; and
their readiness to change. This is done through various activities such as developing a planning
committee, holding community forums, and conducting focus groups, surveys, and/or interviews.
These activities will engage the audience in the planning process and the planners will be able to see
the issues just as the community sees those problems.

Phase 2 epidemiological, behavioral, and environmental diagnosis

a. Epidemiological diagnosis
Defined by health professionals in terms of morbidity, mortality, fertility, ets.
Epidemiological assessment deals with determining and focusing on specific health
issue(s) of the community, and the behavioral and environmental factors related to
prioritized health needs of the community. Based on these priorities, achievable program
goals and objectives for the program being developed are then established.
Epidemiological assessment may include secondary data analysis or original data
collection. Examples of epidemiological data include vital statistics, state and national
health surveys, medical and administrative records etc. Genetic factors, although not
directly changeable through a health promotion program, are becoming increasingly
important in understanding health problems and counseling people with genetic risks, or
may be useful in identifying high-risk groups for intervention.
b. Behavioral diagnosis
Each behavior is defined in terms of timing, frequency, quality, range, and duration
This is the analysis of behavioral links to the goals or problems that are identified in the social or
epidemiological diagnosis. The behavioral ascertainment of a health issue is understood firstly
through those behaviors that exemplify the severity of the disease (e.g. tobacco use among
teenagers). Secondly, through the behavior of the individuals who directly affect the individual at risk
for example parents of the teenagers who keep cigarettes at home . Thirdly, through the actions of
the decision-makers that affects the environment of the individuals at risk, such as law enforcement
actions that restrict the teen's access to cigarettes. Once behavioral diagnosis is completed for each
health problem identified, the planner is able to develop more specific and effective interventions.

c. Environmental diagnosis
This is a parallel analysis of social and physical environmental factors other than specific actions that
could be linked to behaviors. In this assessment, environmental factors beyond the control of the
individual are modified to influence the health outcome. For example, poor nutritional status among
school children may be due to the availability of unhealthful foods in school. This may require not
only educational interventions, but also additional strategies such as influencing the behaviors of the
school's food service managers.

Phase 3 educational and ecological diagnosis

These factors need to be analyzes for each behavior
Once the behavioral and environmental factors are identified and interventions are selected, planners
can start to work on selecting factors that if modified will be most likely to result in behavior change,
and can sustain this change process. These factors are classified as predisposing factors, enabling
factors, and reinforcing factors.
a. Predisposing factors are any characteristics of a person or population that motivates behavior
prior to or during the occurrence of that behavior. They include an individual's knowledge,
beliefs, values, and attitudes.

b. Enabling factors are those characteristics of the environment that facilitate action and any skill or
resource required to attain specific behavior. They include programs, services, availability and
accessibility of resources, or new skills required to enable behavior change.
c. Reinforcing factors are rewards or punishments following or anticipated as a consequence of a
behavior. They serve to strengthen the motivation for behavior. Some of the reinforcing factors
include social support, peer support, etc.
Phase 4 administrative and policy diagnosis
Interventions are matched with educational and behavioral objectives from steps 3 and 4, budgeted,
sequenced, and coordinated
This phase focuses on the administrative and organizational concerns, which must be addressed prior
to program implementation. This includes assessment of resources, development and allocation of
budget, looking at organizational barriers, and coordination of the program with all other
departments, including external organizations and the community. These are detailed further in
Green & Ottoson.
a. Administrative Diagnosis assesses policies, resources, circumstances, prevailing organizational
situations that could hinder or facilitate the development of the health program.
b. Policy Diagnosis assesses the compatibility of the program goals and objectives with those of the
organization and its administration. This evaluates whether the program goals fit into the mission
statements, rules and regulations that are needed for the implementation and sustainability of the
Phase 5 implementation of the program
This phase Involves doing just that setting up and implementing the intervention youve planned.
Phase 6 process evaluation
This phase is used to evaluate the process by which the program is being implemented. This phase
determines whether the program is being implemented according to the protocol, and determines
whether the objectives of the program are being met. It also helps identify modifications that may be
needed to improve the program.
Phase 7 impact evaluation
This phase measures the effectiveness of the program with regards to the intermediate objectives as
well as the changes in predisposing, enabling, and reinforcing factors. Often this phase is used to
evaluate the performance of educators.
Phase 8 outcome evaluation
This phase measures change in terms of overall objectives and changes in health and social benefits
or the quality of life. That is, it determines the effect the program had in the health and quality of life
of the community.


The Health Promotion Model was designed by Nola J. Pender to be a "complementary counterpart to
models of health protection." It defines health as a positive dynamic state rather than simply the absence
of disease. Health promotion is directed at increasing a patient's level of well-being. The health promotion
model describes the multidimensional nature of persons as they interact within their environment to
pursue health.

Developed in the 1980s and revised in 1996, Penders HPM explores many bio psychosocial factors
that influence individuals to pursue health promotion activities. The HPM depicts the complex

multidimensional factors with which people interact as they work to achieve optimum health. This
model contains seven variables related to health behavior outcome.
Pender's model focuses on three areas: individual characteristics and experiences, behavior-specific
cognitions and affect, and behavioral outcomes.
The theory notes that each person has unique personal characteristics and experiences that affect
subsequent actions. The set of variables for behavior specific knowledge and affect have important
motivational significance. The variables can be modified through nursing actions.
Health promoting behavior is the desired behavioral outcome, which makes it the end point in the
Health Promotion Model. These behaviors should result in improved health, enhanced functional
ability and better quality of life at all stages of development.
The final behavioral demand is also influenced by the immediate competing demand and preferences,
which can derail intended actions for promoting health.
The major concepts of the Health Promotion Model are individual characteristics and experiences,
prior behavior, and the frequency of the similar behavior in the past. Direct and indirect effects on the
likelihood of engaging in health-promoting behaviors.

The Health Promotion Model makes four assumptions:

1. Individuals seek to actively regulate their own behavior.
2. Individuals, in all their bio psychosocial complexity, interact with the environment, progressively
transforming the environment as well as being transformed over time.
3. Health professionals, such as nurses, constitute a part of the interpersonal environment, which
exerts influence on people through their life span.
4. Self-initiated reconfiguration of the person-environment interactive patterns is essential to
changing behavior.
There are thirteen theoretical statements that come from the model. They provide a basis for
investigative work on health behaviors. The statements are:
1. Individual characteristics and experiences
Each persons unique characteristics and experiences affect his or her actions. Their
effect depends on the behavior in question.
2. Prior related behavior
Prior behaviors influence subsequent behavior through perceived self-efficacy,
benefits, and barriers, related to that activity. Habit is also a strong indicator of future
3. Personal factors
Personal factors that may influence behavior are biological factors such as age, body
mass index, strength and agility; psychosocial factors include self-esteem, selfmotivation, and perceived health status; sociocultural factors include race, ethnicity,
acculturation, education, and socioeconomic status.
4. Behavior-specific cognitions and affect
In the HPM, these variables are considered to be very 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.
5. Perceived benefits action

The perceived benefits of a behavior are strong motivators of that behavior. These
motivate 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.
6. Perceived barriers
Barriers are perceived unavailability, inconvenience, expense, difficulty or time
regarding health behaviors.

7. Perceived self-efficacy
Self-efficacy is ones belief that he or she is capable of carrying out a health behavior. If
one has high self-efficacy regarding a behavior, one is more likely to engage in that
behavior than if one4 has a low efficacy.
8. Activity-related affect
The feelings associated with a behavior will likely affect whether an individual will
repeat or maintain the behavior.
9. Interpersonal influences
In the HPM, these are feelings or thoughts regarding the beliefs and attitudes of others.
Primary influences are family, peers, and health care providers.
10. Situational influences
These are perceived options available, demand characteristics, and aesthetic features
of the environment where the behavior will take place. For example, lovely days will
increase the probability of one taking a walk; the fire code will prevent one from
smoking indoors.
11. Commitment to a plan of action
Pender states that commitment to a plan of action initiates a behavior. This
commitment will compel one into the behavior until completed, unless a competing
demand or preference intervenes.
12. Immediate competing demands and preferences
These are alternative behaviors that one considers as possible optional behaviors
immediately prior to engaging in the intended, planned behavior. One has little control
over competing demands, but ine has great control ovr competing preferences.
13. Health-promoting behavior
This is the goal or outcome of the HPM. The aim of health-promoting behavior is the
attainment of positive health outcomes.


The TTM is based on the assumptions that behavior change takes place over time, progressing
through a sequence of stages. It also assumes that each of the stages is both stable and open to
change. In other words, one may stop in one stage, progress to the next or return to the previous
Change is difficult, even for the most motivated individuals. People resist change for many reasons.
change may:
1. Be unpleasant (exercising)
2. Requiring giving up pleasure (eating desserts or watching TV)
3. Be painful (undergoing insulin injections)

4. Be stressful (eating new foods)

5. Jeopardize social relationships (meeting new friends and family during gatherings involving
6. Not seem important any more (among older individuals r those with the ill effects of lifestyle
choices such as diabetes an hypertension)
7. Require change in self-image (from being a couch potato to an athlete)
Stages of change
1. Pre-contemplation

2. contemplation
3. preparation
4. action
5. maintenance
Decisional balance

The individual has no intention to take action toward behavior
change in the next 6 months. May be in this phase due to lack
information about the consequences of the behavior or due to
failure on previous attempts at change
The individual has some intention to take action toward behavior
change in the next 6 months. Weighing pros and cons to change
The individual intends to take action within the next month and has
taken steps toward behavior change. Has a plan of action
. The individual has changed overt behavior for less than 6 months.
Has changed behavior sufficiently to reduce risk of disease.
The individual has changed overt behavior for more than 6 months.
Strives to prevent relapse. This phase may last months to years
The benefits of behavior change
The cost of behavior change

Preventive Approach to health

Health promotion activities enhance resources directed at improving well being
Disease Prevention activities protect people from disease and the effects of disease and the effect of the

Three levels of Prevention (Leavell and Clark;)

The terms primary, secondary and tertiary prevention were first documented in the late 1940s by Hugh
Leavell and E. Guerney Clark from the Harvard and Columbia University Schools of Public Health,
respectively. Pioneers in Public Health thinking at that time, Leavell and Clark described the principles
of prevention within the context of the Public Health triad of Host, Agent and Environment commonly
referred to as the epidemiologic triangle model of Causation of diseases.
Relates to activities directed at preventing a problem before it occurs by altering
susceptibility or reducing exposure for susceptible individuals. Primary prevention consists
of two elements: general health promotion and specific protection. Health promotion
efforts enhance resiliency and protective factors and target essentially well populations.
Seeks to prevent a disease or condition at a pre-pathologic state; to stop something from
ever happening.
Examples: promotion of good nutrition, provision of adequate shelter, and encouraging
regular exercise. Specific protection efforts reduce or eliminate risk factors and include
such measures as immunization and water purification.
Health Promotion
health education

marriage counseling
genetic screening
good standard of nutrition adjusted to developmental phase of life
Specific Protection
use of specific immunization
attention to personal hygiene
use of environmental sanitation
protection against occupational hazards
protection from accidents
use of specific nutrients
protections from carcinogens
avoidance to allergens

Individual: dietary teaching during pregnancy, immunizations

Family: education or counseling regarding smoking, dental care, or nutrition, adequate
Group or aggregate: mothers class on breastfeeding, education for drug abuse prevention
for high school students.
Community and population fluoride water supplementation, environmental sanitation,
removal of environmental hazards.
Also known as Health Maintenance. Seeks to identify specific illnesses or conditions at
an early stage with prompt intervention to prevent or limit disability; to prevent
catastrophic effects that could occur if proper attention and treatment are not provided
Early Diagnosis and Prompt Treatment
case finding measures
individual and mass screening survey
prevent spread of communicable disease
prevent complication and sequelae
shorten period of disability
Disability Limitations
Adequate treatment to arrest disease process and prevent further complication and
Provision of facilities to limit disability and prevent death.
3. Tertiary Prevention
Occurs after a disease or disability has occurred and the recovery process has begun;
Intent is to halt the disease or injury process and assist the person in obtaining an optimal
health status. To establish a high-level wellness. To maximize use of remaining capacities

Restoration and Rehabilitation

Work therapy in hospital
Use of shelter colony


It is the development of the communitys collective capacities to solve its own problems and aspire
for development through its own efforts.
It is a process of educating and mobilizing members of the community to enable them to resolve
community problems.

It is a process by which the people, health service and agencies of the community are brought
together to: learn about the common problems; identify these problems as their own; plan the kind
of action to solve problems; and act on this basis.
Studies have underscored some key elements of the community which may be reactivated to bring
social and behaviour change. These include social organization (relationship, structure, structure
and resource), ideology (knowledge, beliefs and attitudes) and change agents. This process of
change is often termed as empowerment or building capability of people for future community

The emphases of community organizing in primary health care are the following:
1. People from the community working together to solve their own problems.
2. Internal organizations consolidation as a pre-requisite to external expansion
3. Social movement first before technical change
4. Health reforms occurring within the context of broader social transformation
Basic values in community organizing
1. Human rights- are universally held principles anchored mainly on the belief in the worth and
dignity of people; these includes the right to life, self-determination, ad development as a persons
and as a people.
2. Social justice- means equitable access to opportunities for satisfying peoples basic needs and
dignity; it requires an equitable distribution of resources and power through peoples participation
in their own development.
3. Social responsibility- is premised on the belief that people as social beings must not limit
themselves to their own concerns but should reach out to and moves jointly with others in meting
common needs and problems; society has the responsibility to ensure an environment for the
fullest development of its members.
1. Community organizing is people centered
Emphasis on the development of human resources necessitating education. The
educational are interactive empowering both the learners and the teacher, leading to
decision making that plays a part in human development.
Community organizing is a process that promotes the development of peoples
autonomy and self-reliance, leading to people empowerment. The organizer serves
as a facilitator or mentor who guides the community through the process. The people
take the lead, make decisions for them, and participate in process that affects their
2. Community organizing is participative
The participation of the community in the entire process-assessment, planning,
implementation and evaluation-should be ensured.
The community is considered as the prime mover and determinant, rather than
beneficiaries and recipients, of development efforts, including health care. Throughout the
steps of community organizing, te organizer must bear in mind that the community is active
participant, learning more form what is said to them. For people empowerment
community participation is a critical; condition for success.
3. Community organizing is democratic
CO should empower the disadvantaged population. It is a process that allows the majority
of people to recognize and critically analyze their difficulties and articulate their
aspirations. Hence, their decisions must reflect the will of the whole more so hat will of the
common people, than that of the leaders and the elite.

4. Community organizing is developmental

CO should be directed towards changing current undesirable conditions. The organizer
desires changes for the betterment of the community shares these aspirations and that
these changes can be achieved.
CO affords empowerment of the marginalized people. Through the process, community
gains insights, hones their capacities, and develops their confidence in themselves and in
each other that will allow them to take the lead in the holistic improvement of their
5. Community organizing is process oriented
CO goals of empowerment and development are achieved through a process of change.
Organizers need to diligently and patiently follow the community organizing process to
achieve its goals. Allowing the community to internalize and embrace the process requires
Goals of community organizing
1. Peoples empowerment
2. Building relatively permanent structures and peoples organizations
3. Improved quality of life

PHASES OF COMMUNITY ORGANIZING (University of Santo Tomas NSTP, 2012)

1. PRE-ENTRY PHASE (area of selection/ocular survey, profiling of community)


Pre entry involves preparation on the part of the organizer and choosing a community for
Preparation includes knowing the goals of the community organizing activity or experience . It may
also be necessary to delineate criteria or guidelines for site selection . Making a list of sources of
information and possible facility resources, both government and private, is recommended.
Skills in community organizing are developed on the job or through an experiential approach.
Novice community organizers, such as student nurses on their related leaning experience, are
therefore not unusual. For the novice organizers, preparation includes a study or reviews of the
basic concepts of community organizing. Although the affective domain is not easy to change, selfexamination helps the organizer identify attitudes both positive and negative that may influence
effectiveness. Positive attitudes include belief in peoples capacity for change and selfdetermination and readiness for hard work and team, effort.
Communities may be identified through different means: initial data gathered through an ocular
survey; review of records of a health facility; a review of the barangay/municipal profile, and soon;
referral from other communities or institutions or through a series of meetings or consultations
from the local government unit (LGUs) or private institutions.
An ocular survey done at this stage may provide answers to essential questions that should include
the following:
Does the community meet the GIDA criterion of the Department of Health? That is, is the
community geographically isolated and in a disadvantaged area? In other words, is it hard to
reach, unserved or undeserved, and economically depressed?
Do the members of the community perceived the need for assistance? Note that resistance or
reluctance among some community members is to be expected; therefore, the organizer must take
this as a challenge in the community organizing process
Does the community show signs of the willingness or hostility towards the organizer or the
organizing agency?
Is there no obvious threat to the safety of the community organizer?

5. Are there other individuals, groups, or agencies working in the area? If so, are they using the
community organizing approach? Will there be a duplication of services for the same target group?
6. Is the partnership among all potential stakeholders (the community, the LGU, and other external
agencies) possible and feasible?
Entry into the community formalizes the start of the organizing process. This is the stage where the
organizer gets to know the community and the community likewise gets to know the organizer.
An important point to remember during this phase is to make courtesy calls to local formal
leaders (mayor and municipal council, barangay chairperson, council members, etc.). equally
crucial but often overlooked is a visit to informal ;leaders recognized in the community , like
the elders, local health workers, traditional healers, church ;leaders, and local neighborhood
association leaders. They are also contact persons who may facilitate the subsequent phases of the
organizing process.
Considerations in the entry phase
As much as we endeavor to get to know and understand the community we are working with, it is
also the community organizers responsibility to clearly introduce themselves and their institution
to the community. A clear explanation of the vision, mission, goals, programs, and activities must
be given in all initial meetings and contacts with the community .
The community organizer must have a basic understanding of the target community. Preparation
for the initial visit includes gathering basic information on socioeconomic conditions, traditions
including religious practices, overall physical environment, general health and illness patterns, and
available health resources. An informal meeting with contacts who have been to the area or some
residents from the community prior to entry will be useful.
People must take care to avoid raising unrealistic expectations in the community. The community
organizer must keep in mind that the goal of the process is to build up the confidence and
capacities of people. Manalili (1990) describes two strategies for gaining entry into a community,
which tend to be counterproductive to the goals of community organizing.
A. The first he describes as the padrino entry where the organizers gains entry into the
community through a padrino or patron, usually a barangay or some other local government
official. In meetings or assemblies with the people, the padrino, in an effort to boost the
organizers image, tends to present the intended project output, thereby creating false hopes.
B. Manalili calls the second strategy as the bongga entry that is seen as the easiest way to catch
the attention and gain approval of the community. This strategy exploits the peoples
weaknesses and usually involves dole-outs, such as free medicines. In addition to creating
unreasonable expectations, the bongga entry reinforces a dole-out mentality, which contradicts
the essence of community organizing.


Community integration, termed as pakikipamuhay, is the phase when the organizer may actually
live in the community better and imbibe community life. The establishment of rapport between the
organizer and the people indicates successful integration.
If the organizers are working for the poor, then they must live and work with the poor. Thus
integration frequently requires immersion in community life. This stage of community organizing
is a gradual process. At this time, the organizer must consciously discard the visitor or guest
image. Respect for community culture and traditions are of utmost importance.
Integration styles
Manlili (1990) describes the following styles of integration:
Now you see, now you dont style. The organizer visits the community as per the schedule but
is not able transcend the guest status.

Boarder style. The organizer rents a room or a house in the village, lives his/her own life and
does not share the life of community.
Elicit style. The organizer lives the barangay chairman or some other prominent person in the
community of local officials. This style makes integration with the larger community difficult.

People-centered approach in integration

The organizers enter the community with a well-conceived plan. They establish contact with
villagers who become their allies. With its emphasis on being where the people are, this approach allows
the organizers to develop a deeper relationship with the whole community through various techniques,
such as those described subsequently in this chapter. This is the approach that is recommended to
guarantee success of the organizing work. The following techniques suggested by Manalili (1990) facilitate
community integration.
Pagbabahay-bahay or occasional home visits. This is an effective way of developing a close
relationship with the community.
Huntahan. Informal conversations help a lot in integrating with the community. It can be done in a
variety of venues, such as village poso during laundry time, basketball court and sari-sari store.
Participation in the production process. The organizer participates in livelihood activities, such
as farming in an agricultural community. This practice allows the organizer to share the daily
experiences of the ordinary people in the community.
Participation in social activities. Social functions and activities help the organizer and the people
to get to know each other through face-to-face encounters. These are fiestas, weddings, baptismal
celebrations, funeral wakes, and other activities that carry social meaning and other importance for
the community.
Social analysis
Social analysis is the process of gathering, collating and analyzing data to gain extensive
understanding of community conditions, help in the identification of problems of the community,
and determine the root causes of these problems. This process is also referred to as social
investigation; community study, community analysis, or community needs assessment.
In nursing practice, it is often called community diagnosis, with emphasis given to health and
health-related problems.
This step requires a comprehensive analysis of the following factors:
1. Demographic data
2. Sociocultural data
3. Economic data
4. Environmental data
5. Data on health patterns (morbidity, mortality, fertility),
6. Data on health resources.
Identifying potential leaders
Since organizing is not a job of one person, it is imperative that the organizer identifies partners and
potential leaders who will help lead the people. Community integration and community study allow
the organizer to have frequent interactions with individuals, families, and/or groups in the
community. These interactions provide the organizer with opportunity to identify prospective allies
in the organizing efforts, particularly credible and influential members of the community who have
expressed willingness to participate in community activities.
The following are other desirable characteristics of potential leaders:
They represent the target group/community. For example, a school teacher cannot be the leader of
a farmers group unless he/she is involved in farming activities. The organizer must also bear in

mind that local officials (e.g., the barangay chairman or council members) do not necessarily
represent the entire community.
They possess or display leadership qualities
They have the trust and confidence of the community.
The express belief in the need to change the current undesirable situation in the community, that
change is possible, and that change must begin with the members of the community.
They are willing to invest time and effort for community organizing work
They must have potential management skills.

Core group formation

As the organizer works with potential leaders, the membership of the group is expanded, as
necessary, by asking them to invite one or two of their neighbors or friends. These new recruits
must also be from the community, sharing the same problems the group seeks to correct, while at
the same time believing in the same core values, principles, and strategies the group is employing.
Keeping the group size manageable, between 8 and 12 members, facilitates arriving at a consensus.
However, a very small core group may be overwhelmed by the tasks required for them.
Community organization
Through various means of information dissemination, the core group, with the assistance of the
organizer, instills awareness of common concerns among other members of the community.
Subsequently, on the initiative of the core group, the community conducts an assembly or a series
of assemblies, with the goals of arriving at a common understanding of community concerns and
formulating a plan of action in dealing with these concerns .

Collective decision making must dictate what projects and strategy must be undertaken. The
organizer must remember that it is their project to be done in their community. The organizer must
let them decide. If the community decides to formalize the organization, it must have the following
An organizational name and structure
A set officers reorganized by the members of the community
Constitution and bylaws stating the vision, mission, and goals (VMG), rules and regulations of the
organization, and duties and responsibilities of its officers and members.

Also known as the mobilization phase, the action phase refers to implementation of the
communitys planned projects and programs.
Important considerations during the mobilization phase are as follows:
1. Allow the community to determine the pace and scope of project implementation. The community
may start with simple barangay projects, such as Tapat Ko Linis Ko or clean and green. As the
organization gains experience and develops, it will move toward more complex programs like
coastal resource management or a community material recovery facility.
2. The process is as important as the output. A project may fail, but as long as the community gains
valuable experience and learns from the process, it is not a failure itself.
3. Regular monitoring and continuing community formation program are essential. Throughout the
mobilization phase, regular meetings are conducted for monitoring and continuous training for
community leaders.

Evaluation is a systematic, critical analysis of the current state of the organization and/or
projects compared to desired or planned goals or objectives. Ideally, evaluation is done
periodically during mobilization (i.e., formative evaluation) to allow revision of strategies
when needed and at the end of the prescribed project period (i.e., summative evaluation).
In community organizing, there are two major areas of evaluation:
1. Program-based evaluation
2. Organizational evaluation
Areas of evaluation and general evaluation parameters
Area of evaluation
General evaluation parameters
Were the goals and objectives of the program/project achieved?
What strategies were implemented? What worked? What did not?
What is the overall impact of the project on the community?
How were the resources of the organization and community utilized?
Were the vision, mission, and goals of the organization achieved?
How are the organizational policies being implemented?
What is the level of participation in the affairs of the community
How were the resources of the organization utilized and managed?
What type of interpersonal relationship is shared among the members
of the organization, among the leaders, and the members of the
community organization?
From the start, the organizer must have a clear vision of the end with a general time frame
in mind. As articulated by Manalili (1990), the best entry plan is an exit plan. The time
required for community organizing depends on the diligence of the organizer and the
acceptance by the community. The time of exit should be mutually determined by the
organizer and the community during a meeting for monitoring and evaluation.
During the exit phase, the organizer may start exploring another community to organize
that is, expanding to another area, while expanding to another area, the organizer stays in
touch with the first community, periodically visiting, not so much as an organizer but as a
friendly consultant.

Indications of readiness for exit by the community organizer should include:

Attainment of the set goals of the community organizing efforts
Demonstration of the capacity of the peoples organization to lead the community in dealing with
common problems, and
People empowerment as manifested by collective involvement in decision making and community
action on matters that impact their lives.


Area selection
Profiling of community

Entry and integration

Social preparation
Spotting and developing potential leaders
Core group of formation
Setting up of community organization
Community diagnosis
Training of health workers
Health services mobilization
Leadership formation activities
Inter-sectoral collaboration
Sourcing out of external resources
Coordination with external institutions, agencies and people
Gradual preparation for turnover of work
Planning for monitoring

Phases of COPAR (by Matt E. Vera)

COPAR has four phases namely: Pre-Entry Phase, Entry Phase, Organization-building phase, and
sustenance and strengthening phase.
1. Pre-Entry Phase
Is the initial phase of the organizing process where the community organizer looks for communities to
serve and help. Activities include:
Preparation of the Institution
Train faculty and students in COPAR.
Formulate plans for institutionalizing COPAR.
Revise/enrich curriculum and immersion program.
Coordinate participants of other departments.
Site Selection
Initial networking with local government.
Conduct preliminary special investigation.
Make long/short list of potential communities.
Do ocular survey of listed communities.
Criteria for Initial Site Selection
Must have a population of 100-200 families.
Economically depressed. No strong resistance from the community.
No serious peace and order problem.
No similar group or organization holding the same program.
Identifying Potential Municipalities
Make long/short list of potential municipalities
Identifying Potential Community
Do the same process as in selecting municipality.
Consult key informants and residents.
Coordinate with local government and NGOs for future activities.
Choosing Final Community

Conduct informal interviews with community residents and key informants.

Determine the need of the program in the community.
Take note of political development.
Develop community profiles for secondary data.
Develop survey tools.
Pay courtesy call to community leaders.
Choose foster families based on guidelines
Identifying Host Family
House is strategically located in the community.
Should not belong to the rich segment.
Respected by both formal and informal leaders.
Neighbors are not hesitant to enter the house.
No member of the host family should be moving out in the community.
2. Entry Phase

Sometimes called the social preparation phase. Is crucial in determining which strategies for
organizing would suit the chosen community. Success of the activities depends on how much the
community organizers have integrated with the community.

Guidelines for Entry

Recognize the role of local authorities by paying them visits to inform their presence and activities.
Her appearance, speech, behavior and lifestyle should be in keeping with those of the community
residents without disregard of their being role model.
Avoid raising the consciousness of the community residents; adopt a low-key profile.
Activities in the Entry Phase
Integration. Establishing rapport with the people in continuing effort to imbibe community life.
o living with the community
o seek out to converse with people where they usually congregate
o lend a hand in household chores
o avoid gambling and drinking
Deepening social investigation/community study
o verification and enrichment of data collected from initial survey
o conduct baseline survey by students, results relayed through community assembly
Core Group Formation
Leader spotting through sociogram.
o Key Persons. Approached by most people
o Opinion Leader. Approached by key persons
o Isolates. Never or hardly consulted
3. Organization-building Phase

Entails the formation of more formal structure and the inclusion of more formal procedure of
planning, implementing, and evaluating community-wise activities. It is at this phase where the
organized leaders or groups are being given training (formal, informal, OJT) to develop their style in
managing their own concerns/programs.

Key Activities
Community Health Organization (CHO)
o preparation of legal requirements
o guidelines in the organization of the CHO by the core group
o election of officers

Research Team Committee

Planning Committee
Health Committee Organization
Formation of by-laws by the CHO
4. Sustenance and Strengthening Phase

Occurs when the community organization has already been established and the community
members are already actively participating in community-wide undertakings. At this point, the
different committees setup in the organization-building phase is already expected to be
functioning by way of planning, implementing and evaluating their own programs, with the overall
guidance from the community-wide organization.

Key Activities
Training of CHO for monitoring and implementing of community health program.
Identification of secondary leaders.
Linkaging and networking.
Conduct of mobilization on health and development concerns.
Implementation of livelihood projects.

COPAR-Community Organizing
Participatory Action Research

Participatory action research (PAR) is an approach to research that aims at promoting change
among the participants. Members of the group being studied participate as partners in all phase of
the research, including design, data collection, analysis and dissemination.
It was around the mid-1990s when PAR was first introduced. It is a utilized mostly in social
psychology that encourage researches and those who will benefit from the research (families,
providers, policy makers) to work together as full partners in all phases of the research.
Community Organizing Participatory Action Research (COPAR) is a community development
that allows the community (participatory) to systematically analyze the situation, and implement
projects/programs (action) utilizing the process of community organizing. It is essentially a
research project done by the community that leads to actions to improve conditions in the
Both COPAR and traditional research approach in nursing endeavor using methods of scientific
inquiry; however, they differ in certain ways.
For COPAR to succeed, the nurse-researcher must be able to adopt methodologies that are
creative interesting and easy to apply at the community level. Strategies that are informal, provide
fun, utilize local resources, and create excitement among the people are plus factors.
The major role of the nurse in COPAR is to facilitate and guide the community in the critical
assessment of the situation.
Comparison of traditional research approach and COPAR

Points of comparison
Decision making

Traditional research approach

Expert/nurse-driven process

Community-driven process




Much premium is placed on the

data and output.

Premium is placed on the


Nurse as researcher: the community

members are subjects or objects of
research, usually respondents of the
research instrument.
Data analysis is done by the nurse,
and then presented to the
Research tools and methodologies
are predetermined/prepackaged by
the nurse-organizer.

Community members as
researches: the nurse is a
facilitator and recorder.
Data analysis is done collective
by the community.

Upon completion, the study is

packaged, submitted to the agency,
and published. Recommendations
are made by the researcher based
on the finding of the study.

Conclusions and
recommendations are made by
the community. These will lead
to agreed community
actions/projects. The whole
research cycle continues until
it becomes part of community
life, leading towards
community development.
Community members
formulate the

Research tools and

methodologies are identified
and developed by the

Who is the Community Organizer?

Basic qualities of a Community Organizer
A community organizer is someone who:
Has exemplary professional and moral qualities
Possess good communication/facilitation skills to be able to call and lead small group
discussions/training and community meetings.
Has the ability to set good leadership examples for the community to emulate.
Displays a charismatic personality that draws people towards the organizing work and community
Adopts and enjoys working with and living with all types of communities/people.
Can empathize with the people or community he/she is working with.
Believes in the vision of change, empowerment, and development
Has a personal conviction consistent with the values and principles being advocated.

Transect walk

Participatory data-gathering methods for COPAR

For making an ocular survey, the nurse asks a group from the community to
come along and join. The nurse requests the community members to take the


lead in the inspection (pasyal), asks them critical questions about the
community, and allows them to analyze and draw conclusions.
The nurse asks some members to draw a detailed map of the community
emphasizing certain aspects of the community such as:
Resource Map depending on its purpose, this may show the sources of their
livelihood, such as farming areas, what specific plants are planted in particular
areas of the community, fishing grounds, grazing area, and water sources. A
resource map may also show physical resources, such as health centers,
barangay health stations, churches/chapels, basketball courts, ad barangay halls
Healthy Map health worker respondents (barangay health workers or the
midwife) may draw a spot map of the community, highlighting households with
identified health problems, such as malnutrition, tuberculosis, diabetes, and
diarrhea. Households with vulnerable members such as pregnant mother,
infants, differently abled persons, or elderly may also be indicated.
Seasonal Map or Calendar people are asked to make a calendar showing
various activities and events significant to the community. It may focus on
livelihood (planting season, harvest season, fishing season), social events (fiesta,
Christmas, religious activities), or it may be a historical mapping of significant
disasters that the community has experienced (floods, drought, fire, food
shortage, etc.)
Mapping allows the people to view their community from a different perspective
and provides them with insights as to how they can deal effectively with
community concerns.

Venn diagram

This method focuses on relationships within the community and between the
community and outside groups or agencies.
The community is asked to draw a big circle representing their community, with
smaller circles inside the big circle signifying organizations or groups in the
community, they are instructed to draw at the center the circle of the most active
or influential organization or group. Smaller circles outside the big circle stand
for institutions or organizations-government or private-outside their community.
The proximity or distance of the outside circles in relation to the big circles
symbolizes the outside institutions degree of support and influence among their
The diagram provides the community with a visual representation of the social
support systems, particularly of the groups that actively support community
efforts in various capacities. The diagram also provides a clear idea of social
resources that can be tapped for the future efforts.





Community health purposes and goals are realized through the application of a series of steps that
lead to desired results.
The nursing process is a systematic, scientific, dynamic, on-going interpersonal process in which
the nurses and the clients are viewed as a system with each affecting the other and both being
affected by the factors within the behavior.
Steps in Community Health Nursing Process
1. Assessment of community health needs
2. Planning of community health nursing services
3. Implementing the community health nursing services
4. Evaluating community health nursing services
5. Reporting and Recording


Initiate contact
Demonstrate caring attitudes
Build Mutual trust and confidence
Collect data from all possible sources
Identify health problems
Assess coping abilities
Analyze and interpret data
Components of community needs assessment

Health status
Health resources
Health action potential

Collection of Data
Relevant data are collected on the health status of the family, groups and community:
demographic data, vital health statistics, community dynamics including power structure, studies
of disease surveillance, economic, cultural and environmental characteristics, utilization of health
services by the population: and on individual and families: health status, education, socio
cultural, religious and occupational background, family dynamics, environment and patterns of
Various methods are employed to collect data: community surveys: interview of individuals,
families, groups and significant others: observation of health-related behaviors of individuals,
family groups and environmental factors: review statistics, epidemiological and relevant studies:

individual and family health records: laboratory and screening tests and physical examinations of
These data are collected systematically and continuously, then are recorded in appropriate forms
and kept systematically so that retrieval of information is facilitated. Collected data are treated

Categories of Health Problems

1. Health deficits, health threats and foreseeable crisis or stress points are categories of health
problems. The public health nurse analyses the data in accordance with the nurses conception of
the source of the clients problems and needs that can be met through nursing intervention. The
nursing diagnoses are interpreted and validated with individuals, members of the community and
family groups concerned. Their capabilities and limitations to cope are identified.



1. Health deficit
Are instances of failure in health maintenance
Occurs when there is a gap between actual and achievable health status. Exploration and
evaluation of possible precursors of health deficits such as history or repeated, infections
or miscarriages are noted. No regular health check-up is another example.
2. Health threats
Are conditions that are conducive to disease, accident or failure
Are conditions that promote diseases or injury and prevent p[people form realizing their
health potential. An example of a health threat is when the population is adequately
immunized against preventable diseases.
3. Foreseeable crisis/Stress Points
Are anticipated periods of unusual demand on the individual or family in terms of
adjustment/family resources
Includes stressful occurrences such as death or illness of a family member.
4. Wellness conditions
Wellness potential is a nursing judgment on wellness state but no explicit expression of
client desire.
Readiness for enhanced wellness state is a judgment on wellness state based on current
competencies and performance, clinical data and explicit expression of desire to achieve
higher level of functioning or state.

A health need exists when theres a health problem that can be alleviated with medical or social the
A health problem is a situation in which there is a demonstrated health need combined with actual or
potential resources to apply remedial measures and a commitment to act on the part of the provider or the
Inability to recognize the presence of the condition or problem
Inability to make decisions with respect taking appropriate health action.
Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at-risk
member of the family.

Inability to provide home environment conducive to health maintenance and personal

Inability to utilize community resources for health care.

Criteria for ranking health conditions and problem according to priorities:

1. Nature of the condition or problem presented
Health deficit (3)
Health threat (2)
Foreseeable crisis (1)
2. Modifiability of the condition or problem (probability of success)
Easily (2)
Partially (1)
Non-modifiable (0)
3. Preventive potential
High (3)
Moderate (2)
Low (1)
4. Salience (perception or evaluation of seriousness and urgency by the client)
Needing immediate attention (2)
Not needing immediate attention (1)
Not perceived as a problem or condition needing change (0)
The process of assessment in community health nursing includes intensive fact finding, the application
of professional judgment in estimating the meaning and importance of these facts to the family and the
community, the availability of nursing resources that can be provided, and the degree of-change which
nursing intervention can be expected to effect.


An in-depth process in finding out the profiles, health status of the community and the factors
affecting the preset status
According to WHO definition, it is a quantitative and qualitative description of the health of
citizens and the factors which influence their health. It identifies problems, proposes areas for
improvement and stimulates action


1. Comprehensive
2. Problem oriented or focused
A. Preparation for Community Diagnosis
1. Identify the barangay to survey or required by the health center
2. Ocular survey
a. Courtesy call on the barangay captain; kagawad for health
b. Identification key of leaders and barangay health workers
c. Conduct ocular survey of a few households
d. Start preparing the spot map
3. Community assembly
a. Inform people of purpose of presence in the barangay
b. Disseminate initial findings specially presence of infectious diseases in the area: explaining
its mode of transmission; signs and symptoms

B. Data Gathering (spot map, key informant interview, community survey, records review)
Conduct of survey proper using the format/survey form
1. Random Sampling or saturation
Random sampling-10% of population, employ one group
Saturation-house to house survey; to chek total population and determine true picture of
barangay; employ several groups.
2. Guidelines in filling survey
3. Data collection techniques
It is important that you must decide the needed data for your community analysis. Data
can be collected or obtained from the health center, NSO, City or Municipal Hall
planning division and barangay hall or other resources within the said community.
a. Key information approach, same as grape-vine approach
Certain individuals or key informants by virtue of their experience, profession or elected
officers who can contribute valuable information on issues pertaining to health needs of the
b. Steps in the process includes:
B.1. identify characteristics of key informants likely to have an insight into issues understudy
B.2. Select potential key informants, and make initial contact
B.3. Determine specific information you wish to obtain, and specific questions you to ask]
B.4. Administer instruments like interview, mailing, telephone, etc.
B.5. Tabulate data collected and draw conclusions
C. Data presentation
Make graph or chart of each data gathered
D. Problem Identification (1st & 2nd level assessment, problem prioritization)
Data Analysis and Interpretation
E. Preparation of action plan/project plan
Note: The problem mostly encountered during the coduuct of the survey is uncooperative community. To
address such problem, do activities to attract the community, example; BP taking, weight taking,
temperature taking, go around the area carrying placards to inform presence of infectious diseases,
explaining mode of transmission, signs & symptoms, its prevention and management
Rationale: accurate, valid, timely and relevant information on the community profile and health
problems are essential so that the communities limited resource can be maximized. And because
of inherent difference among communities, relevant data can best be gathered thru communitybased approach.
Purpose; to analyze the data in order to develop responsive intervention strategies that address
the root cause of the problem.
Statement of Objectives:
General objective: statement of what are to be accomplished to attain the study
Specific Objectives: statements of what are to be accomplished to the general objectives or goals
Methodology and tool used: a description of the adoption, construction and administration of
Limitation of the study: state any limitations that exist in the reference or given population/area
of assignment.
1. Geographic identifiers

a. Historical background- includes description of past population, location or proximity to

metropolitan area, organizational chart of barangay, relationship to surrounding
communities and other pertinent data
b. Describe the location, boundaries, total population, physical features, climate (seasonal
change), medium of communication, and means of transportation and resource (e.g.,
hospital, market, school, health centers etc.) available in the community
c. Create spot map
Note: The North should always be located on the top, legends and color coding are used to indicate house
interviewed, and resources of the community such as markets, barangay hall, church, communal water
source, public toilets. Health centers, stores and other land marks.
2. Population profile
a. Total estimated population of barangay (based on NSO)
b. Population density (PD)
PD= Total No. of population x 1000
Total No. of square meters
c. Total population of the area surveyed
d. Total of families surveyed
e. Total number of household surveyed
3. Socio-demographic profile
a. Total population of families surveyed
b. Total population surveyed
c. Total number of households surveyed
d. Age and sex distribution
e. Sex ration (SR)
SR= No of males x 100
No. of females
f. Dependency ratio (DR)
DR= No of population 0-14 + 65 y.o & above
Population 15-64 years old
g. Civil status
h. Types of families
i. Religious distribution
j. Place of origin
k. Length of residency
4. Socio-economic indicators
a. Educational attainment
b. Literacy rate
LR= No of population 8 years above who can read and write
Total number of population 8 years old and above
c. Occupation
d. Income
e. Housing condition
f. Ventilation
5. Environmental indicators
a. water supply
b. Excreta disposal
c. Garbage disposal
d. Others: Pet ownership: Domestic animals (pig, dog, birds, cats) er family surveyed
6. Health profile
a. Food storage


Infant feeding practices

Immunization status of children (0-12 mos)
Community facilities and resources
Health seeking behaviors/Awareness of medical/dental services utilized commonly used
by the community people
f. Communication resource
g. Family planning
7. Morbidity and Mortality data
a. Leading cause of morbidity
b. Leading cause of mortality
c. Leading cause of infant mortality
d. Leading cause of maternal mortality
1. Identification of health problems
2. Prioritized problems identified
1. Intervention strategies
2. Review of related literature, if any regarding possible solutions to the health problems
3. Specific activities to be done
4. Gantt chart of activities to be done
5. Budget
NOTE: include the following: spot map, survey questionnaire, definition of terms, forms (lab results),
letters (endorsement from local health Department, Brgy. Captain), photographs, GANT chart or group
activities, Organizational chart of Barangay Officials, health center, list of student group members and
other pertinent data for documentation.



Demography (from prefix demo- from Ancient Greek dmos, meaning "the people",
and -graphy from graph, implies "writing, description or measurement".
It is the statistical study of populations, especially human beings. As a very general science,
it can analyze any kind of dynamic living population, i.e., one that changes over time or
space (see population dynamics).
Demography encompasses the study of the size, structure, and distribution of these
populations, and spatial or temporal changes in them in response to birth, migration,
ageing, and death.
Components of demography
a. Describing population size
b. Describing population composition
c. Describing spatial distribution
Population size
Population size is the actual number of individuals in a population. Population density is a
measurement of population size per unit area, i.e., population size divided by total land area.
Population composition
Population composition is the description of a population according to characteristics such as age, sex,
race and marital status. These data are often compared over time using population pyramids.
Spatial distribution


A spatial distribution is the arrangement of a phenomenon across the Earth's surface and a graphical
display of such an arrangement is an important tool in geographical and environmental statistics.
Birth, death and migration are called demographic component as well as the determining elements of
population change because they affect the situation of population. Therefore, the size of population
depends mainly upon birth, death and migration
Births are affected by fertility, death by mortality and migration by the process of migration. In this way,
fertility is related to the population growth and mortality to the population decrease. Similarly,
migration is also related to the population change due to the incoming and outgoing migration.
Marriage also causes the migration of women. The mentioned fertility, mortality and migration are
called demographic processes. These processes also cause the change in population size,
composition and distribution
Demographic measures are the actual changes in size, composition and distribution due to changes in
demographic components like birth, death and migration, as a result of their respective processes like
rate of fertility, mortality and migration. Demographic measures are enumerated by applying specific
formulas for specific type of measurement.
Fertility refers to the reproductive function. It is the ability to bear offspring. It is the production of live
birth which starts when a women gives the first birth. Its period is generally 15-49 years of age.
Likewise, fecundity is the psychological capacity to participate in reproduction. It starts with the
regulation of monthly menstrual cycle. Fertility results in birth. It is measured by the actual number of


Statistics refers to a systematic approach of obtaining, organizing and analyzing
Numerical facts so that conclusion may be drawn from them.
Vital Statistics refers to the systematic study of vital events such as births,
Illnesses, marriages, divorce, separation and deaths.
Statistics of disease (morbidity) and death (mortality) indicate the status of health of community
and the success or failure of health work.
Statistics on population and the characteristics such as age and sex, distribution are obtained from
the National Statistics Office (NSO).
Births and Deaths are registered in the Office of the Local Civil Registrar of the Municipality or
city. In cities, births and deaths are registered at the City health Department.
Uses of Vital Statistics:
Indices of the health and illness status of a community
Serves as basis for planning, implementing, monitoring and evaluating
Community health nursing programs and services
Sources of Data:
Population census
Registration of Vital data
Health Survey
Studies and researches
Rates and Ratios:
Rate show the relationship between a vital event and those persons exposed to the occurrence of said
event, within a given area and during a specified unit of time, it is evident that the person experiencing the

event. (Numerator) must come from the total population exposed to the risk of same event
Ratio is used to describe the relationship between two (2) numerical quantities or measures of events
without taking particular consideration of the time or place. These quantities need not necessarily
represent the same entities, although the unit of measure must be the same for both numerator and
denominator of the ratio.
Crude or General Rates referred to the total living population. It must be presumed that the total
population was exposed to the risk of the occurrence of the event.
Specific Rate the relationship is for a specific population class or group. It limits the occurrence of the
event to the portion of the population definitely exposed to it.
Crude Birth Rate a measure of one characteristic of the natural growth or increase of a population.
Total No. Of live births registered in a
Given calendar year
CBR= ----------------------------------------x 1,000
Estimated population as of July 1 of same year
Crude Death Rate a measure of one mortality from all causes which may result in a decrease of

Total No. of deaths registered in a given calendar year

------------------------------------------- x 1000
Estimated population as of July 1 of same year

Infant mortality Rate measure the risk of dying during the 1st year of life. It is a good index of the
general health condition of a community since it reflects the changes in the environment and medical
condition of a community.
Total No. Of death under 1 year of age registered in a given calendar year
IMR= -----------------------------------------------------------x 1,000
Total No. Of registered live births of same calendar year
Maternal Mortality Rate measures the risk of dying from cause related to pregnancy, childbirth and
puerperium. It is an index of the obstetrical care needed and received by women in a community.
Total No. of deaths from maternal causes Registered for a given year
MMR = --------------------------------------------------------x 1,000
Total No. Of live births registered of same year
Fetal Death Rate measures pregnancy wastage. Death of the product of conception occurs prior to its
complete expulsion, irrespective of duration of pregnancy.
Total No. Of Fetal Deaths registered in a given calendar year
FDR = -----------------------------------------------------------x 1,000
Total No. Of live births registered on same year
Neonatal Death Rate measures the risk of dying the 1st month of life. It serves as an index of the effects
of prenatal care and obstetrical management of the newborn.
No. Of Deaths under 28 days of age registered in a given calendar year
NDR = -----------------------------------------------------------x 1,000

No. Of live births registered of same year

Specific Death Rate describes more accurately the risk of exposure of certain classes or group to
particular diseases. To understand the forces of mortality, the rates should be made specific provided the
data are available for both the population and the event in their specification. Specific rates render more
comparable and thus reveal the problem of public health
Deaths in specific class / group registered in a given calendar year
Specific Death Rate = ------------------------------------x 100,000
Estimated population as of July 1 in same
Specified class / group of said year
No. Of death from specific cause registered in a given year
Cause Specific Death Rate = -----------------------------------x 100,000
Estimated population as of July 1 st of same year
No. Of death in a particular age group registered in a given calendar year
Age Specific Death Rate = -------------------------------------x 100,000
Estimate population as of July 1 st in same age group of same year
No. Of death of a certain sex registered in a given calendar year
Sex Specific Death Rate = -------------------------------------x 100,000
Estimate population as of July 1 st in same sex for same year
Incidence Rate measures the frequency of occurrence of the phenomenon during a given period of time
No. of new cases of a particular disease registered during a specified period of time
IR = -------------------------------------------------------x 100,000
Population at Risk
Prevalence Rate measures the proportion of the population which exhibits a particular disease at a
particular time. This can only be determined following a survey of the population concerned, deals with
total (new and old) number of cases
No. Of new and old of a certain disease registered at a given time
PR= --------------------------------------------------------x 100
Total No. Of person examined at same time at given time
Attack Rate a more accurate measure of the risk of exposure
No. Of person acquiring a disease registered in a given year
AR = -------------------------------------------------------x 100
No. Of exposed to same disease in the same year
Proportionate Mortality (Death Ratios) shows the numerical relationship between deaths from all
causes (or group of causes), age (or group of age) etc., and the total no. Of deaths from all causes in all
ages taken together
No. of registered deaths from specific cause or age for a given calendar year
PM= --------------------------------------------------------x 100
No. of registration deaths from all causes all ages in same year

Adjusted or Standardized Rate

To render the of 2 communities comparable, adjustment for the differences in age, sex, race and any other
factor which influence vital events have to be made.
By applying observed specific rates to some standard population
By applying specific rates of standard population group of the local population
Case Fatality Ratio - index of a killing power of a disease and is influence by incomplete reporting and
poor morbidity data.
No. of registered deaths from specific disease for a given year
CFR= -------------------------------------------------------x 100
No. of registered cases from same specific disease in same year
Presentation of Data
Observations of events in the community are presented in the form of tables, charts and graphs.
The following are most commonly used graph in presenting Data:

Line or curved graphs - show peaks, valleys and seasonal trends. Also used to show the trends of
birth and death rates over a period of time;
Bar graphs - each bar represent or express a quantity in terms of rate or percentages of a particular
observation like causes of illness and deaths.
Area Diagram - (Pie Charts) shows the relative importance of parts to the whole.

Functions of the Nurse:

Collects data
Tabulates data
Analyzes and interprets data
Evaluates data
Recommends redirection and / or strengthening of specific areas of health programs as needed.
Epidemiology is the study of occurrences and distribution of diseases as well as the
distribution and determinants of health state or events in specified population, and the
application of this study to the control of health problems. This emphasizes that epidemiologist
are concerned not only with deaths, illness and disability, but also with more positive health
states and with the means to improve health.
Two main areas of investigation are concerned in the definition, the study of the distribution
of disease and the search for the determinants (causes) of the disease and its observed
d. The first area describes the distribution of health status in terms of age, gender,
race, geography to health and diseases.
e. The second area involves explanation of the patterns of disease distribution. In
terms of causal factors. Many disciplines seek to learn about the causes of the
diseases; the special contribution of epidemiology is its search for concordance
between the known or suspected causes of the disease and the known patterns to
investigate for possible causal roles.

Consequently, we speak of the epidemiology of heart disease, measles or accidents because each
disease has the same elements; the disease determinants, the human population in which the
disease occurs, and the distribution of the disease in the population.
Epidemiology therefore is the backbone of the prevention of the disease. In order to control a
disease effectively, the condition surrounding its occurrence and the favoring the development of
the disease must first be known.

Uses of Epidemiology:
According to Morris, epidemiology is used to:
Study the history of the health population and the rise and fall of diseases and changes in their
Diagnose the health of the community and the condition of people to measure the distribution and
dimension of illness in term of incidence , prevalence, disability and mortality, to set health
problems in perspective and to define their relative importance and to identify groups needing
special attention.
Study the work of health services with a view of improving them. Operational research show how
community expectation can result in the actual provision of service.
Estimate the risk of disease, accident, defects and the chances of avoiding them
Identify syndromes by describing the distribution and association of clinical phenomena in the
Complete the clinical picture of chronic disease and describe their natural history
Search for causes of health and disease by comparing the experience of groups that are clearly
defined by their composition, inheritance, experience, behaviour and environment.

Models of Disease Causation

1. Epidemiologic triad or triangle model



Figure 4- The Epidemiology Triangle

The Epidemiology Triangle
The Epidemiology Triangle consists of three component- host, environment and agent. The
model implies that each must be analysed and understood for comprehensions and prediction of
patterns of a disease a change in any of the component will alter an existing equilibrium to increase
or decrease the frequency of the disease.


We focus on human and the forces within him and within the environment that influence his state
of health. From this view point, the human is the host organism, other organism like animals are
considered only as they relate to the human health. The host is any organism the harbors and
provides nourishment for another organism.
Agent is the intrinsic property of microorganism to survive and multiply in the environment to
produce disease. Causative agent is the infectious agent or its toxic component that is transmitted
from the source of infection to the susceptible body.
The state of the host at any given time is a result of the interaction of genetic endowment with
environment over the entire lifespan. Environment is the sum total of all external condition and
influences that affects the development of an organism which can be biological, social and
physical. The environment affects both the agent and the host.

Three components of the environment:

1. Physical environment - is composed of the inanimate surrounding such as the geophysical
condition of the climate.
2. Biological environment-makes up the living things around us such as plants and animal life.
3. Socio economic environment- which may be in the form of level of economic development of
the community, presence of social disruption and the like.
2. Wheel model of disease causation
Is basically the same as that of the triad, but is gives emphasis on the role of the genetic
make-up of the host that is presented as the inner core of the wheels hub. The outer core
of the hub includes host characteristics like sex, age, socioeconomic status, and behaviors.
The rim of the outer edge represents the biologic, physical, and chemical environment.
Approach to Disease and its Determinants
The present epidemiology approach is based on the interaction of the host, the causative agent, and the
environment. Essentially, epidemiology patterns depend upon these factors which influence the
probability of contact between an infectious agent and a susceptible host.
The presence of infectious materials varies with the duration and the extent of its excretion from an
infected person the climatic conditions affecting survival of the agent, route of entry into the host and the
existence of alternative reservoirs or host of the agent. The availability of susceptible host depend upon
the extend mobility and interpersonal contact within the population group, and the degree and duration of
immunity from previous infection with the same or related agent.
Classification of Agents, Host and Environmental Factors which determine the occurrence of Disease in
Human Population
1. Agent of disease
Etiological factors:
A. Nutritive elements
Vitamins, proteins
B. Chemical agent
Carbon monoxide, drugs
Ragweed, poison ivy
C. Physical agent
Heat, light, ionizing radiation
D. Infectious agents
Hookworm, schistosomiasis
Amoeba Malaria
Rheumatic fever, lobar
Pneumonia, typhoid


Histoplasmosis, athletes foot

Rocky Mountain, spotted fever
Measles, mumps, chicken pox
Poliomyelitis, rabies

2. Host factors (Intrinsic factors) - influences exposure, susceptibility or response to agent

A. Genetic
Sickle cell disease
B. Age
C. Sex
D. Ethnic group
E. Physiologic
Fatigue , pregnancy , puberty, stress
F. Immunologic
Prior infection, immunization
Maternal antibodies, gammaglobulin
G. Inter-current or pre-existing
H. Human behaviour

Personal hygiene, food handling

3. Environmental factors (Extrinsic Factors)-influences existence of the agent, exposure , or

susceptibility to agent
A. Physical environment
B. Biologic Environment
Human population

Geology, climate

Sources of food, influence as source
of agent
C. Socio-economic environment
Exposure to chemical agents
Urban crowding, tension and pressures
Wars, disasters
Disease Distribution
The methods and technique of epidemiology are desired to detect the cause of a disease in relation to the
characteristic of the person who has it or to a factor present in his environment. Since neither population
and environment of different times or places are similar, these characteristics and factor are called
Epidemiology variables. These variables are studied since they determine the individual and population
at greatest risks of acquiring particular disease, and knowledge of these associations may have predictive
For the purpose of analyzing epidemiology data, it has been found helpful to organize that data according
to the variables of time, person and place;
1. Time - refers both to the period during which the cases of the disease being studied were exposed to
the source of infection and the period during which the illness occurred. The common practice is to
record the temporal occurrence of disease according to date, when appropriate, the hour of onset of
symptoms. Subsequently, all similar cases are grouped or examined for various span of time: An
epidemic period, a year, or a number of consecutive years. This analysis of cases by time enables the

formulation of hypotheses concerning time and source of infection, mode of transmission, and
causative agent.
Epidemic period: a period during which the reported number of cases of a disease exceed the
expected or usual number for that period.
Year: For many diseases the incidence (Frequency of occurrence) is not uniform during each of 12
consecutive months. Instead, the frequency is greater in one season the any of the others. This
seasonal variation is associated with variation in the risk of exposure of susceptible to the source of
Period of Consecutive years: recording the reported cases of a disease over a period of year-by
weeks, months or year of occurrence-useful in predicting the probable future incidence of the
disease and in planning appropriate prevention and control programs.
2. Person- refers to the characteristics of the individual who were exposed and who contacted the
infection or the disease in question. Person can be described in terms of their inherent or their
acquired characteristics (such as age, race sex, practices, customs); and the circumstances under
which they live (social, economic and environmental condition).
Age: for most diseases, there is more variation in disease frequency by age than any other variableand for this reason age is considered the single most useful variable associated in describing the
occurrence and distribution of disease. This usefulness is largely a consequence of the association
between a person age and their:
a) Potential for exposure to a source of infection
b) Level of immunity or resistance
c) Physiologic activity at the tissue level (which sects the manifestation of a disease subsequent to
Sex and occupation: In general, males experience higher mortality rates than female for a wide
range of diseases. It is the female however who have higher morbidity rates. This is also because of
differing pattern of behaviour between sexes or activities as recreation, travel, occupation which
result in different opportunities for exposure to a source of infection
Place- refers to the features, factor or conditions which existed in or described the environment in
which the disease occurred. It is the geographic area described in terms of street, address, city,
municipality, province, region or country. The association of a disease with a place implies that the
factors of greatest etiologic importance are present either in the inhabitants or in the environment
or both.
Urban / Rural Differences: in general, disease spreads more rapidly in urban areas than in
rural areas primarily because of the greater population density of urban area rural provides
more opportunities for susceptible individual to come into contact with a source of infection.
Socio-economic areas: different communities can be usually divided into geographic areas
which are relatively homogenous with respect to the socio-eco-economic circumstances of
the residents. It commonly has been observed that the incidence rate of many diseases, both
communicable and chronic, varies inversely with differences in large geographic areas within
a country; geographic variations in the incidence of infectious diseases commonly results from
variation in the geographic distribution of the reservoirs or vectors of the disease or in the
ecological requirement of the disease agent.
Patterns of Occurrence and Distribution
The variables of disease as to person, time and place are reflected in distinct pattern of occurrence and
distribution in a given community. Distinct patterns are recognized as: sporadic, endemic and epidemic
occurrences. The following are the characteristic features of those patterns of disease occurrence;


1. Sporadic --occurrence in the Philippines. In a given year, there are few unrelated cases in a given
locality. The cases are few and scattered, so that there is no apparent relationship between them
and they occur on and off, intermittently, through a period of time.
Rabies occurs sporadically in the Philippine. In a given year, there are few
Cases during certain weeks of the year, while there are no cases at all during
The other weeks. During the week when the few cases are occurring, the
Cases are scattered throughout the country, so that the cases are not related at all to the cases in
other area.
2. Endemic - occurrence is the continuous occurrence throughout a period of time, of the usual
number of cases in a given locality. The disease is therefore always occurring in the locality and the
level of occurrence is more or less constant through a period of time. The level of occurrence
maybe low or high when the given level is continuously maintained, then the pattern maybe low
endemic or high endemic as the case maybe. The disease is more or less inherent in that locality, it
is in a way already identifiable with the locality itself.
Fox example: Schistosomiasis is endemic in Leyte and Samar, Filariasis is
Endemic in Sorsogon, Tuberculosis is endemic practically in all specific areas of the country
3. Epidemic-- occurrence is of unusually large number of cases in relatively short period of time. The
is a disproportion ate relationship between the number of cases and the period of occurrence, the
more acute is the disproportion, The more urgent and serious is the problem. The number of cases
is not in itself necessarily big or large, but such number of cases when compared with the usual
number of cases may constitute an epidemic in a given locality, as long as that number is so much
more than the usual number in that locality . It is therefore not the absolute largeness of the
number of cases but its relative largeness in comparison with the usual number of cases which
determine s an epidemic occurrence.
Fox example, there has been no case of birds flu in any
Area of the country, so that the occurrence of few cases in a given area in a/Given time would
constitute a birds flu epidemic
4. Pandemic is the simultaneous of epidemic of the same disease in several countries. It is another
pattern of occurrence from an international perspective.
Of the pattern of occurrence of disease, epidemic is the most interesting and meaningful as it
demands immediate effective action which includes epidemiological investigation emergency
epidemiology as well as control.
Factors Contributory to epidemic Occurrence:
1. Agent factor the result of the introduction of new disease agent into the population. It may also
result from changes in the number of living microorganisms in the immediate environment or from
their growth in some favorable culture medium.
2. Host Factors are related to lower resistance as a result of exposure to the elements during floods of
other disaster, to relaxed supervision of water and milk supply or sewage disposal, or to change habit
of eating. Further, the host factor may be related to change in immunity and susceptibility to
population density and movement, crowding, to sexual habits, personal hygiene or to changes in
motivation as a result of health education.
3. Environmental Factors changes in the physical environment; temperature, Humidity, rainfall may
directly or indirectly influence equilibrium of agent and host.
Outline of Plan for Epidemiology Investigation
1. Establish fact of presence of epidemic

Verify Diagnosis do clinical and laboratory studies to confirm he date

Is the disease that which is reported to be?
Are all the cases due to the same disease?
Is it reasonably complete?
Is it prompt enough so the present situation?
Is there an unusual prevalence of the disease?
Post experience of a given community
Relation to nature of disease
Which cases may be considered epidemic and which are endemic?
2. Establish time and space relationship of the disease
Are the cases limited to or concentrated in any particular geographical subdivision of the affected
Relation of cases by days of onset of the first known cases maybe done by days, week or months.
3. Relation to characteristic of the group of community
Relation of cases to age, group, sex, color, occupation school attendance, past immunization, etc.
Relation of sanitary facilities, especially water supply, sewerage disposal, general sanitation of
homes, relation to animal or insect vectors.
Relation to milk and food supply
Relation of cases and known carries if any

4. Correlation of all data obtained

Summarize the data clearly with the aid of such tables and charts which are
Necessary to give a clear picture of the situation
Build up the cases for the final conclusion carefully utilizing all the evidence available.
Establish the source of the epidemic and the manner of the spread, if possible.
Make suggestion as to the control, if disease is still present in community and as to prevention of
future outbreaks.

Epidemiology and Surveillance Units

Epidemiology and Surveillance units have been established in regional and some local office as
support to the public health system. As an epidemiologic information service, the unit is mainly
responsible for providing timely and accurate information on diseases in the locality. Such
information will be used mainly as basis for identifying health problems, allocation of resources
and other discussion in health care.
Among its responsibilities include:
a. Surveillance of infectious diseases with outbreak potential
b. Assisting local government units in investigation of outbreak and their control
c. Developing information package on public health
d. Providing technical assistance related to epidemiology
For the team to carry out their duties and responsibilities, it is imperative that
They have the knowledge and skills in infection disease epidemiology and surveillance.

Public Health Surveillance

Public Health Surveillance is an on-going systematic collection, analysis interpretation and

dissemination of health data.

Surveillance system is often considered information loops or cycles involving health care provider,
public health agencies and the public.
The cycle begins when cases of diseases occur and reported by health care p rovider to the public
health agencies. information about cases are relayed to those responsible for disease prevention
and control and other who need to know. Because health providers, health agencies and the
public have responsibility on disease prevention and control, they should be included among those
who receive feedback of surveillance information. Other who need to know may include other
government agencies, potentially exposed individuals, employers, vaccine manufacturers, private
voluntary organization. (See Figure 5)


One of the areas where public health nurse function as researcher is disease Surveillance. Surveillance is
a continuous collection and analysis of data of cases and death. It is also important in monitoring the
progress of the disease reduction initiatives and an integral of many programs.
The objectives of surveillance are:
1. To measure the magnitude of the problem
2. To measure the effect of the control program.
Hence, the data collection can be used to improve strategies and prevent disease from occurring.
The National Epidemic sentinel Surveillance System (NESSS) and its role
National Epidemic Sentinel Surveillance System is hospital based information
System that monitors the occurrence of infectious diseases with outbreak potential. It also serves as a
supplemental information system of the Department of Health.
The NESSS Data shows:
Trends of cases across time
Demographic characteristics of cases
Estimates of case fatality ratio
Clustering of cases in a geographical area
Information to formulate hypotheses for disease causation
Diseases under Surveillance (NESSS)
Laboratory diagnosed
1) Cholera
2) Hepatitis A
3) Hepatitis B
4) Malaria
5) Typhoid Fever
Clinically Diagnosed
1) Dengue Hemorrhagic Fever
2) Diphtheria
3) Measles
4) Meningococcal Disease
5) Neonatal Tetanus
6) Non Neonatal Tetanus
7) Pertussis
8) Rabies
9) Leptospirosis
10) Acute Flaccid Paralysis (Poliomyelitis)
Under Surveillance System:
1. Acute flaccid paralysis
2. Measles
3. Maternal and neonatal tetanus
4. Paralytic shellfish poisoning

5. Fireworks and related injury

Why is there a need Investigate an outbreak?
Importance of Outbreak investigation:
Control and prevention measure
Research opportunities
Public, political or legal concerns
Program consideration
Surveillance data
Medical Practitioner
Affected persons / group
Steps in Outbreak Investigation:
Step 1 Prepare for field work
Scientific knowledge
Supplies / equipment
Administrative procedure like travel document, allowance
Know expected role
Local contact person
Step 2-Establish the existence of an outbreak
Cluster is a aggregation of cases in a given area over a particular period without regards to
whether the number of cases is more than the expected
Outbreak or an epidemic is the occurrence of more cases of disease than expected in a given
area or among a specific group of people over a particular period of time.
Compare the current number of cases with the number of cases from comparable period during
the previous years.
Surveillance records
Hospital records, registries, mortality statistics
Data from neigh boring areas
Community survey
Step 3 -Verify Diagnosis
Ensure proper diagnosis of reported cases
Rule out laboratory error as basis the increase in diagnosed cases
Review clinical findings
review laboratory results
Summarize clinical finding with frequency distribution
Visit patients
Step 4-Define and Identify cases
A. Establish a case definition
Standard set of criteria for the health condition:
Restriction by time, place and person
Apply without bias
Note exposure or risk factor is not included in the case definition
B. Identify and count cases

Identifying information name , address, contact number

Demographic information age, sex, race, and occupation
clinical information death of onset, hospitalization, death
risk factor information food or water sources, toilet facility
reporter information
Step 5 Perform descriptive epidemiology
Describe and orient the data in terms of time, place and person
Characterizes by Time
Difference between maximum and minimum incubation period
Probable time of exposure
Incubation period when probable time of exposure is known
Characterized by Place
Geographic extent
Spot map
Area map
Characterized by person
Host characteristics
Medical status
leisure activities
Tobacco use
Use of medication / drugs
Step 6 Developing Hypotheses
source of the agent
Mode of transmission
Vectors of transmission
Risk factors
Hypotheses should be testable
Step 7 Evaluate hypotheses by:
Comparing with established facts
Use analytical epidemiology
Case control studies
Retrospective control studies
Step 8 Refine hypotheses and execute additional studies because:
Unrevealing analytic studies = poor hypotheses
May need more specific exposure histories
May need more specific control group
Step 9 Implement control and prevention measures
Prevent additional cases
Prevent outbreaks in the future
Step 10 Communicate findings
writhing and disseminating full report

Meeting and discussions

Local and mass media
To the;
Local government official
Local health workers
Concerned health authorities
Regional health authorities
Department of Health
Step 11 Follow-up Recommendations
What activities have been undertaken?
If health status has improved
If health problem has been reduced
Function of the Epidemiology Nurse:
a) Implement public health surveillance
b) Monitor local health personnel conducting disease surveillance
c) Conduct and / or assist other health personnel in outbreak investigation
d) Assist in the conduct of rapid surveys and surveillance during disasters
e) Assist in the conduct of surveys, program evaluation, and other epidemiologic studies
f) Assist in the conduct of training course in epidemiology
g) Assist the epidemiologist in preparing the annual report and financial plan
h) Responsible for inventory and maintenance of epidemiology and surveillance
Unit (ESU) equipment
Specific role during Epidemiological Investigations:
Maintains surveillance of the occurrence of notifiable disease.
Coordinates with other members of the health team during the disease outbreak.
Participates in case finding and collection of laboratory specimens.
Isolates cases of communicable disease.
Render nursing care, teaches and supervises giving of care.
Perform and teach household members method, concurrent and terminal disinfection.
Give health teachings to prevent further spreads of disease to individual and families.
Follow up cases and contacts.
Organizes, coordinates and conducts community health education campaign /meetings.
Refer cases when necessary.
Coordinates with other concerned community agencies.
Accomplishes and keeps records and report and submits to proper office / agent


Prioritize needs
Establish goals based on needs and capabilities of staff
Construct action and operation plan
Develop evaluation parameters
Revise plan as needed
The plan for nursing action or care is based on the actual and potential problems that were
identified and prioritized. Planning nursing actions include the following steps:

Goal Setting

A goal is a declaration of purpose or intent that gives essential direction to action. Specific
objectives of care are made with the individual family in terms of activities of daily living. And
adaptive functioning based on remaining capabilities resulting from this condition and capability to
cope with stress associated with his/her disease condition or environment. These objectives are
stated in behavioral terms: specific, measurable, attainable, and realistic and time bounded. The
nurse prioritizes these objectives.

Constructing a Plan of Action

The planning phase of community health nursing process is concerned with choosing from among
the possible course of action selecting the appropriate types of nursing intervention, identifying
appropriate and available resources for care and developing an operational plan.
The courses of action may have positive and/or negative effects. The positive consequences must
be weighed against those with negative aspects. The ability of the family to cope or solve its own
problems and make decisions on health matters should be considered.
The most appropriate action is selected such as those that the clients could not perform
themselves, those that facilitate actions that remove barriers to care and those that improve the
capacity of the clients to act in their behalf.
The appropriate resources are identified which include the family, the neighborhood, the schools,
the industrial population: the whole, medical system, the hospitals, clinics, publics and private
practitioners of medicine, health units of welfare departments, voluntary health agencies and other
health related agencies: non-health facilities such as social, educational and counseling agencies.
Developing an Operational Plan
To develop an operational plan, the public health nurse must establish priorities, and coordinate
activities. Plans of care are prioritized in order of urgency to determine those that need the earliest
action or attention such as those that actually threaten the health of the client (individual, family or
community). These plans are broken down to manageable units and properly sequenced. Periodic
evaluation and modification of the plan is necessary. The plan and activities should be coordinated
with the various with the various services so that it would synchronize with the total health
program of the community.
Development of evaluation parameters is done in the planning stage and based on standards set
by the nursing services, problems identified, goals and priorities as reflected in the plan or
program, of nursing care for the clients.
Republic Act 7160 (October 10, 1991) known as the Local Government Code provided for the
decentralization of the entire government. This brought about a major shift in the role and functions of the
Department of Health. Under this law, all structures, personnel and budgetary allocations from the
provincial health level down to the barangays were devolved to the local government units (LGUs) to
facilitate health service delivery. As such, delivery of basic health services is now the responsibility of the
LGUs. The Department of Health changed its role from one of implementation to one of governance.
Executive Order No. 102 (May 24,199) Redirecting the Functions and Operations of the
Department of Health by President Joseph E. Estrada granted the DOH to proceed with its
Rationalization and Streamlining Plan which prescribed the current organizational, staffing and resource
structure consistent with its new mandate, roles and functions post devolution.
The shift in policy and functions is indicated in the de-emphasis from direct service provision and program
implementation, to an emphasis on policy formulation, standard setting and quality assurance, technical
leadership and resource assistance. The shift in policy direction of the DOH is shown in its new role as the
national authority on health providing technical and other resource assistance to concerned groups.

EO102 mandates the Department of Health to provide assistance to local government units, peoples
organization, and other members of civic society in effectively implementing programs, projects and
services that will promote the health and well-being of every Filipino; prevent and control diseases among
population at risks; protect individuals, families and communities exposed to hazards and risks that could
affect their health; and treat, manage and rehabilitate individuals affected by diseases and disability.
Development of the Health Sector reform Agenda (1999-2004) which describes the major strategies,
organizational and policy changes and public investments needed to improve the way health care is
delivered, regulated and financed.
2005 ongoing
Development of a plan to rationalize the bureaucracy in an attempt to scale down including the
Department of Health.


The family nursing process is the same nursing process as applied to the family, the unit of care in
the community. These are the common assessment cues and diagnoses for families in creating
Family Nursing Care Plans.

A. Nursing Assessment first major phase of the nursing process

Involves a set of actions by which the nurse measures the status of the family as client, its ability to
maintain itself as a system and functioning unit, its ability to maintain wellness, prevent, control or
resolve problems in order to achieve health and well-being among its members.
First level Nursing Assessment includes:
Data collection
Data analysis or interpretation
Problem definition or nursing diagnosis end result of two major types of nursing
assessment in family health nursing practice.
First Level Assessment
is a process whereby existing and potential health conditions or problems of the family are
Category of Health conditions/Problems:
Wellness state/s
Health Threats
Health deficits
Stress points or foreseeable crisis situations
The process of determining existing and potential health conditions or problems of the family.
These health conditions are categorized as:

I. Presence of Wellness Condition

Stated as Potential or Readiness; a clinical or nursing judgment about a client in transition from a
specific level of wellness or capability to a higher level. Wellness potential is a nursing judgment on
wellness state or condition based on clients performance, current competencies, or performance, clinical
data or explicit expression of desire to achieve a higher level of state or function in a specific area on health
promotion and maintenance. Examples of this are the following
A. Potential for Enhanced Capability for:
Healthy lifestyle-e.g. nutrition/diet, exercise/activity
Healthy maintenance/health management


Spiritual well-being-process of clients developing/unfolding of mystery through harmonious
interconnectedness that comes from inner strength/sacred source/God (NANDA 2001)
Others. Specify.
B.Readiness for Enhanced Capability for:
Healthy lifestyle
Health maintenance/health management
Spiritual well-being
Others. Specify.
II. Presence of Health Threats
Are conditions that are conducive to disease and accident, or may result to failure to maintain
wellness or realize health potential. Examples are the following:
A. Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic syndrome, smoking)
B. Threat of cross infection from communicable disease case
C. Family size beyond what family resources can adequately provide
D. Accident hazards specify.
Broken chairs
Pointed /sharp objects, poisons and medicines improperly kept
Fire hazards
Fall hazards
Others specify.
E. Faulty/unhealthful nutritional/eating habits or feeding techniques/practices. Specify.
Inadequate food intake both in quality and quantity
Excessive intake of certain nutrients
Faulty eating habits
Ineffective breastfeeding
Faulty feeding techniques
F. Stress Provoking Factors. Specify.
Strained marital relationship
Strained parent-sibling relationship
Interpersonal conflicts between family members
Care-giving burden
G. Poor Home/Environmental Condition/Sanitation. Specify.
Inadequate living space
Lack of food storage facilities
Polluted water supply
Presence of breeding or resting sights of vectors of diseases
Improper garbage/refuse disposal
Unsanitary waste disposal
Improper drainage system
Poor lightning and ventilation
Noise pollution
Air pollution
H. Unsanitary Food Handling and Preparation
I. Unhealthy Lifestyle and Personal Habits/Practices. Specify.
Alcohol drinking
Cigarette/tobacco smoking


Walking barefooted or inadequate footwear

Eating raw meat or fish
Poor personal hygiene
Self medication/substance abuse
Sexual promiscuity
Engaging in dangerous sports
Inadequate rest or sleep
Lack of /inadequate exercise/physical activity
Lack of/relaxation activities
Non-use of self-protection measures (e.g. non use of bed nets in malaria and filariasis endemic
J. Inherent Personal Characteristics
e.g. poor impulse control
K. Health History, which may Participate/Induce the Occurrence of Health Deficit
e.g. previous history of difficult labor.
L. Inappropriate Role Assumption
e.g. child assuming mothers role, father not assuming his role.
M. Lack of Immunization/Inadequate Immunization Status Especially of Children

N. Family Disunity
Self-oriented behavior of member(s)
Unresolved conflicts of member(s)
Intolerable disagreement
O. Others. Specify._________
III. Presence of health deficits
These are instances of failure in health maintenance.
Examples include:
A. Illness states, regardless of whether it is diagnosed or undiagnosed by medical practitioner.
B. Failure to thrive/develop according to normal rate
C. Disability
Whether congenital or arising from illness; transient/temporary (e.g. aphasia or temporary
paralysis after a CVA) or permanent (e.g. leg amputation, blindness from measles, lameness from
IV. Presence of stress points/foreseeable crisis situations
Are anticipated periods of unusual demand on the individual or family in terms of
adjustment/family resources. Examples of this include:
A. Marriage
B. Pregnancy, labor, puerperium
C. Parenthood
D. Additional member-e.g. newborn, lodger
E. Abortion
F. Entrance at school
G. Adolescence
H. Divorce or separation
I. Menopause
J. Loss of job
K. Hospitalization of a family member
L. Death of a member
M. Resettlement in a new community
N. Illegitimacy

O. Others, specify.___________
Second-Level Assessment
Second level assessment identifies the nature or type of nursing problems the family experiences in
the performance of their health tasks with respect to a certain health condition or health problem.
The nature or type of nursing problems that the family encounters in performing the health tasks
with respect to a given health condition or problem, and the etiology or barriers to the familys
assumption of the tasks.
I. Inability to recognize the presence of the condition or problem due to:
A. Lack of or inadequate knowledge
B. Denial about its existence or severity as a result of fear of consequences of diagnosis of problem,
Social-stigma, loss of respect of peer/significant others
Economic/cost implications
Physical consequences
Emotional/psychological issues/concerns
C. Attitude/Philosophy in life, which hinders recognition/acceptance of a problem
D. Others. Specify _________
II. Inability to make decisions with respect to taking appropriate health action due to:
A. Failure to comprehend the nature/magnitude of the problem/condition
B. Low salience of the problem/condition
C. Feeling of confusion, helplessness and/or resignation brought about by perceive magnitude/severity of
the situation or problem, i.e. failure to break down problems into manageable units of attack.
D. Lack of/inadequate knowledge/insight as to alternative courses of action open to them
E. Inability to decide which action to take from among a list of alternatives
F. Conflicting opinions among family members/significant others regarding action to take.
G. Lack of/inadequate knowledge of community resources for care
H. Fear of consequences of action, specifically:
Social consequences
Economic consequences
Physical consequences
Emotional/psychological consequences
I. Negative attitude towards the health condition or problem-by negative attitude is meant one that
interferes with rational decision-making.
J. In accessibility of appropriate resources for care, specifically:
Physical Inaccessibility
Costs constraints or economic/financial inaccessibility
K. Lack of trust/confidence in the health personnel/agency
L. Misconceptions or erroneous information about proposed course(s) of action
M. Others specify._________
III. Inability to provide adequate nursing care to the sick, disabled, dependent or vulnerable/at risk
member of the family due to:
A. Lack of/inadequate knowledge about the disease/health condition (nature, severity, complications,
prognosis and management)
B. Lack of/inadequate knowledge about child development and care
C. Lack of/inadequate knowledge of the nature or extent of nursing care needed
D. Lack of the necessary facilities, equipment and supplies of care
E. Lack of/inadequate knowledge or skill in carrying out the necessary intervention or
treatment/procedure of care (i.e. complex therapeutic regimen or healthy lifestyle program).

F. Inadequate family resources of care specifically:

Absence of responsible member
Financial constraints
Limitation of luck/lack of physical resources
G. Significant persons unexpressed feelings (e.g. hostility/anger, guilt, fear/anxiety, despair, rejection)
which his/her capacities to provide care.
H. Philosophy in life which negates/hinder caring for the sick, disabled, dependent, vulnerable/at risk
I. Members preoccupation with on concerns/interests
J. Prolonged disease or disabilities, which exhaust supportive capacity of family members.
K. Altered role performance, specify.
Role denials or ambivalence
Role strain
Role dissatisfaction
Role conflict
Role confusion
Role overload
L. Others. Specify._________
IV. Inability to provide a home environment conducive to health maintenance and personal
development due to:
A. Inadequate family resources specifically:
Financial constraints/limited financial resources
Limited physical resources-e.i. lack of space to construct facility
B. Failure to see benefits (specifically long term ones) of investments in home environment improvement
C. Lack of/inadequate knowledge of importance of hygiene and sanitation
D. Lack of/inadequate knowledge of preventive measures
E. Lack of skill in carrying out measures to improve home environment
F. Ineffective communication pattern within the family
G. Lack of supportive relationship among family members
H. Negative attitudes/philosophy in life which is not conducive to health maintenance and personal
I. Lack of adequate competencies in relating to each other for mutual growth and maturation
Example: reduced ability to meet the physical and psychological needs of other members as a
result of familys preoccupation with current problem or condition.
J. Others specify._________
V. Failure to utilize community resources for health care due to:
A. Lack of/inadequate knowledge of community resources for health care
B. Failure to perceive the benefits of health care/services
C. Lack of trust/confidence in the agency/personnel
D. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic, rehabilitative) specifically:
Physical/psychological consequences
Financial consequences
Social consequences
F. Unavailability of required care/services
G. Inaccessibility of required services due to:
Cost constraints
Physical inaccessibility
H. Lack of or inadequate family resources, specifically
Manpower resources, e.g. baby sitter

Financial resources, cost of medicines prescribe

I. Feeling of alienation to/lack of support from the community
e.g. stigma due to mental illness, AIDS, etc.
J. Negative attitude/ philosophy in life which hinders effective/maximum utilization of community
resources for health care
K. Others, specify __________

Steps in Family Nursing Assessment

1. Data Collection gathering of five types of data which will generate the categories of health
conditions or problems of the family.
a.) family structure, characteristics &dynamics include the composition and demographic data of the
members of the family/household, their relationship to the head and place of residence; the type of, and
family interaction/communication and decision-making patterns and dynamics.
b.) socio-economic & cultural characteristics include occupation, place of work, and income of each
working member; educational attainment of each family member; ethnic background and religious
affiliation; significant others and the other role(s) they play in the familys life; and, the relationship of the
family to the larger community
c.) home and environment include information on housing and sanitation facilities; kind of
neighborhood and availability of social, health, communication and transportation facilities in the
d.)Health status of each member includes current and past significant illness; beliefs and practices
conducive to health and illness; nutritional and developmental status; physical assessment findings and
significant results of laboratory/diagnostic tests/screening procedures.
e.) values and practices on health promotion/maintenance & disease prevention include use of
preventive services; adequacy of rest/sleep, exercise, relaxation activities, and stress management or other
healthy lifestyle activities, and immunization status of at-risk family members.
Data Gathering Methods & Tools
a.)Observation method of data collection through the use of sensory capacities ---sight, hearing, smell
and touch. Data gathered through this method have the advantage of being subjected to validation and
reliability testing by other observers.
b.) Physical Examination done through inspection, palpation, percussion, auscultation, measurement
of specific body parts and reviewing the body systems.
c.)Interview completing the health history of each family member. The health history determines
current health status based on significant past health history. The second type of interview is collecting
data by personally asking significant family members or relatives questions regarding health, family life
experiences and home environment to generate data on what wellness condition and health problems
existing the family. Productivity of the interview process depends upon the use of effective communication
techniques to elicit the needed responses.
d.) Record Review reviewing existing records and reports pertinent to the client.( individual clinical
records of the family members; laboratory & diagnostic reports; immunization records; reports about the
home & environmental conditions.
e.) Laboratory/Diagnostic Tests performing laboratory tests, diagnostic procedures or other tests of
integrity and functions carried out by the nurse herself and/or other health workers.


sort data
cluster/group related date
distinguish relevant from irrelevant data
identify patterns

compare patterns with norms or standards

interpret results
make inferences/draw conclusions


A wellness condition is a nursing judgment related with the clients capability for wellness.
A health condition or problem is a situation which interferes with the promotion and/or
maintenance of health and recovery from illness or injury.
NURSING DIAGNOSIS in the FAMILY NURSING PRACTICE - the familys failure to perform
adequately specific health tasks to enhance the wellness state or manage the health problem.
1. COMPREHENSIVE COMMUNITYDIAGNOSIS aims to obtain a general information about the
A. Demographic Variables
B. Socio-Economic and Cultural Variable
C. Health and Illness Patterns
D. Health resources
E. Political/Leadership Patterns
2. PROBLEM-ORIENTED COMMUNITYDIAGNOSIS type of assessment that responds to a particular
Analyzing and interpreting health data


The nurse decides on the depth and scope of the data she needs to gather.
The nurse identifies the population group to be included in the study.
The objectives will guide the nurse in identifying the specific data she will collect, and will also
decide on the sources of these data.
The nurse decides on the specific methods depending on the type of data to be generated.
Instruments/tools facilitate the nurses data-gathering activities. Most common instruments:
survey questionnaire
interview guide
observation checklist
The nurse supervises the data collectors by checking the filled-up instruments in terms of
completeness, accuracy and reliability of the information collected.
7. DATA COLLATION the nurse is now ready to put together all the information
8. DATA PRESENTATION will depend largely on the type of data obtained.(descriptive & numerical
9. DATA ANALYSIS aims to establish trends and patterns in terms of health needs and problems of the

Health status problems increased or decreased morbidity, mortality, fertility or reduced

capability for wellness.
Health resources problems lack of or absence of manpower, money, materials or institutions
necessary to solve health problems.
Health-related problems existence of social, economic, environmental and political factors that
aggravate the illness-inducing situations in the community.
11. PRIORITY-SETTING prioritizes which health problems can be attended to considering the
resources available at the moment.


PLANNING is a process that entails formulation of steps to be undertaken in the future in order to
achieve a desired end.
Concepts of Planning:
Planning is futuristic
Planning is change-oriented
Planning is a continuous and dynamic process.
Planning is flexible.
Planning is a systematic process


1. Situational Analysis
gather health data
tabulate, analyze and interpret data
identify health problems
set priority
2. Goal and Objective Setting
define program goals and objectives
assign priorities among objectives
3. Strategy/Activity Setting
Design CHN Program
Ascertain resources
Analyze constraints and limitations
4. Evaluation
determines outcomes
specify criteria and standards
THE FAMILY CARE PLAN is the blueprint of the care that the nurse designs to systematically minimize
or eliminate the identified health and family nursing problems through explicitly formulated outcomes of
care ( goals and objectives) and deliberately chosen of interventions, resources and evaluation criteria,
standards, methods and tools.
a. It should be based on clear, explicit definition of the problems. A good nursing plan is based
on a comprehensive analysis of the problem situation.
b. A good plan is realistic.
c. The nursing care plan is prepared jointly with the family. The nurse involves the family in
determining health needs and problems, in establishing priorities, in selecting appropriate
courses of action, implementing them and evaluating outcomes.

d. The nursing care plan is most useful in written form.

They individualize care to clients.
The nursing care plan helps in setting priorities by providing information about the client as
well as the nature of his problems
.The nursing care plan promotes systematic communication among those involved in the
health care effort.
Continuity of care is facilitated through the use of nursing care plans. Gaps and duplications in
the services provided are minimized, if not totally eliminated.
Nursing care plans, facilitate the coordination of care by making known to other members of
the health team what the nurse is doing.
1. The prioritized condition/s or problems based on:
nature of condition or problem
preventive potential
2. The goals and objectives of nursing care.
Expected Outcomes:
Conditions to be observed to show problem is prevented, controlled, resolved or
Client response/s or behavior
> Specific, Measurable, Client-centered Statements/Competencies
3. The plan of interventions.
Decide on:
- Measures to help family eliminate: Barriers to performance of health tasks. underlying cause/s of
non-performance of health tasks
- Family-centered alternatives to recognize/detect, monitor, control or manage health condition or
- Determine Methods of Nurse-Family Contact
- Specify Resources Needed
4. The plan for evaluating.
- Criteria/Outcomes Based on Objectives of Care
- Methods/Tools


Put nursing plan in to action
Coordinate care/services
Utilize community resources
Supervise/monitor health services provided
Provide health education and training
Document responses to nursing action
Components of Program Implementation
2. Coordinating the health program
3. Monitoring health program
4. Supervising the program staff

National health Programs of the DOH

1. Family health services
2. Control of Non-communicable diseases
3. Control of Communicable Diseases
4. Environmental health


The patient visits the health center/clinic to avail of the services there to offered by the facility
primarily consultation on matter that ailed them physically. Nowadays, patient are becoming aware
of the other services that the health center offer such as pre-natal and post-partum care , well
baby checkup, immunization, free medicine under DOTS and other health care.
Most often, patients utilized the facility mainly for the said purpose. But with the changing time,
close interaction between health care providers and patient have been intensified with other health
programs prior to the actual nurse-patient contact such as enhanced health education and
promotion on health care of the family in totality. The nurse plays a very important role in building
closer ties with patient to gain their trust and confidence and particularly in the implementation
and promotion of health care.
Pre-consultation conference
A pre-clinic lecture is usually conducted prior to the admission of patient, which is one of
providing health education.
Standard procedure performed during clinic visit
5. Great the client upon entry and establish rapport.
6. Prepare the family record the client and record it accordingly.
Waiting time
5. Give priority number to client.
6. Implement the, first served policy except for emergency/urgent cases.
1. Manage program-based cases. (Certain program of the DOH like the IMCI utilize an
acceptable decision to which the nurse has to follow in the management of a simple case)
EXAMPLE-for control of diarrheal diseases (CDD), asses if the child has diarrhea
If he has, for how long is their blood in the tool?
asses the childs general condition-sleepy, difficult to awaken, restless and irritable
observe for sunken eyes
Offer fluid. Is he able to drink or is he drinking regularly, thirsty
Pinch skin of the abdomen-does it go back very slowly?
2. Refer all non-program based case to the physician. For all other cases which has no
potential danger, treatment/management is initiated by the nurse and she decides to do her
own nursing diagnosis and then refer to the physician medical management
3. Provide first-aid treatment to emergency cases and refer wheel necessary to the next level
of care.

Clinic evaluation
1. Validate clinical history and physical examination
2. The nurse arrives at evidence-based diagnosis and provides rational treatment based on DOH
Identify the patients program.
formulate/write the nursing diagnosis and validate




give/perform the nursing intervention

evaluate the intervention if it has enabled the patient to achieved the desired outcome
3. Inform the client on the nature of the illness, the appropriate treatment and prevention and
control measures.
Laboratory and other diagnostic examination
1. Identify a designated referral laboratory when needed.
Referral system
1. Refer the patient if he needs further management following the two-way referral system
(BHS to RHU ,RHU to RHU,RHU to Hospital).
2. Accompany the patient when an emergency referral is needed.
Give proper instruction on drug intake
Health Education
Conduct one-on-one counseling with the patient.
Reinforce health education and counseling messages
Give appointments for the next visit.

The home visit is a family-nurse contact which allows the health worker to access the home and
family situation in order to provide the necessary nursing care and health related activities. In
performing this activity, it is essential to prepare a plan of visit to meet the needs of the client and
achieve the best result desired outcome.
Purpose of home visit
1. To give nursing care to the sick, to post-partum mother and her newborn with the view to teach a
responsible family member to give the subsequent care.
2. To assess the living condition of the patient and his family and their health practices in order for
provide the appropriate health teaching
3. To give health teaching regarding the prevention and control of diseases.
4. o establish close relationship between the health agencies and the public for the promotion of
5. To make use of the inter-referral system and to promote the utilization of community services.
Principles involved in preparing for a home visit
When we plan to go on a home visit, it is necessary to assemble the record of the patient and list
the name to be visited, study the case and have a written nursing care plan.
1. A home visit must have purpose or objective.
2. Planning for a home visit should make use of all available information about the patient and his
family through family record.
3. In planning for a visit, we should consider and give priority to the essential need of the individual and
his family.
4. Planning and delivery of care should involve the individual and family.
5. The plan should be flexible.
Guideline to consider regarding the frequency of home visits
There is no definite rule to be followed on the frequency of home visits. The schedule of the visit
may vary according to the need of the patient or family for nursing care, but one has to consider the
following factor:
b. The physical needs psychological need and educational need of the individual and
c. The acceptance of the family for the service to be rendered , their interest and the
willingness to cooperate

d. The policy of the specific agency and the and the emphasis given to wards their
health programs
e. Take in to account other health agencies and the number of health personnel
already involved in the care of a specific family.
f. Careful evaluation of past service given to a family and how the family avail of a
nursing services
g. The ability of the patient and his family to recognize their own needs, their
knowledge of avail resources and their ability to make use of their resources for
their benefits
Step in conducting home visits
1. Greet the patient and introduce you self
2. State the purpose of the visit
3. Observe the patient and determine the health needs
4. Put the bag in a convenient place the proceed to perform the bag technique
5. Perform the nursing care needed and give health teachings
6. Record all important data, observation and care rendered
7. Make appointment for a return visit.

National Health Programs of the DOH

The term Family is defined as the basic unit of the community. All the members of the family are
empowered to maintain their health status. They must be free from disease or infirmity with no
disabilities. In public health perspectives, the health of the family is considered as a whole and not
The family health office is tasked to operationalize health programs geared towards the health of
the family. It is concerned with the health of mother and the unborn, the newborn, infant, child, the
adolescent and youth, the adult men and women and older person.
Specifically, it aims to:
1. Improve the survival, health and well-being of mothers and the unborn through a package of
service for the pre-pregnancy, prenatal, natal and postnatal stages.
2. Reduce morbidity and mortality rates for children 0-9 years
3. Reduce mortality from preventable causes among adolescents and young people.
4. Reduce morbidity and mortality among Filipino adults and improve their quality of life.
5. Reduce morbidity and mortality of older persons and improve their quality of life.
Public Health Nurses have significant role in ensuring the health of the family. Every effort has to be
made to provide packages of health service to the family for a better and quality life.
A. Maternal Health Program
Essential Health Service Packages Available in the Health Care Facilities. These are the packages of
service that every woman has to receive before and after pregnancy and or delivery of a baby.
1. Antenatal Registration
I. Pregnancy poses a risk to the life of every woman. Pregnant women may suffer
complication or die. Every woman has to visit the nearest health facility for antenatal
registration and to avail prenatal care service. This is the only way to guide her in pregnancy
care to make her prepare for child birth. The standard pre-natal visits that a women has to
receive during pregnancy are as follows:


Pre-natal visits
1st visit
2nd visit
3rd visit
Every 2 weeks

Period of pregnancy
As early in pregnancy as possible before four months or
during the first trimester
During the 2nd trimester
During the 3rd trimester
After 8th month of pregnancy till delivery

2. Tetanus Toxoid Immunization

Neonatal Tetanus is one of the public health concerns that we need to address among newborn.
To protect them from deadly disease tetanus toxoid immunization important for pregnant women
and child bearing age women. Both mother and child are protected against tetanus and neonatal
tetanus. A series of 2`doses of Tetanus Toxoid vaccination must be received by women one
month before delivery to protect baby from neonatal tetanus. And the 3 booster dose shots to
complete the five doses following the recommended schedule provide full protection for both
mother and child. The mother then is called as a fully immunized mother (FIM)



Minimum age
As early as possible
during pregnancy
At least 4 weeks later


At least 6 months later



At least one year later



At least one year later



Duration of protection
-gives initial protection


-infants born to mother will be protected from

neonatal tetanus
-gives 3 years protection for the mother
-infants born to mother will be protected from
neonatal tetanus
-gives 5 years protection for the mother
-infants born to mother will be protected from
neonatal tetanus
-gives 10 years protection for the mother
-all infants born to that mother will be protected
-gives lifetime protection for the mother

3. Micronutrient Supplementation
Micronutrient Supplement is vital for pregnant women. These are necessary to prevent anemia,
vitamin A deficiency and other nutritional disorder. They are:



Vitamin A supplementation for pregnant women and postpartum women

10,000 IU
1 capsule/tablet Start from the 4th
Vit.A should not be given to
of 10,000 IU
month of pregnancy
pregnant women who are
twice a week
until delivery
already taking pre-natal
vitamins or multiple
micronutrients tablets that also
contain vitamin A
200,000 IU
1 capsule
One dose only within Vit.A of 200,000 IU should not
200,000 IU
4 weeks after
be given to pregnant women





Tablet (preferably
1 tab OD for 6 months or 180 days
A dose of 800 mcg of
coated) containing 60 mg during the pregnancy period
folic acid is still safe
elemental iron with 400
to the pregnant
mcg folic acid
2 tablets per day if prenatal
consultations are done during the 2
and 3rd trimester
Tablet (preferably
coated) containing 60 mg
elemental iron with 400
mcg folic acid

1 tablet once a day for 3 months or 90


4. Treatment of diseases and other conditions

There are other conditions that might occur among pregnant women. These conditions may endanger
her health and complication could occur. Follow first aid treatment.
Conditions or diseases
Difficulty of
breathing/obstruction of

Post-partum bleeding

Intestinal parasite infection

What to do?
Clear airway
Place in her best position
Refer woman to hospital with
EMOC/BEMONC capabilities
Keep on her back arms at the side
Tilt head backwards (unless trauma is
Lift chin to open airway
Clear secretions from throat
Give IVF to prevent or correct shock
Monitor blood pressure, pulse and
shortness of breath every 15 minutes.
Monitor fluid give. If difficulty of breathing
and puffiness develops, stop infusion
Monitor urine output
Massage uterus and expels clots
If bleeding persists:
- Place cupped palmed on uterine
fundus and feel for state of contraction
- Massage fundus in a circular motion
- Apply bimanual uterine compression if
ergometrine treatment done and
postpartum bleeding still persists
- Give ergometrine 0.2 mg IM and
another dose after 15 minutes
Give mebendazole 500 mg table single dose

Do not give


Do not give ORS to a

woman who is
unconscious or has
Do not give IVF if you
are not trained to do

Do not give mebendazole

anytime from 4-9 months of pregnancy if none

was given in the pas 6 months


in the first 1-3 months of

pregnancy. This might
cause congenital
problems in baby.

Give sulfadoxine-pyrimethamine to women

from malaria endemic areas who are in 1st or
2nd pregnancy, 500-25 mg tab, 3 tabs at the
beginning of 2nd to 3rd trimesters not less than
one month interval

5. Clean and Safety Delivery

The presence of a skilled birth attendance will ensure hygiene during labor and delivery. It may
also provide safe and non-traumatic care, recognize complications and also manage and refer the
women to a higher level of care when necessary. The necessary step to follow during labor,
childbirth and immediate post-partum Include:
a. Do a Quick check upon admission for emergency signs:
Vaginal bleeding
Severe abdominal pain
Looks very ill
Severe headache with visual disturbance
Severe breathing difficulty
Severe vomiting
b. Make the women comfortable
Establish rapport with the client by greeting and interviewing to make her comfortable.
c. Assess the women in labor
Assessing the client is a reference guide for a health worker to determine its status during labor
stage. This can be done by taking the history of the ff:
Last menstrual period(LMP)
Number of pregnancy
Start of labor pains
Danger signs of pregnancy
Taking the history through interviewing will help determine the clients condition during delivery of
a baby.
d. Determine the stage of labor
Labor can be determine when womens response to contraction is observed pushing down and
vulva is bulging, with leaking amniotic fluid, and vaginal bleeding. A vaginal examination can be
performed to determine the degree of contraction.
e. Decide if the women can safety deliver
By assessing the condition of the client and not finding any indication that could harm the delivery
of a baby, a trained health worker can decide a safe delivery a mother.
f. Give supportive care throughout labor
There are many things that a women needs to do during labor. This will help her delivery clean,
safe and free from fatigue. There are:

Encourage to take a bath at the onset of labor

Encourage to drink but not to eat as this may interfere surgery in case needed
Encourage to empty bladder and bowels to facilitate delivery of the baby
Remind to empty bladder every 2 hours.
Encourage to do breathing technique to halt energy in pushing baby out the vagina. Panting can be
done by breathing with open mouth with 2 short breaths followed by long breath. This prevents
pushing at the end of the first stage.
g. Monitor and manage labor
Stages of labor
What to do
Not to do
Do not do vaginal examination
First stage (not yet in
Check every hour for emergency
more frequently that every 4
active labor, cervix is
signs, frequency and duration of
dilated 0-3 cm and
contractions, fetal heart rate
Check every 4 hours for fever, pulse,
contractions are weak,
BP and cervical dilatation
less than 2 to 10 minutes)
Record time of rupture of
membranes and color of amniotic
Assess progress of labor
- Refer woman immediately to
hospital facility with
comprehensive emergency
obstetrical care capabilities if after
8 hours, contractions are stronger
and more frequent but no progress
in cervical dilation, with or without
membranes ruptured.
- It is false labor if after 8 hours there
is no increase in contractions,
membranes are not ruptured and
no progress in cervical dilatation.
First stage (in active labor, Check every 30 minutes for
Do not allow the woman to
cervix is dilated 4 cm or
emergency signs
push unless delivery is

imminent. It will just exhaust
BP and cervical dilatation
the woman.
Record time of rupture of
Do not give the medications
membranes and color of amniotic
to speed up labor. It may
endanger and cause trauma
Record findings in
to mother and baby
partograph/patient record
Second stage (cervix
Check every 5 minutes for perineum
Do not apply fundal pressure
dilated 10 cm or bulging
thinning and bulging, visible descend
to help deliver the baby
thin perineum and head
of the head during contraction,
emergency signs, fetal heart rate and
mood and behavior
Continue recording in the partograph
Third stage: between the
Deliver the placenta
Do not squeeze or massage


birth of the baby and

delivery of the placenta

Check the completeness of placenta

and membranes

the abdomen to deliver the


8. Monitor closely within one hour after delivery and give supportive care
9. Continue care after one hour postpartum. Keep watch closely for at least 2 hours.
10. Educate and counsel on FP and provide FP method if available and decision was made by a
11. Inform, teach and counsel the women on important MCH messages:
Importance of BF
Newborn Screening for babies delivered in RHU or at home within 48hours up to 2 weeks
after birth
Schedule when to return for consultation for post-partum visits
Recommended Schedule of Post-Partum Care Visits:
1st visit
1st week post-partum preferably 3-5 days
2nd visit
6 weeks post-partum
BeMONC- Basic Emergency Obstetrics and Newborn Care
o It refers to lifesaving services for emergency maternal and newborn conditions/complications
being provided by a health facility or professional to include the following services.
Administration of Parenteral oxytocic drugs.
Administration of dose of Parenteral anticonvulsants.
Administration of Parenteral antibiotics
Administration of maternal steroids for preterm labor
Performance of assisted vaginal deliveries.
Removal of retained placental products
Manual removal of retained placenta
o It also includes neonatal interventions which include at the minimum:
Newborn resuscitation
Provision of warmth
Blood transfusion
BeMONC facility consists of the core district hospital.
For geographically isolated/disadvantaged areas/densely populated areas, the designated
BeMONC facilities are the following:
Rural Health Unit (RHU)
Barangay Health Station (BHS)
Lying-in-Clinics and Birthing Homes
o Accessibility within 1 hour from residence or referring facility within the ILHZ (Inter-Local Health
o Shall operate within 24 hours within 6 signal obstetric function.
o Shall have access to communication and transportation facilities to mobilize referrals.
o Staff composition:
1 medical doctor
1 registered nurse
1 registered midwife
CeMONC- Comprehensive Emergency Obstetrics and Newborn Care Facility


Refers to lifesaving services for emergency maternal and newborn condition/complications as in

Basic Emergency Obstetric and Newborn Care plus the provision of surgical delivery and blood
bank services and other specialized obstetric interventions.
o Essential Health Services available in the Health Care Facilities
o Antenatal Registration/Prenatal Care
o OBJECTIVE: To reach all pregnant women, to give sufficient care to ensure a healthy pregnancy
and the birth of a full term healthy baby.
o Normal Patients- following the initial evaluation they will be given healthy instructions and
counseling. This will include advice for prompt prenatal care examination.
o Patients with mild complications-a thorough evaluation of the needs of patients with mild
complications will determine the frequency of follow-up of these cases by the rural health unit, city
health clinic or puericulture center.
o Patients with potentially serious complications-these patients shall be referred to the most
skilled source of medical and hospital care. As a first choice they will be referred if at all possible
for continuing care or consultation. Second choice will be followed carefully by the rural health
unit, city health clinic or puericulture center.
o All RHUs and BHS should have a master list of pregnant women in their respective catchment
o The Home Based Mothers Record (HBMR) shall be used when rendering prenatal care as a
guide in the identification of risk factors, danger signs and to be able to do appropriate measure.
o There should be at least 3 prenatal visits following the prescribed timing:
First prenatal visit- as early in pregnancy as possible, during the first trimester.
Second prenatal visit- during the second trimester
Third and subsequent visits- during the third trimester
More frequent visits should be done for those at risk or with complications.
6. Support to Breast Feeding
Most mothers do not know the importance of breastfeeding. A support care groups like nurses
have a critical role to motivate them to practice breastfeeding.
Here is an acronym on the benefits of breast feeding.

B- est for baby, also best for mommy

R-educes the incidence of allergies
E-economical, no waste
A-nti-bodies to protect baby against infection
S-terile and pure
T-emperature is always ideal
F-resh milk never goes off
E-asy to prepare and to digest
E-radicates feeding difficulties
D-evelops mother and child bonding
I-mmediately available
N-utritionally optimal
G-astroenteritis greatly reduced
Tips when breast feeding
1. With a clean washcloth or cotton swabs, wipe your breasts clean before your baby feeds.
2. Sit comfortably in an upright position.
3. Support your baby's head


4. Guide your nipple towards his mouth. Baby's chin should be against the breast and his tongue
underneath your nipple. Make sure that he's sucking the whole areola ( darkened area of the
5. When he's sucking subsides, switch him to other breast until stops feeding
6. Next time he feeds, start from the breast he nursed from last.
7. If your nipples get sore, never wash your nipples with soap, give a minute for them to be exposed
for air dry
8. ALWAYS burp your baby after feeding.
7. Family Planning counseling
Proper counselling of couples on the importance of FB will help them inform on the right choice of
FB methods, proper spacing of birth and addressing the right number of children. Birth spacing of
three of five years interval will help completely recover the health of a mother from previous
pregnancy and childbirth. The risks of complications increase after the second birth.
The overall goal family planning is to provide universal access to family planning information and
service wherever and whenever these are needed.
Family Planning aims to contribute to:
Reduce infant deaths
Neonatal deaths
Under-five death
Maternal deaths
It has the following objectives:
Address the need to help couples and individuals achieve their desired family size within
the context of responsible parenthood and improve their reproductive health to attain
sustainable development
Ensure that quality FP services are available in DOH retained hospitals, LGU managed
health facilities, NGOs, and private sector
There are different strategies adopted to achieve goal and objective such as:
Focus service delivery to the urban and rural poor
Re-establish the FP outreach program
Strengthen FP provision in regions with high unmet needs
Promote frontline participation of hospitals
Mainstream modern naturel family planning
Promote and implement CSR strategy
Methods of Contraception
1.) Spacing methods:
Help in prevention of pregnancy as long as they are used.- These methods can help in timing
and spacing of pregnancies, preventing unwanted children. These methods are temporary
a. Natural methods
Natural methods do not involve the use of any of the manmade devices. These methods are
useful for timing and spacing of pregnancies.
b. Barrier :
Physical/mechanical barrier methods
chemical barrier methods
hormonal methods
2.) Terminal methods

Tubal ligation

Natural Family Planning

Involves no introduction of chemical or foreign material into the body. The effectiveness of
these methods depending mainly on the couples ability to refrain from sexual relations on
fertile days.
Refraining from sexual relations
Advantage: most effective way to prevent STIs, no cost
Disadvantage: it has a failure rate of 85%, high motivation needed, highly unreliable
Requires a couple to abstain from coitus on the days of menstrual cycle when the woman is
likely conceive (3 or 4 days before ovulation and 3 or 4 days after ovulation)
To plan for this, the woman keeps a diary of 6 menstrual cycles.
To calculate safe days, subtracts 18 from the shortest cycle documented. This number
represents her first fertile day. Then subtracts 11 from the longest cycle. This represents her
last fertile days. If she had 6 menstrual cycles ranging from 25 to 29 days, her fertile period
would be from 7th day to the 18th day. To avoid pregnancy she would avoid coitus during those
Advantage: no cost
Disadvantage: failure rate of 9-25%, requires motivation and cooperation



Just before the day of ovulation, a womans BBT or temperature of her body at rest falls about
0.5oF at the time of ovulation, her BBT rise a full degree because of the influence of
The woman takes her temperature each morning immediately after waking either orally or with
an ear thermometer before she undertakes any activity, this is her BBT. As soon as she notices
a slight dip in temperature followed by an increase she knows that she was ovulated
The woman should refrains from having coitus for the next 3 days after ovulation ( the life of
discharged ovum). Because sperm can survive for at least 4 days in the female reproductive
tract, it is usually recommended that the couple combine this method with a calendar method,
so that they abstain for a few days before ovulation as well.
Advantage: no cost
Disadvantage: requires motivation and cooperation, failure rate of 9-25%
Before ovulation each month, the cervical mucus is thick and does not stretch when pulled
between the thumb and finger. Just before ovulation mucus secretion increases. With
ovulation, cervical mucus becomes copious, thin, watery and transparent. It feels
slippery and stretches at least 1 inch before the strand break, a property known as
spinnbarkeit. In addition, breast tenderness and anterior tilt to the cervix occur.
All the days on which cervical mucus is copious and for at least 1 day afterward, are considered
to be fertile days or days on which the woman should abstain from coitus to avoid conception.
Advantage: no cost
Disadvantage; requires motivation and cooperation
Combines the cervical mucus and BBT method
The woman takes her temperature daily, watching for the rise in temperature that marks
ovulation. She also analyzes her cervical mucus every day and observes for other signs of
ovulation such as mittelschmertz (mid-cycle abdominal pain).
The couple must abstain from intercourse until 3 days after the rise in temperature or the
fourth day after the peak of mucus change, because these are womans fertile days.

The symptothermal method is more effective than either the BBT or the cervical mucus
method alone.
Advantage; no cost
Disadvantage: requires motivation and cooperation
Still another method to predict ovulation is by the use of an over-the-counter ovulation
detection kit. These kits detects the mid-cycle surge of luteinizing hormone (LH) that can be
detected in urine 12 to 24 hours before ovulation
Such kits are 98% to 100% accurate in predicting ovulation.
Advantage: easy to use
Disadvantage: needs funds for monthly kit.
As long as woman is breastfeeding an infant, there is some natural suppression of ovulation.
Disadvantage: Because women may ovulate, however, but not menstruate, a woman may still
be fertile even if she had a period since childbirth.
If the infant is receiving a supplemental feeding or not sucking well, the use of lactation as an
effective birth control method is questionable.
As a rule after 3 months of breastfeeding, the woman should be advised to choose another
method of contraception.

Is one of the oldest known methods of contraception. The couple proceeds with coitus until
the moment of ejaculation. Then the man withdraws and spermatozoa are emitted outside the
Disadvantage: Unfortunately, ejaculation may occur before withdrawal is complete and
despite the care used, some spermatozoa may be deposited in the vagina. Furthermore,
because there may be a few spermatozoa present In pre-ejaculation fluid, fertilization may
occur even if withdrawal seems controlled. For these reasons, coitus interruptus is only about
75% effective.
Douching following intercourse, no matter what solution is used, is ineffective as a contraceptive
measure, as sperm may be present in cervical mucus as quickly as 90 seconds after ejaculation
Artificial Family Planning
IBarrier methods
Are forms of birth control that work by placement of a chemical or other barrier between the
cervix and advancing sperm so that sperm cannot enter the uterus or fallopian tubes and
fertilize the ovum.
Advantage: they lack of hormonal side effects associated with Combined Oral Contraceptives
Disadvantage: failure rate are higher and sexual enjoyment may be lessened.
Types of Barriers: Chemical Barrier and Mechanical Barrier
A- Chemical Barrier Method
o A spermicidal is an agent that causes death of spermatozoa before they can enter the cervix. Such
agents are not only actively spermicidal but also change the vaginal pH to a strong acid level, a
condition not conducive to sperm survival.
o Advantages:
They may be purchased without a prescription
When used in conjunction with another contraceptive, they increase the other methods


Various preparations are available including gels, creams, sponges, films, foams and
Side effects and contraindication of Chemical Barrier:
Vaginally inserted, spermicidal products are contraindicated in women with acute
cervicitis, because they might further irritate the cervix.
May cause leakage (disadvantage)
Are inserted to the vagina before coitus with an applicator.
The woman should do this no more than 1 hour before coitus for the most effective results.
The woman should not douche to remove the spermicidal for 6 hours after coitus, to ensure that
the agent has completed its spermicidal action.
Another form of spermicidal protection is a film of glycerin impregnated with a spermicidal agent
that is folded and is inserted vaginally.
On contact with vaginal secretions or pre-coital penile emissions, the film dissolves and a carbon
dioxide foams forms to protect the cervix against invading spermatozoa.

o Still other vaginal products are cocoa butter and glycerin-based vaginal suppositories filled with
spermicide. Inserted vaginally these dissolve and release the spermicidal ingredients. Because it
takes about 15 minutes for a suppository to dissolve, it must be inserted 15 minutes before coitus.
o Are foam impregnated synthetic sponges that are moistened to activate the impregnated
spermicide and then inserted vaginally to block sperm access to the cervix.
o They should remain in place for 6 hours after intercourse to ensure sperm destruction.
B- Mechanical Barrier (Physical)
o Is a circular rubber disk that is placed over the cervix before intercourse.
o A diaphragm is prescribed and fitted initially by a physician, nurse practitioner or nurse-midwife to
ensure a correct fit. Because the shape of a womans cervix changes with pregnancy, miscarriage,
cervical surgery (D & C) or elective termination of pregnancy.
o Health teachings:
Teach woman to return for a second fitting if any of these circumstances occur.
A woman should also have the fit of the diaphragm checked if she gains or losses more than
15 lbs because this could also change her pelvic and vaginal contours.
o How to use it?
It is inserted into the vagina after first coating the rim and center portion with a spermicidal
gel, by sliding it along the posterior wall and pressing it up against the cervix so that it is
held in place by the vaginal fornices.
A woman should check her diaphragm with a finger after insertion to be certain that it is
fitted well up over the cervix, she can palpate the cervical os through the diaphragm.
A diaphragm should remain in place for at least 6 hours after coitus because spermatozoa
remain viable in the vagina for the length of time. It may be left in place for as long as 24
hours. If it is left in the vagina longer than 24 hours, the stasis of fluid may cause cervical
inflammation or urethral irritation.
A diaphragm is removed by inserting a finger into the vagina and loosening the diaphragm
by pressing against the anterior rim and then withdrawing it vaginally.
After use, a diaphragm should be washed in mild soap and water, dried gently and stored in
its protective case. With this case, a diaphragm will last for 2-3 years.


Advantage: easy to insert

Disadvantage: prescription needed

Side effects and Contraindications:

If there is an abnormality in the position of the uterus
If there is an intrusion on the vagina (cystocele, rectocele)
History of toxic shock syndrome/TSS-staphylococcal infection introduced through the
Allergy to rubber or spermicide
History of recurrent UTIs
o To prevent TSS while using a diaphragm, advice women to:
Wash their hands thoroughly with soap and water before insertion or removal.
Do not use a diaphragm during a menstrual period
Do not leave a diaphragm in place longer than 24 hours.
Be aware of the symptoms of TSS, such as elevated temperature, diarrhea, vomiting,
muscle aches, & sun-burn like rash.
If symptoms of TSS should occur, immediately remove the diaphragm and call a health care
o Are made of soft rubber, is shape like a thimble with a thin rim and fit snugly over the uterine
o The precautions for use are the same as for diaphragm use except it can be kept in place longer.
o Advantage:
Can be use for several days if desired.
Cervical caps can remain in place longer than diaphragm because they do not put pressure
on the vaginal walls or urethra, however this time period should not exceed 48 hours, to
prevent cervical irritation.
o Disadvantages:
May be difficult to insert, can irritate cervix.
Caps tend to dislodge more readily than diaphragm during coitus.
Cervical caps, like diaphragm must be fitted individually by a health care provider.
o Contraindications:
An abnormally short or long cervix.
A previous abnormal Pap smear
A history of TSS
An allergy to latex or spermicide
A history of pelvic inflammatory disease, cervicitis or papillomavirus infection.
A history of cervical cancer.
An undiagnosed vaginal bleeding


Thin sheath of latex rubber made of fit on mans erect penis to prevent the passage of sperm cells
and sexually transmitted disease organisms into the vagina. It provides dual protection from STIs
including HIV preventing transmission of diseases microorganisms during intercourse
Safe and has no hormonal effect
Protects against microorganisms causing STIs/HIV
Encourages male participation in family planning
Easily accessible
Is used in managing premature ejaculation
May causes allergy for people who are sensitive to latex or lubricant
May decrease sensation, making sex less enjoyable for other partner
Interrupts the sexual act
Requires a mans cooperation for its use
How it is used:
Condom is inserted into the erected penis preventing the sperm from getting in contact with egg
% of Effectiveness:
Perfect Use: 98%
Typical Use: 85%
o Are latex sheaths made of polyurethane and pre-lubricated with a spermicide. The inner ring
(closed end) covers the cervix and the outer ring (closed end) covers the cervix and the outer ring
(open end) rests against the vaginal opening.
o The sheath may be inserted any time before sexual activity begins and then removed after
ejaculation occurs.
o Like male condoms they are intended for one time use and offer protection against both
conception and STIs
C- Hormonal Contraception


As the name implies, hormones that cause such fluctuations in a normal menstrual cycle
that ovulation does not occur.
It may be administered orally, transdermally, vaginally, by implantation or through

Contains hormones-estrogen and progesterone taken daily to prevent contraception
Actions: the estrogen acts to suppress FSH and LH, thereby suppressing ovulation. The progesterone
action complements that of estrogen by causing a decrease in the permeability of cervical mucus, thereby,
limiting sperm motility and access to ova. Progesterone also interferes with tubal transport and
endometrial proliferation to such degrees that the possibility of implantation is significantly decreased.
Benefits: decreased incidence of:
Dysmenorrheal (because of lack of ovulation)
Premenstrual dysphoric syndrome and acne (because of the increased progesterone level)
Iron deficiency anemia (because of the reduced amount of menstrual flow)
Acute pelvic inflammatory disease/PID and tubal scarring
Endometrial and ovarian cancer, ovarian cysts and ectopic pregnancies
Fibrocystic breast disease
Possibly osteoporosis, endometriosis, uterine myoma (fibroid uterine tumors) and of progression
of rheumatoid arthritis
Colon cancer
Side effects:
Weight gain
Breast tenderness
Breakthrough bleeding (bleeding outside the menstrual period)
Monilial vaginal infections
Mild hypertension
Safe as proven through extensive studies
Convenient and easy to use
Makes menstrual cycle occur regularly and is predictable
Reduces gynecologic symptoms such as painful menses and endometriosis
Reduce the risk of ovarian and endometrial cancer
Reversible, rapid return of fertility
Does not interfere with sexual intercourse
Often not use correctly and consistently, lowering its effectiveness
Has side effect such as nausea, dizziness, or breast tenderness, which are not generally harmful
but which some women may find difficult to tolerate
May pose health risk for a small number of women
Offers no protection against sexually transmitted infections. Effectiveness may be lowered when
taken with certain drugs such as rifampicin and most anti-convulsants
Can suppress lactation

Requires regular resupply

Types of Pills
a. Combined oral contraceptives (COCs)
Not advisable for breastfeeding mothers
b. Progestin only Pills (POPs)
Can be taken by breastfeeding mothers because it will not reduce the flow of milk
How it is used:
Drugs are taken daily per orem
% of Effectivesness:
Perfect Use: 99.7%
Typical Use: 92.0%
What to do if woman forgets to take the pill?
If a patient misses a menstrual period while taking an oral contraceptive exactly as prescribed, she
should continue taking the contraceptive.
If a patient misses two consecutive menstrual periods while taking an oral contraceptive, she
should discontinue the contraceptive and take a pregnancy test.
If a patient who is taking an oral contraceptive misses a dose, she should take the pill as soon as
she remember or take two at the next scheduled interval and continue with the normal schedule.
If a patient who is taking an oral contraceptive misses two consecutive doses, she should double
the dose for 2 days and then resume her normal schedule. She should also use an additional birth
control method for 1 week.
If the pill omitted was one of the placebo ones, ignore it and just take the next pill on time the next
If you miss three or more pills in a row, throw out the rest of the pack and start a new pack of pills.
You should use extra protection until 7 days after starting a new pack of pills.
If you think that you might be pregnant, stop taking pills and notify your health care provider
Description/Uses: Contained synthetic hormone, progestin which suppresses ovulation, thickens
cervical mucus, making difficult for sperm to pass through and changes uterine lining
Do not massage the injection site after administration as you want the drug to absorb slowly from
the muscle
Progesterone given every 12 weeks/3 months inhibits ovulation, alters the endometrium and
changes the cervical mucus
No need for daily intake
Does not interfere with sexual intercourse
Perceived as culturally acceptable by some women
Private since it is not coitally dependent
Has no estrogen related side effects such as nausea, dizziness, nor serious complication, such as
thrombophlebitis or pulmonary embolism
Does not affect breast feeding-quantity and quantity of milk not affected
Has beneficial noncontraception effects
How it is uses:
Drug containing progestin into the body to suppress ovulation making sperm difficult to pass
through uterine lining

% of Effectiveness
Perfect Use: 99.7%
Typical Use: 97.0%
Refers to patches that slowly but continuously release a combination of estrogen and
How to use it?
Patches are applied each week for 3 weeks. No patch is applied the fourth week. During the
week on which the woman is patch free, a menstrual flow will occur. After the patch free
week, a new cycle of 3 weeks on / 1 week off begins again.
The efficiency of transdermal patches is equal to that of COCc although they may be less
effective in women weighs more than 90 kg (198 lbs ). Because they contain estrogen,
they have the same risk for thromboembolic symptoms as COCs.
May be applied one of the following areas:
Upper outer arm
Upper torso (front or back excluding the breast)

Side effects:
Mild breast discomfort
Irritation at the application site
They should not be placed on any area where make-up, lotions or creams will be applied, at
the waist where bending might loosen the patch or anywhere the skin is red or irritated or
has an open lesion.
If a patch comes loose, the woman should remove it and immediately replace it with a new
patch. No additional contraception is needed if the woman is sure the patch has been loose
for less than 24 hours.
If the woman is not sure how long the patch has been loose, she should remove it and apply
a new patch, but this will start a new 4 week cycle, with a new day one and a new day to
change the patch. She should also use a back-up contraception method such as a condom
or spermicide for the first week of a new cycle.

Vaginal ring is a silicone ring that surrounds the cervix and continually releases a combination of
estrogen and progesterone.
It is inserted vaginally by the woman and left in place for 3 weeks, then remove for 1 week.
Menstrual bleeding occurs during the ring-free week.

The hormones released are absorbed directly by the mucus membrane of the vagina, thereby
avoiding a first pass through the liver as happens with COCs, this is an advantage for woman
with liver disease.

The rods contain estonogestrial, the metabolite of desogestrel, the same progestin that is used
in Nuva ring. Once embedded, the implants appear as irregular lines on the skin, simulating the
small veins.
Over the next 3-5 years, the implants slowly release the hormone, suppressing ovulation,
stimulating thick cervical mucus and changing the endometrium so that implantation is difficult.
Can be used while breastfeeding
Women have fewer, lighter periods
30% women have no more bleeding periods
May lessen typical PMS symptoms
Side effects:
Weight gain
Irregular menstruation
Scarring at the insertion site
Need for removal
The implants are inserted with the use of local anesthetic, during the menses or no later than day 7
of the menstrual cycle, to be certain that the woman is not pregnant at the time of insertion. At the
end of 3-5 years, the implants are removed under local anesthesia.


What is it?
Contraceptive implants are small rods
about the size of match stick which are
put under the skin in the inside of your
arm. You can feel them under the skin.
They slowly release a hormone called
progesterone. Implants last either 3 or 5
years depending on which one you have.
These implants are effective as
contraception but are not useful for
women who are trying to control painful
periods or bleeding problems
How do they work?
Implants can stop the body from
releasing an egg each month. They also
thicken the mucus in the cervix so that
sperm cannot travel up to meet an egg.

What are the advantages?

Long-acting-once inserted it will be effective for
several years.
Easy to use-there is nothing to do or remember once it
has been inserted.
Effective- it is extremely effective as a contraceptive
Return to fertility- rapid return once it is removed

What are the disadvantages?

Irregular bleeding, or periods that last longer . This
is quite common especially in the first 6 months and
may last for whole 5 years. While it can be annoying, it
is not harmful and does not mean the implant is less
effective. There are treatments to control irregular
bleeding so ask Family Planning or your health
professional about it if this is a problem for you.
No bleeding- periods stops for some women. This is
safe for your body.
Wound problem- you may have bruising.
Occasionally there can be soreness or infection.
Insertion and removal-needs to be done by the
trained health practitioner
Difficulty in removing implant-occasionally the
implant cannot be easily felt under the skin and you
may need to be referred to someone else to remove it.
The research does not show the implants cause any
change in weight, mood, headaches or libido.

How well does it work?

Implants are more than 99% effective in
preventing pregnancy (this means that
only a few women out of a thousand will
get pregnant each year)

What will I notice?

Your periods are likely to change. A few
women have no periods, a few women
have their normal periods, but most
women have a change in bleeding
pattern. This may be infrequent bleeding,
frequent bleeding, light bleeding or heavy
bleeding. This is safe for your body, and
there are pills to treat this if it happens.
Research has shown that about one
woman in every seven has the implant
removed because of bleeding problems.
Does it Protect you from sexually
transmissible infections (STIs)
No, you need to use condom (and
lubricant) as well to protect against STIs.

Becoming pregnant after removal?

Your natural fertility will return as soon as you have the
implant removed.
If you get pregnant with the implant in place and
decide to continue with your pregnancy and the
change of having an abnormal baby is not increased.
You will need to have the implant removed.
Who can use it?
Almost every woman can use it whatever her age. It
is suitable for women who may forget pills,
injection appointments or who may have a medical
reason that stops them using the combined pill.

Who should not use it?

Women who had breast cancer
Women who are taking some medications-check
with your doctor if you are taking regular

How is it put in and taken out?

You need to see someone who is trained
to insert and remove implants. A local
injection is used to numb the area. The
rods are placed under the skin and
steristrips are used to hold the skin
together until the skin heals. It is
removed in the same way. You will have a
small scar from each procedure.
o It is a small plastic object that is inserted into the uterus through the vagina.
o Today, the IUD is thought to prevent fertilization as well as creating a local sterile inflammatory
condition that prevents implantation. When copper is added to the device, sperm mobility appears to
be affected as well. This decreases the possibility that sperm will successfully cross the uterine space
and reaches the ovum.
o An IUD must be fitted by a physician, nurse practitioner or nurse midwife. The device is inserted
before a woman has had coitus menstrual flow to ascertain that the woman is not pregnant.
o A T-shape plastic device wound with copper and LNG-IUS (Mirena), which holds a drug reservoir of
reservoir of progesterone in the stem. The progesterone in the drug reservoir gradually diffuses into
the uterus through plastic. It both prevents endometrium proliferation and thickens cervical mucus.
o It should be avoided by woman who are prone or at risk for STI.

o Effective until 12 years (Mirena Type-5 to 7 years) (Copper T380-10 years)

o The client may experience heavy bleeding
Who can use it?
What is an IUD?
Most women are able to use an IUD-including A small device that fits inside your womb. You
young women and women who have not had
cant feel it or tell it is there except by checking
for the threads. Your partner should not be able
to feel it and you can use tampons. The removal
Mirena is particularly suitable for women with
threads come out your cervix and curl up inside
heavy periods.
the top of your vagina-they dont hang outside
There are two types of IUD. One type contains
copper (Copper IUD). The other type has a
progesterone hormone which is slowly released
into your womb (Mirena)

Who should not use it?

Women who have symptoms of infection should have
treatment before an IUD is inserted.

The Copper IUD is not suitable for women with heavy

or painful periods as it may make them more heavy or

Getting an IUD
Talk to Family Planning about all the possible
benefits, risks and side effects of an IUD for you.
You may be offered tests for STIs (sexually
transmitted infections)
An IUD can be inserted any time it is clear you are not
already pregnant
During or just after menstrual period
6 weeks after your baby is born
At the time of a surgical abortion
Copper IUD as emergency contraception
after unprotected intercourse.
Eat something before your appointment as you are
less likely to feel faint.
You may want to take pain relief tablets before the
appointment-ask the doctor or nurse which tablets
and when to take them.
Most people go straight back to their routine after an
IUD is put in. in case you feel faint or have cramps
after the procedure, you may want to have someone

How does it work?

The main an IUD works is by preventing
fertilization of the egg. The copper or the
hormone from the IUD stops the sperm
moving through the womb towards the egg.
Occasionally an egg is fertilized. The IUD
then stops the egg setting (implanting) into
the womb.
What will I notice?
Copper IUD: spotting, light bleeding,
heavier or prolonged bleeding is
common in the first 3-6 months of use.
This is usually improves with time
Mirena: for the first 3-6 months your
periods may be lighter but longer and
you may have some bleeding or spotting
in between your periods. After this, most
women have lighter periods and some
have no bleeding at all. This is safe for
your body.
Caring for your IUD
You will be given more details when your
IUD is put in.
You should return to the clinic for a
check up about 6 weeks after your IUD is
put in, to make sure it is still in the
correct place.
Self care:
Check your IUD threads after each

available to drive you home, and have the option of

resting for a few hours.
Allow an hour to be in clinic
What are the advantages?
Long acting reversible contraception
Very effective contraception
Can stay in place for many years
Multiload and Mirena licensed for 5 years, Copper T
licensed for 10 years.
However IUDs may be effective longer for some
women-you can discuss this with your doctor or
Can be easily removed (by any doctor or Family
Planning Nurse) if you dont like it or want to get

It is possible to get pregnant as soon as the IUD is

It does not affect breastfeeding
It does not interfere with sexual intercourse.
No one else need know you are using it.
There is no evidence of an increased risk of cancer
Copper IUDs do not contain any hormones.
Copper IUDs can also be used to prevent pregnancy
after unprotected sexual intercourse (emergency
Mirena IUDs have a very small dose of hormone and
most women have no side effects from this:
Mirena reduces period bleeding and pain so most
women will have light bleeding or no periods at all.
What are the disadvantages?
You have to have the IUD inserted. This is usually a
simple, safe procedure carried out by a doctor or
nurse who is experienced at fitting IUDs. it takes
about 5-1o minutes. Most women have some periodlike cramping. Some women feel pain and
occasionally feel faint when the IUD is put in or taken
There are some risks from having an IUD put in:
There may be small chance of infection (about 1%)
when an IUD is put in.
There is a very small risk of damage or perforation of
the womb (about 1 in 1,000)

period or at the beginning of each

calendar month.
See a doctor if:
You have unusual pain, bleeding or
You think your IUD is coming out or
has come out (you may need
emergency contraception)
You think you may be pregnant

If you are pregnant with an UD in place

you need to have a check that the
pregnancy is not ectopic (in the tubes). If
you decide to continue with the
pregnancy the IUD needs to be removed
to decrease the risk of infection and
Safer Sex:
An IUD does not stop you from getting
sexually transmissible infections (STIs).
If you or your partner has sexual
intercourse with someone else, always
use a condom (and lubricant). If there is
a chance you may have an STI, have a
IUD removal
Your doctor or nurse can remove an IUD
by inserting a speculum and pulling the
threads. This may be uncomfortable for a
few seconds. If you want to become
pregnant the IUD can be removed at any
time of your cycle. If you dont want to
become pregnant we need to be sure
there is no chance of an unplanned
pregnancy from sexual intercourse
during the last week. It is better to start
removing the IUD or do not have any
sexual intercourse for at least 7 days
before the removal.
Becoming pregnant after removal
Your natural fertility will return as soon
as you have the IUD removed.

You may (rarely) get pregnant with an IUD in place.

Any pregnancy can be ectopic (in the tubes) this risks
is less than in women not in using any contraception.
Copper IUDs may cause more bleeding and cramping
during periods.
Copper can very rarely cause an allergic reaction.
Mirena may initially cause irregular, light bleeding for
more days than normal.
There is no evidence that Mirena causes acne,
headaches, breast tenderness, nausea, mood
changes, and loss of libido or weight gain.
An IUD can occasionally come out by itself (about
5%)-you can check the strings are still in place after
each period or at the beginning of each month.
Sometimes the thread cannot be seen so that it may
be more difficult t remove the IUD.

If you get pregnant with an IUD in place

and decide to continue with your
pregnancy, the chance of having an
abnormal baby is not increased. You will
need to have the IUD removed


Safe and simple surgical procedure which provides permanent contraception for women who do
not want more children. Also known as bilateral tubal ligation for involves cutting or blocking the
two fallopian tubes.

Permanent method of contraception. A single procedure leads to lifelong, safe and very effective
Nothing to remember, no supplies needed, and no repeated clinic visits required
Does not interfere with sex.

Results in increased sexual enjoyment-no need to worry about pregnancy

No effect on breastfeeding-quantity and quality of milk not effected
No known long term side effects of health risks
Minilaparotomy can be performed after a women gives birth
Uncommon complication of surgery: infection of bleeding at the incision site, internal infection or
bleeding, injury to internal organs, anesthesia risk uncommon with local anesthesia
In rare cases, when pregnancy occurs, it is more likely to be ectopic than in a women who has not
undergone the procedure
Requires physical examination and minor surgery by trained service provider
Requires an operating set up
Permanent-reversal surgery is difficult, expensive, and not available in most areas.
Do not protect against sexually transmitted infection including HIV/AIDS
Clients may have limitation in physical activities such as heavy work and lifting
Heavy objects immediately after surgery
%of Effectiveness:
Perfect Use: 99.5%
Typical Use: 99.5%
Permanent method wherein the vas deferens (passage of sperm) is tied and cut or blocked through
a small opening on the scrotal skin. It is also known as vasectomy

Very effective 3 months after the procedure
Permanent, safe, simple, and easy to perform
Can be performed in a clinic, office or at a primary care center
No apparent long term health risks
An option for couples whose female partner could not undergo permanent contraception
A man who had vasectomy will not lose his sexually ability and ejaculation

Does not affect male hormonal function, erection, and ejaculation

Does not lessen but may actually increase the couples sexual drive and enjoyment
The man can have better sex since he does not fear that his partner will get Pregnant
It may be uncomfortable due to slight pain and swelling 2-3 days after the procedure
Reversibility is difficult and expensive
Bleeding may result in hematoma in the scrotum
% of Effectives:
Perfect Use: 99.9%
Typical Use: 99.9%
Misconception about family planning methods
There are misconceptions to family planning methods. These misconceptions usually come from persons
who lack knowledge and proper training are inexperienced, or not updated on the use of family planning
methods. They may also come from clients who had bad experience during (UI insertions or vasectomy
procedures; who have side effect and may others. Several misconceptions are listed below with the
corresponding proof from research.
Some Family planning methods causes abortion. This is not true. Abortion is the termination of
pregnancy. While family planning prevents pregnancy through the use of contraceptives, and
abstinence during fertile periods, blocking of tubes, all of which prevent the meeting unplanned
Using contraceptives will render couples sterile. When couples use temporary methods such as
fertility awareness based methods and contraceptives such as pills, IUD, injectable and condoms
which are used for birth spacing, when pregnancy is desired, a couple can stop using the
contraceptives method and they can are children again. Vasectomy in men tubal ligation in women
are considered permanent methods and chosen by couples who have completed their desired
family size.
Using contraceptives will result to loss of sexual desire. Sex drive or sexual desire varies from
person to person. In general, use of contraceptives does not affect an individuals sexual desire. In
fact, the use of contraceptives frees the couple from the fear of unwanted pregnancies. This
enhances the couples sexual relationship.
The Roles of Public Health Nurse on Family Planning Program
Nurses play a vital role in FP program. The following activities that a nurse can do are:
Provide counseling among the clients will help increase FP acceptors and avoid defaulters
To inform and educate and convince mothers on the use of family planning methods.
To inform and discuss the importance and benefits/advantages /disadvantages of family
To inform its side effects, complications and what to do if problems develop
to inform its effectiveness of FP methods
Provide packages of health services among reproductive age group in all health facilities
Family planning
Management of reproductive tract infection including STIs/HIV/AIDS
Violence against women
Management of breast and other reproductive cancers
Ensure the availability of FP supplies and logistics for the client



The Maternal Health Program is a set of actions and services administered by the Department of
Health to aid women before, during and after pregnancy. The Philippines is tasked to reduce the
maternal mortality ratio (MMR) by three quarters by 2015 to achieve its millennium development goal.
Millennium Development Goal 5: Improve maternal health
OVERALL GOAL: Improve maternal health and ensure the survival, health and well-being of mothers and
their unborn.
Provide information on FP-MCH through the CHTs and other organized local efforts
Ensure availability of reproductive health and other pre-pregnancy services including adolescent health
and control of sexually-transmitted infections and HIV prevention services through local public health
Increase competencies of health providers in providing comprehensive reproductive health and
maternal and child health services.
Promote facility-based births attended by skilled health professionals catering to the specific needs of
the mother and the newborn (Essential Newborn Care).
Immediate postpartum and postnatal care by skilled health professionals to include immediate and
thorough drying, skin-to-skin contact, properly-timed cord clamping, sustained contact for initiation of
breastfeeding within the first hour (ENC)
Presence of local capacities for securing reliable, updated and complete information about the use of
health services on maternal and child health.
This means a MMR of 112/100,000 live births in 2010 and 80/100,000 live births by 2015.
The maternal mortality ratio (MMR) has declined from an estimated 209 per 100,000 live births in
1987-93 (NDHS 1993) to 172 in 1998. The Philippines found it hard to reduce mortality. Similarly,
perinatal mortality reduction has been minimal. It went down by 11% in 10 years from 27.1 to 24 per
thousand live births.
The percentage of pregnant woman with at least four prenatal visits decreased from 77% in 1998 to
70.4 in 2003. In addition, pregnant women who received at least two doses of tetanus toxoid also
decreased from 38% in 1998 to 37.3% in 2003. Only about 76.8% of pregnant women received iron
supplementation during pregnancy.
The Philippine Health Statistics revealed that maternal deaths are due to:
Pregnancy with abortive outcomes
However births attended by health professionals increased from 56% in 1998 to 59.8% in 2003. There
was also a notable increase to 51% in 2003 from 43% in 1998 in the percentage of women with at least
one prenatal visit. Only 44.6% of postpartum women received a dose of Vitamin A.
The underlying causes of maternal deaths are delays in taking critical actions:
delay in seeking care,
delay in making referral and
delay in providing of appropriate medical management.
Other factors that contribute to maternal deaths includes
closely spaced births,
frequent pregnancies,
poor detection and management of high-risk pregnancies,
poor access to health facilities brought about by geographic distance and
cost of transportation, and
as well as health care and health staff who lack competence in handling obstetrical emergencies.
The overall goal of the Maternal Health Program is to improve the survival, health and well-being of
mothers and unborn through a package of services all throughout the course of and before pregnancy.



Newborns, infants and children are vulnerable age group for common childhood diseases. The risk of
infection among children is higher when not screened for metabolic disorder, not exclusively
breastfed, unvaccinated not properly manage when sick, not given with vitamin supplementation and
many others. To address problems, child health programs have been created and available in all health
facilities which include:
Infant and young child feeding
Newborn screening
Expanded program on immunization
Management of childhood illnesses
Micronutrient supplementation
Dental health
Early child development
Child health injuries
Its main goal is to reduce morbidity and mortality rates for children 0-9 years with the strategies
necessary for program implementation.

A- Millennium Development Goal 1: Eradicate extreme poverty and hunger

National Objectives for 2011-2016
OVERALL GOALS: Protein energy malnutrition and iron deficiency anemia are reduced. Vitamin A and
iodine deficiencies are eliminated as public health problems. Nutritional risk factors and their healthrelated effects are managed.


Target the nutritionally at-risk and vulnerable. Priority will be given to areas with high prevalence of
under-nutrition and micronutrient deficiencies and to children 0-5 years old, pregnant, and
lactating mothers using the CHTs.
Promote optimum infant and young child feeding practices in various settings to reduce the
prevalence of underweight and stunted under-five children
Adopt and implement appropriate guidelines for the community-based management of acute
Integrate and strengthen nutrition services in the maternal continuum of care (ante-natal, delivery,
post-partum care)
Deliver an integrated package of nutrition services in the school and alternative school system
Increasing the supply and consumption of micronutrients to reduce or maintain the prevalence of
vitamin A deficiency and iodine deficiency disorders to levels below public health significance


Importance of Breastfeeding

Exclusive breastfeeding of infants recommended for the first six months of their lives and
breastfeeding with complementary foods thereafter. Breastfeeding has many psychological
benefits for children and mother as well as economic benefits for families and societies.
The Benefits of Breastfeeding
a. To infants
Provide a nutritional complete food for the young infant
Strengthen the infants immune system, preventing many infection
Safely rehydrates and provides essential nutrients to a sick child, specially to those
suffering from diarrheal disease
Reduces the infants exposure to infection
Increase IQ points
b. To Mother
Reduces womans risk of excessive blood loss after birth
Provides natural methods of delaying pregnancies
Reduces the risk of ovarian and breast cancer and osteoporosis

c. To Household and the Community

Conserve fund that otherwise would be spend on breast milk substitute, supplies and fuel
to prepare them.
Saves medical cost to families and government by preventing illnesses and by providing
immediate postpartum and contraception
After six months of age, all babies require other foods to complementary breast milk
- We call these complementary foods. when complementary foods are introduced breastfeeding
should still continue for up to two years of age or beyond
Complementary foods should be:
Timely meaning that they are introduces when the need for energy, protein and micronutrients
exceeds what can be provide through exclusive and frequent breastfeeding
Adequate - meaning that they provide sufficient energy, protein and micronutrients to meet a
growing childs nutritional needs.
Safe meaning that they are hygienically stored and prepared and fed with clean hands using clean
utensils and not bottles and teats.
Property fed meaning they are given consistent with a childs signals of hunger and that meal
frequency and feeding methods are suitable for the childs age.
Low - birth weight babies
The term low birth weight (LBW) means a birth weight of less than 2,500 grams. This includes babies
who are born before term, and who are premature and babies who are small for gestational age.
Babies may be small for both these reasons. In many countries 15.20% of all babies are low birthweight. Low-bright weight babies are at particular risk of infection, and they need breast milk more
than larger babies.
Many LBW babies can breastfeed without difficulty. Babies born at term, who are small for-dates,
usually suckle effective. They are often very hungry and need to breastfeed more often than larger
babies, so that their growth can catch up. Babies who are born preterm may have difficulty suckling
effectively at first. But they can be fed on breast milk by tube or cup, and helped to establish full
breastfeeding later. Breastfeeding is easier for these babies than bottle feeding.
The fluid needs of the young child
The baby who is exclusively breastfeeding receives all the liquid he needs in the breast milk. When other
foods are added to the diet, the baby may need extra fluids. Likewise, a baby who is under six months of

age and only receiving replacement milks does not need extra water. Extra fluid is needed if the child has a
fever or diarrhea.
Fluid needs of the young child
Water is good for thirst. A variety of pure juice can be used also. Too much fruit juice may cause
diarrhea of sugar may actually make the child appetite for foods.
Drinks that contain a lot of sugar may actually make the child thirstier as their body has to deal with
the extra sugar. If package juice drinks are available in your area, find out which one are pure juices
and which ones have added sugar. Fizzy drinks (sodas) are not suitable for young children.
Teas and coffee reduce the iron that is absorbed from foods. If they are given, they should not be
given at the same times as food or within two hours before or after food.
Sometimes a child is thirsty during a meal. A small drink will satisfy the thirst and they may then eat
more of their meal.
Drinks should not replace foods or breastfeeding. If a drink is given with a meal, give only small
amounts and leave most until the end of the meal. Drinks can fill up the childs stomach sot they
do not have room for foods.
Remember that children who are not receiving breast milk need special attention and special
recommendations. A non-breastfed child age 6-24 months of age needs approximately 2-3 cups of
water per day in a temperature climate and 4-6 cups of water per day in a hot climate. This water
can be incorporated into porridges or stews, but clean water should also be offered to the child
several times a day to ensure that the infants thirst is satisfied.
Feeding the Child who is ill
Encourage the child to drink and to eat with lots of patience
Feed small amounts frequently
Give foods that the child likes
Give a variety of nutrient rich foods
Continue to breastfeed often ill children breastfeed more frequently
Feeding during recovery
The childs appetite may be poor during illness. Even with encouragement to eat, the child may not eat
well. The childs appetite usually increases after illness so it important to continue to give extra attention to
feeding after the illness. This is a good time for families to give extra food so that lost weight is quickly
regained. This allows catch-up growth. Young children need extra food until they have regained all their
lost weight and are growing at a healthy rate.
Give extra breastfeeds
Feed an extra meal
Give an extra amount
Used extra rich foods
Feed with extra patience
Breast milk and breast feeding
Breastmilk is the best food for the baby form birth up to 6 months.
It meets all the food and fluid needs of the baby from birth up to 6 months
It protects the baby from disease and malnutrition.
Give colostrum to the baby.
It prepares your babys stomach to digest milk.
It contains many protective substances against infection.
It does not cause tummy ache or diarrhea.
Do NOT give plain water, sugared water, chewed sticky rice, herbal preparations or starve the baby
while waiting for the milk to come in.
Giving feeds other than breast milk will deprive the baby of needed nutrients and other
protective substances form colostrum.

Water, chewed sticky rice or herbal preparations may be contaminated with germs that may
cause diarrhea.
Giving feeds other than breast milk after birth will deprive you of the crucial time for
immediate breastfeeding which will help to prevent breast problems.
Give only breast milk and no other food or drink to your baby form birth up to 6 months.
Breast milk will satisfy all the nutrient and fluid needs of your baby from birth up to 6
Giving other food and drinks may cause digestion problems and infection in the baby and
will decrease your milk production.
Breastfeed as often as the baby wants, day and night.
Breastfeeding per babys demand ensures that he/she gets sufficient nutrients.
This is the best stimulus for continued milk production.
Use both breasts alternately at each feeding.
This will prevent engorgement and infection.
After one breast is emptied, offer first the breast that has not been emptied in the next feeding.

Key message on feeding babies over six months old

1. Breastfeeding for two years or longer helps a child to develop and grow strong and healthy.
2. Starting other foods in addition to breast milk at 6 complemented months helps a child to grow
3. Foods that are thick enough to stay in the spoon give more energy to the child
4. Animal-source foods are especially good for children to help them grow strong and lively.
5. Peas, beans, lentils, nuts and seeds are also good for children.
6. Dark green leaves and yellow-coloured fruits and vegetables help a child to have healthy eyes and
fewer infections.
7. A growing child needs three meals plus snacks: give variety of foods.
8. A growing child needs increasing amounts of foods.
9. A growing child needs to learn to eat, encourage and give help with lots of patience.
10. Encourage children to drink and eat during illness and provide extra food after illness to help them
recover quickly.
Laws That Protects Infant and Young Child Feeding
1. Milk Code (EO 51) products covered by Milk Code consists of breast milk substitutes, including
infant formula; other milk products, foods and beverages, including bottle-fed complementary
2. The Rooming-In and Breastfeeding Act of 1992 requires both public and private health
institutions to promote rooming-in and to encourage, protect, and support the practice of breast
feeding. It targets the creation of an environment where basic physical, emotional and
psychological needs of mothers and infants are fulfilled through the practice of rooming-in and
breast feeding. The law also requires institutions adopting rooming-in to provide a human milk
bank to ensure collection, storage and utilization of breast milk.
Compliance to the law is ensured through one of the 10 th steps to Mother.
Baby Friendly Hospitals wherein the mother and the baby should be together for 24 hours and as
long as both are in the hospital.
3. Food Fortification Law or An Act Establishing the Philippine Food Fortification Program and
for Other Purposes-Food Fortification law (Republic act 8976) passed by Congress in 2000
declares as a policy that food fortification is vital in the promotion of optimal health and to
compensate for the loss of nutrients due to processing and / or storage of food.


Malnutrition continues to be public health concerns in the country. The common nutritional
deficiencies are: 1) Vitamin A 2) Iron and , 3.) Iodine These deficiencies lead to a serious
physical, mental, social and economic condition among children and women.
The goal of the nutrition program is to improve quality Filipinos through better nutrition, improved
health and increased productivity.
1. Reduction in the proportion of Filipinos household with intake below 100% of the dietary energy
requirement from 53.2%to 44%.
2. Reduction in:
a. Underweight among preschool children
b. Stunting among preschool children
c. Chronic energy deficiency among pregnant woman
d. Iron deficiency among children 6 months to five years old, pregnant and lactating mothers
e. Prevalence of overweight, obesity non-communicable diseases
f. Reduction in the prevalence of iron deficiency disorder among lactating mothers
g. Elimination of moderate and severe IDD among school children and pregnant women.
h. Reduction in the prevalence of low birth weight
1. Food base intervention for sustained improvements in nutritional status
2. Life-cycle approach with strategic attention to 0-3years old children, adolescent females and
pregnant /lactating women
3. Effective complementation of nutrition interventions with other services
4. Geographical focus to needier areas
Program and Project:
1. Micronutrient and Supplementation
Micronutrient supplementation is one of the interventions to address the health and nutritional
needs of infants and children and improve their growth and survival. The twice-a-year distribution
of vitamin A capsules through the
Araw ng sangkap pinoy (ASAP), knowas garantisadong pambata (GS), or child health week is the
approach adopted to provide micronutrient supplement to 6-71 months old preschooler on a
nationwide scale. While the micronutrient guideline provide for the giving of iron supplements
depend on the capability of LGUs to procure the drugs. The iron and vitamin A supplementation
among under five years old children nationwide has reached about 63.3% and 76.0% respectively.
2. Food Fortification
Food fortification is also pushed to improve the nutrition status of the populace to include the
children. The addition of essential nutrients to a widely consumed food product at level above
its natural state is a cost effective and sustainable intervention to address micronutrient
deficiencies. The Food Fortification Act of 2000 provides for the mandatory fortification of
staples namely: flour, with iron and Vitamin A, cooking oil and refined sugar with Vitamin A and
rice with iron and the voluntary fortification of processed foods though the Sangkap Pinoy
Seal The household utilization of iodized salt is at 55%. The prevalence of iodine
Deficiency Disorders (IDD) has decreased among school children 6-12 years old based on
urinary iodine excretion level (UIE) from 35.% in 1998 to 11.1% in 2003 (FNRI-NNS,2003).The
usage of fortified products is at 52.7% of households with at least one product with a Sangkap
Pinoy Seal at home.
3. Essential Maternal and Child Health Service Package.
This ensures the right of the child to survival, development, protection and participation. It
includes the delivery of essential maternal and child health and nutrition package of services
that will ensure the right to survival, development protection and participation as follows:
Breast feeding
Complementary feeding


4. Nutrition information, communication and education these includes the promotion to

nutritional guidelines for Filipinos and other nutrition key messages and training of health
5. Home, School and Community Food Production
It includes establishment of kitchen, gardens in homes, schools and in communities in urban
and rural areas to serve as source of additional food for the home and establishment of
demonstration centers and nurseries and distribution of planting materials.
6. Food assistance includes center based complementary feeding for wasted/stunted
children and pregnant women with delivering low birth weight. This may be done in
school. Rice distribution is done in school through the efforts of local units. Food discount
were provided through Tindahan Natin proGram.
Livelihood assistance is done by provision of credits and livelihood opportunities to poor
household especially those with malnourished children through linkage with lending and financial
institutions. Functional literacy training helps in this endeavor
Universal Supplementation of Vitamin A
Infants 6-11 months
100,000 IU
1 dose only
One capsule given anytime
between the 6-11 months but
usually given at 9 months
during the measles
Chindren 12-71
200,000 IU
1 capsule every 6
Vitamin A supplementation to high-risk children
One capsule given upon diagnosis, regardless
100,000 IU
of when the last dose was given
Infants 6-11 months
200,000 IU
Pre-school children (12-71
100,000 IU
One capsule given upon diagnosis, regardless
Severe pneumonia, persistent
of when the last dose was given
diarrhea, malnutrition
Infants 6-11 months
200,000 IU
One capsule given upon diagnosis, except
Severe pneumonia, persistent
when the child was given less than 4 weeks
diarrhea, malnutrition
before diagnosis
12-71 months
200,000 IU
One capsule given upon diagnosis, except
when the child was given less than 4 weeks
6yrs-12 yrs
before diagnosis
Iron Supplementation to Infant-School Children
Low birth weight
Drops: 15 mg elemental iron/0,6 mL
0.3 ml once a day to start at 2
months of age until 6 months
Children 1-5 yrs. Old
Syrup containing 30 mg iron/5 ml
1 tbsp OD for 3 months or 30 mg
once a week for 6 months
Children 6-11 yrs. Old
Syrup containing 30 mg elemental
2 tbsp OD for 6 months
anemic and underweight
iron/5 ml



In the Philippines, the main oral health problems are dental caries (tooth decay) and periodontal
disease (gum disease). These two diseases are widespread that 92% of our people are suffering
from tooth decay and 78.0% have gum disease.
In terms of decayed, missing, filled teeth (DMFT) Index, Philippines ranked second worst among
21 WHO Western Pacific countries. Dental caries and periodontal disease are observed to be
significantly more prevalent in rural than in urban areas.

Reduce the prevalence rate of dental caries and periodontal diseases from 92% in 1998 to 85% and
from 78% by end of 2010 among general population.
1. To increase the proportion of Orally Fit Children under 6 years old to 80%by 2010
2. To control oral health risks among the young people
3. To improve the oral health conditions of pregnant women by 20%and older persons by
10%every year until 2010
Basic Package of Oral Health Care:
The following are the basic package of essential oral services/care for every lifecycle to be provided
in all health facilities including schools or at home.
Stage of Life
Mother (pregnant)

Neonatal and infants under 1 year


Children 12-71 months old

School Children 96-12 years)


Oral examination
Oral prophylaxis
Permanent Filings
Gum treatment
Health Education
Dental check up as soon as the first
tooth erupts
Health instruction on infant oral health
care and advice on exclusive
Dental check-up as soon as the first
tooth appears and every 6 months
Supervised tooth brushing drills
Oral urgent treatment OUT)
- Removal of unsavable teeth
- Referral of complicated cases
- Treatment of post extraction
Application of Atraumatic Restorative
Oral examination
Supervised tooth brushing drills
Topical Fluoride Therapy
Pits and Fissure Sealant application
Oral Prophylaxis

Permanent Filings

Adolescent and Youth (10-12years old)

Other adults (25-59 years old)

Older Persons

Oral examination
Health promotion and education,
adverse effect of consumption of
sweets and sugary beverages.
Tobacco and alcohol
Oral examination
Emergency dental treatment
Health instruction and advise
Oral examination
Extraction of unsavable tooth
Gum treatment
Relief of pain
Health instruction and advice

Classification of Oral Interventions:

There are classifications of oral interventions that need to be carried out to address oral problems.
There are: 1) preventive, 2) curative, 3) Promotive services.
Preventive services consist of the following measures which will promote oral health and provide
specific protection from the occurrence of dental caries and other oral diseases. There are types of
preventive interventions:
Oral examination is the careful checking of the oral cavity by duty trained dentist to detect sign
diagnose oral diseases and conditions, oral examinations, and detect signs and symptoms of
Sexually Transmitted Disease-AIDS and other non communicable diseases such as diabetes
0ral hygiene is a basic personal measure to prevent and control tooth decay and gum disease. It
includes among other oral prophylaxis, regular and proper way of tooth brushing, gum massage,
eating detersive foods and the use of mouthwashes
Pit and fissure sealant program a non-invasive preventive and control measure against tooth
decay for children. Fluoride therapy is best for smooth surfaces but limited where grinding
surfaces are concerned owing to the presence of pit and fissures on the surfaces.
Fluoride Utilization Program a non invasive and control measures through multiple use of
fluoride in areas where fluoride content is low. Flouridation can be done in systemic and local
Curative/Treatment services these are remedial measure applied to halt the progress of oral
disease and restore the condition of the teeth and supporting tissues. It includes:
Permanent filing which is the restoration of savable teeth with amalgam, composite or glass filing
Gum Treatment is the deep scaling and root planning of effected tooth or teeth for pregnant
mothers and older person with periodontal disease


Atraumatic restorative treatment is one form of permanent filling for priority target groups by
manually cleaning dental cavities using hand instruments and filling the cavities with fluoride glass
releasing glass ionomer restorative materials.
Temporary filling is the treatment of deep seated tooth decay with zinc oxide and eugenol
Extraction is the removal of unsavable teeth to control foci of infection
Treatment of post extraction complication such as dry sockets and bleeding
Drainage of localized oral abscesses-incision and drainage

B.Millennium Development Goal 4: Reduce Child mortality


OVERALL GOAL: Reduction of under-five mortality rate by two-thirds.
Promote universal access to the standard child survival package of interventions. Priority will
be given to areas with high prevalence of under-five mortality rate using the CHTs.
Routine vaccination of all infants ages 0-11 months adopting the Reaching Every Barangay
Supplemental immunization activity either as small scale or large scale immunization
Enhance the capacity and coordination of the service delivery networks as channels of child
survival interventions.
Create opportunities for communities to overcome barriers to utilization of child survival (CS)
Build the LGUs resolve to adopt and implement the CS Strategy.
Harmonize efforts of DOH, allied agencies and partners in supporting local delivery of CS


The Concept and importance of Vaccination

Immunization is the process by which vaccines are introduced into the body before infection sets in
Vaccines are administered to induce immunity thereby causing the recipients immune system to
react to the vaccine that protect children antibodies to fight infection. Vaccinations promote health
and protect children from disease-causing agent. Infant and newborns need to be vaccinated at an
early age since they belong to vulnerable age group. They are susceptible to childhood diseases.
There are several general principles which apply in vaccinating children:
It is safe and immunologically effective to administer all EPI vaccines on the same day at different
sites of the body.
Measles vaccine should be given as soon as the child is 9 months old, regard- less of whether other
vaccine will be given on that day. Measles vaccines given at 9 months provide 85% protection
against measles infection. When given at the year and older provides 95% protection.
The vaccination schedule should not be restarted from the beginning even if the interval between
doses exceeded the recommended interval by month or years.
Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea and vomiting are not
contraindication to vaccination. Generally, one should immunize unless the child is so sick the he
needs to be hospitalize.
The absolute contraindication to immunization are:
DPT2 or DPT3 a child who has had convulsion or shock within 3 days the previous dose.
Vaccines containing the whole cell pertussis component should not be given to children
with an evolving neurological disease (uncontrolled epilepsy of progressive


Live vaccines like BCG vaccine must not be given to individuals who are
immunosuppressed due to malignant disease (child with clinical AIDS), therapy with
immunosuppressive agent, or irradiation.
It is safe and effective with mild side effects after vaccination. Local reaction, fever and systemic
symptoms can result as part of the normal immune response.
Giving doses of a vaccine at less than the recommended 4 weeks interval may lessen the antibody
response. Lengthening the interval between doses of vaccines leads to higher antibody levels.
No extra doses must be given to children/mother who missed a dose of DPT/HB/OPV/TT. The
vaccination must be continued as if no time had elapsed between doses.
Strictly follow the principle of never, ever reconstituting the freeze dried vaccines in anything other
than the diluent supplied with them.
False contraindications to immunizations are children with malnutrition, low grade fever, mild
respiratory infections and other minor illnesses and diarrhea should not be considered a
contraindication to OPV vaccination. Repeat BCG vaccination if the child does not develop a scar
after 1st injection.
Use one syringe one needle per child during vaccination.
The EPI Target Diseases
Vaccination among infants and newborns (0-12 months) against the seven vaccine preventable diseases.
These includes: tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, measles and Hepatitis (See list
of EPI Diseases with the corresponding WHO standard case definition)
The EPI Vaccines and its Characteristics
Vaccines are substances very sensitive at various temperatures. To avoid spoilage and maintain its
potency, vaccines need to be stored at correct temperature.
Below are recommended storage temperatures of EPI vaccines.

Most Sensitive to Heat

Type / from of Vaccines

Storage Temperature

Oral Polio ( live attenuated)

-15 C to -25 C (at the

freezer )
-15 C to -25 C (at the
freezer )
+2 C to +8 C (in the body of
the refrigerator)

Measles (freeze dried)

Least Sensitive to Heat

D Toxiod which is a
weakened toxin
P Killed bacteria
T Toxiod which is a
weakened toxin
Hep B

+2 C to +8 C (in the body of

the refrigerator)

BCG (freeze dried)

+2 C to +8 C (in the
body of the refrigerator

Tetanus Toxoid

When handling, transporting and storing vaccines, special care must be given to provide quality
potent vaccines among the targets.
A first expiry and first out (FEFO) vaccines is practiced to assure that all vaccines are utilized
before its expiry date, Proper arrangement of vaccines and/or labeling of vaccines expiry date
are done to identify those near to expire vaccines.

Temperature monitoring of vaccines is done in all levels of health facilities to monitor vaccine
temperature. This is done twice a day early in the morning and in the afternoon before going
home. Temperature is plotted every day in a temperature monitoring chart to monitor break in the
cold chain.
Each level of health has cold chain equipment for use in the storage of vaccines. these are: cold room,
freezer refrigerator, transport box, vaccine carrier. Other cold chain logistics supplies includes:
thermometers, cold chain monitor, ice packs, temperature monitoring, chart, safety collector box, etc.
these are essentials in proper management of vaccines and other EPI logistics.


# of


age at
first dose
Birth or
any time
after birth
6 weeks




9 months

Hep B

At birth


12 months


6 weeks


Administration of Vaccines
Route,Dosage, Interval

Type/form of


Freeze dried, live

attenuated bacteria

2-80C body of

D-weakened toxin
P-killed bacteria
Live attenuated
Freeze dried, live
attenuated virus

2-80C body of

6 wks interval
from 1st dose to
2nd dose, 8 wks
interval from 2nd
to 3rd dose

RNA recombinant

2-80C body of

Live attenuated

2-80C body of

4 weeks

D- Weakened
P- killed bacteria
T- toxin
CHON conjugate
Live attenuated

2-80C body of

ID, 0.05 ml at
Right arm
IM, 0.5 ml at
vastus lateralis
Oral, 2 drops by
SQ, 0.5 ml outer
part of upper
IM, 0.5 at vastus
lateralis (thigh)

SQ, 0.5 ml, outer

part of upper
IM, 0.5 ml, at
vastus lateralis


4 weeks

4 weeks

Rota6 weeks
4 weeks
IM, 0.5 ml at
deltoid region
Procedures in the giving of vaccines:
Reconstituting the freeze dried BCG Vaccine:

-15 to -25 C
-15 to -25 C

2-80C body of

a. Always keep the diluents cold by sustaining with BCG vaccine ampoules in refrigerator or vaccine
b. Using a 5 ml. syringe fitted with a long needle, aspirate 2 ml. of saline solution from the opened
ampule of diluents.
c. Inject the 2 ml. saline into the ampule of freeze dried BCG.
d. Thoroughly mix the diluents and vaccine by drawing the mixture back into the syringe and expel it
slowly into the ampule several times.
e. Return the reconstituted vaccine on the slit of the foam provided in the vaccine carrier.
Absolute Contraindications
DPT2 and DPT3 to a child who has had a convulsions or shock within 3 days of the previous dose
Live vaccines like BCG must not be given to individuals who are immunosuppressed
Giving BCG Vaccine :
a. Clean the skin with a cotton ball moistened with water and let skin dry.
b. Hold the child arm with your left hand so that: your hand is under the arm, and your thumb and
fingers come around the arm and stretch the skin.
c. Hold the syringe in your right hand with the bevel and the scale pointing up towards you.
d. Lay the syringe and needle almost flat the childs arm,
e. Insert the tip of the needle into skin- just the bevel and a little bit more. Keep the needle flat along
the skin and the bevel facing upwards, so that the vaccine only goes into the upper layers of the
f. Put your left thumb over the needle end of the syringe to hold it in position. Hold the plunger end
of the syringe between the index and middle fingers of your right hand press the plunger in with
your right thumb.
g. If the vaccine is injected correctly into the skin, a flat wheal with the surface pitted like an orange
peel will appear at the injection site.
h. Withdraw the needle gently.
Giving Oral Polio Vaccine
a. Read the manufacturers instructions to determine number of drops to be given. Use the dropper
provided for.
b. Let the mother hold the child lying firmly on his back.
c. If necessary open childs mouth by squeezing the cheeks gently between your fingers to make his
lips point upwards.
d. Put drops of vaccine straight from the dropper onto the childs tongue but do not let the dropper
touch the childs tongue.
e. Make sure that child swallows the vaccine. If he spits it out. Give another dose.
Hepatitis B and DPT
Giving Hepatitis B/DPT
a. Ask mother to hold the child across her knees so that his thigh is facing upwards. Ask her to hold
childs legs
b. Clean the skin with a cotton ball, moistened with water and let skin dry.
c. Place your thumb and index finger on each side of the injection site and grasp the muscles slightly.
The best injection site is the outer part of the childs mid thigh
d. Quickly push the needle into the space between your fingers, going deep in the muscle
e. Slightly pull the plunger back before injection to be sure that vaccine is not injected into a vein (if
using disposable syringes and needles)
f. Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton.
Reconstituting the Freeze Dried Measles Vaccine
a. Using a 10 ml. syringe into the vial with the vaccine.
b. Empty the diluents from the syringe into the vial with the vaccine.

c. Thoroughly mix the diluents and vaccine by drawing the mixture back into the syringe and
expelling it slowly into the vial several times. Do not shake the vial
d. Protect reconstituted measles vaccine from sunlight. Wrap vial in foil.
e. Place the reconstituted measles vaccine in the slit of the foam provided in the vaccine carrier.
Giving Measles Vaccine
a. Ask the mother to hold the child firmly.
b. Clean the skin with a cotton ball, moistened with water and let the skin dry.
c. With the fingers of one hand, pinch up the skin on the outer side of the upper arm.
d. Without touching the needle, push the needle into the pinched-up skin so that it is not pointing.
e. Slightly pull the plunger back to make sure that the vaccine is not injected into a vein (if using
disposables syringe and needle ).
f. Press the plunger gently and inject.
Tetanus Toxiod
Giving Tetanus Toxiod
a. Shake the vial
b. Clean the skin with a cotton ball, moistened with water and let skin dry.
c. Place your thumb and index finger on each side of the injection site and grasp the muscles, slightly.
The best injection site for a woman is outer side of the left upper arm.
d. Slightly pull the plunger back before injecting to be sure that vaccine is not injected into a vein.
e. Quickly push the needle into the space between your fingers, going deep in the muscle.
f. Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton.
Note: Shake the vial before every injection.
The Role of a Nurse In Improving the Delivery of Immunization Services in the Community
Health workers are vital to health care delivery system. The most critical problem we are facing
now is the lock of nurses and other discipline in carrying health activities in immunization. Your
presence in the community is a big contribution to program health development. For every child
you have been immunized reduces missed opportunity and help increase population immunity of
the population groups.
As a nurse you need to:
Actively master list infant s eligible for vaccination in the community
Immunize infant following the recommended immunization schedule, route of administration,
correct dosage and following the proper cold chain storage of vaccine.
Observe aseptic technique on immunization and use one syringe and one needle per child. This
reduces blood borne diseases and promotes safety injection practices.
Dispose used syringes and needle properly by using collector box and disposing it in the septic
vault to prevent health hazard
Inform, educate and communicate with the parents
- to create awareness/motivate to submit their children for vaccination
- to provide health teachings on the importance and benefits of immunization, importance of
follow up dose to avoid defaulters and normal course of vaccine
- to inform immunization schedule as adopted by local units
Conduct health visit in the community to assess other health needs of the community and
be able to provide package of health services to targets
Identify cases of EPI target diseases per standard case definition
Manage vaccines properly by following the recommended storage of vaccines
Record the children given with vaccination in the Target. Client list and GECD/GMC card or
any standard recording form utilized
Submit report and record of children vaccinated , cases and deaths on EPI diseases,
vaccine received and utilized and any other EPI related report

Identify and actively search cases and death of EPI target diseases following standard case

Newborn Screening Act of 2004 RA 9288
48th to the 72nd hour of life may also be done 24 hours from birth
Must be screened again after 2 weeks for more accurate results
In participating Newborn Screening Facilities that includes hospitals, lying-in centers, RHUs
and health centers
Uses the heel prick method
A few drops of blood are taken from the babys heel and blotted on a special absorbent filter
card. The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab)
Newborn screening results are available within 7 working days after the samples are
received in the NBS lab.
Any lab. Results indicating an increased risk of heritable disorder shall be immediately
released within 24 hours.
A negative screen means that the result of the test indicates extremely low risk of having
any of the disorders being screened
A positive screen means that the baby is at risk of having one of the disorders being
Roles of RHUs Staff
1. Advocacy for the newborn screening of every baby
2. Sample collection
3. Assures transports of specimen to the nearest Newborn Screening Facility within 24 hours.
4. Advice and counsel parents upon receiving the screening results




List disorders screened

CH (Congenital Hypothyroidism)
Results from lack of or absence of thyroid hormone, which is essential to growth of the
brain and the body.
If the disorder is not detected and hormone replacement is not initiated within 4 weeks,
the babys physical growth will be stunted and he/she may suffer from mental
Congenital adrenal hyperplasia
Is an endocrine disorder that causes severe salt loss, dehydration and abnormally high
levels of male sex hormones in both boys and girls.
If not detected and treated early, babies may die within 7-14 days.
Is a condition in which the body is unable to process galactose, the sugar present in
milk. Accumulation of excessive galactose in the body can cause many problems
including liver damage, brain damage and cataracts.
G6PD (Gluscose-6-Phosphate Dehydrogenase Deficiency)
Is a condition where the body lacks the enzyme called G6PD


Babies with this deficiency may have hemolytic anemia resulting from exposure to
certain drugs, foods and chemicals.
5. Phenylketonuria (PKU)
Is a metabolic disorder in which the body cannot properly use one of the building blocks
of protein called phenylalanine. Excessive accumulation of phenylalanine in the body
causes brain damage


There are essential package of health services that a newborn, infant and child has to receive during the
early stages of development. Children who were provided with these interventions are protected from
common preventable disease and other conditions.
1. Newborn resuscitation
2. Newborn routine eye prophylaxis
3. Prevention and management of hypothermia of the newborn
4. Newborn screening
5. Immediate and exclusive breastfeeding
6. Complementary feeding at six months
7. Birth registration
8. Birth weight and growth monitoring
9. Full immunization
10. Micronutrient supplementation
11. Dental Care
12. Developmental milestone screening
13. Advise on psychosocial stimulation
14. Growth monitoring and promotion
15. Nutritional screening
16. Micronutrient supplementation
17. Disability detection
18. Management of common childhood illness
19. Counseling on accident prevention and use of safe toys
20. First Aid
Essential Health Care Package for the Adolescent and Youth:

Management of illness
Counseling on substance abuse, sexuality and reproductive tract infections
Nutrition and diet counseling
Mental health
Family planning and responsible sexual behavior
Dental care

Essential health care package for the adult Male and Female:
1. Management of illness
2. Counseling on substance abuse, sexuality and reproductive tract infectious
3. Nutrition and diet counseling
4. Mental health
5. Family planning and responsible sexual behavior
6. Dental care
7. Screening and management of lifestyle related and other degenerative diseases

Essential Health Care Package for the Older Persons:

1. Management of illness
2. Counseling on substance abuse, sexuality and reproductive tract infectious
3. Nutrition and diet counseling
4. Mental health
5. Family planning and responsible sexual behavior
6. Dental care
7. Screening and management of lifestyle related and other degenerative diseases
8. Screening and management of chronic debilitating and infectious diseases
9. Post-productive care


Target age of IMCI strategy
1. Sick young infant: 0 up to 2 mos.
2. Sick young child: age 2 mos. Up to 5 years
Case Management Process
A. Young infant
1. Assess and classify
2. Treat and counsel
3. Follow-up
B. Child
1. Assess and classify: Check for DGS, ask about the main symptoms
2. Treat
3. Follow-up
4. Counsel the mother
The main symptoms
a. Infant
1. Check for very severe disease and local bacterial infection
2. Check for jaundice
3. Diarrhea
4. HIV infection
5. Feeding problem or low weight for age
6. Feeding problem or low weight for age in non-breastfeed infants
b. Child
1. Cough or difficulty of breathing
2. Diarrhea
3. Fever
4. Ear problem
5. Acute malnutrition
6. Anemia
7. HIV infection
General Danger Signs
1. Vomits everything

2. Convulsions
3. Unable to drink/breastfeed
4. Abnormally sleepy


Nursing audit
Care outcomes
Performance appraisal
Estimate cost benefit ratio
Assessment of problems
Identify need alterations
Revise plans as necessary
Evaluation is interwoven in every nursing activity and every step of the public health nurses. There are
three classic frameworks from which nursing care is delivered. An improvement in anyone of these three
teds to produce favorable change in the other two.
Structural elements include the physical settings, instrumentalities and conditions through which nursing
care us given such as philosophy, objectives, building, organizational structure, financial resources such a
budget, equipment and staff.
Outcome elements are change in the clients health status that results from nursing intervention. These
changes include modification of symptom, signs, knowledge, attitudes, satisfaction, skill level and
compliance with treatment regimen.
Each of these frameworks permits more than one approach to a quality assurance. For example, structure
can be examined from the standpoint of the total community in which the patient lives and the public
health agencies from which he/she receives his/her care. Process can be examined by focusing on the
actions and decisions of the public health nurse in providing care. Outcome elements refer to the results of
care provided and the clients served, changes in the knowledge, skills and attitudes and satisfaction of
hose served/including members of the nursing and health team.
Quality assurance efforts now recommend that evaluation of structure, process and outcomes criteria be
made. This will evaluate the effectiveness of nursing care done or changes in behavior, condition, or
Evaluation based on professional practice include conformity with accepted community and public health
standards of practice, continued refinement and enhancement of nursing skills through continued field
experience and a program of continuing education.
Evaluation structure include cost-benefit ratio, qualifications and number of members of the health team
especially nurses in proportion to the populations served and the material resources in terms of quality.

Evaluation based on information gathered is utilized to improve community health nursing services as part
of the total community health services.