Professional Documents
Culture Documents
Course Code
CHN
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
Pre-requisite
Placement
Course Objectives:
Course Outline
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
particular.
5. Community health nursing is part of the community health
system, which in turn is part of the larger human services
system.
iv.
Roles of the nurse in caring for communities and population
groups
v.
Brief history of community health/public health nursing
practice in the Philippines.
IICommunity health and Development Concepts, Principles and
Strategies
a. Primary health care approach
i.
Definition, PHC as a philosophy, approach, structure and
services.
ii.
Legal basis of PHC in the Philippines
iii.
Components of PHC
b. Health promotion
i.
Concept of health promotion (as embodied in the Ottawa
Charter, November 1986)
ii.
Health promotion strategies:
1. Build healthy public policy
2. Create supportive environments.
3. Strengthen community action.
4. Develop personal skills.
5. Reorient health services.
iii.
Examples of Theories/Models of Health Promotion: Pender,
Bandura, Green
c. Community Organizing towards community participation in
Health
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
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Diseases
a. National prevention of Blindness
b. Mental Health and Mental Disorders
c. Renal Disease Control program
d. Community-Based Rehabilitation Program
iii.
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
program
iv.
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
i.
School health Nursing
ii.
Occupational Health Nursing
iii.
Community mental health Nursing
V. Evaluating Community Health Nursing Services
a. Definition of Evaluation
i.
Types of evaluation: quantitative, qualitative
ii.
Aspects of evaluation: process, impact and
outcome
iii.
Methods and tools of evaluation
iv.
Evaluation indicators
b. Quality Assurance: Sentrong Sigla Movement
VI. Recording and Reporting
a. Family Health Service Information System
b. Components of FSHIS
i.
Family Treatment Record
ii.
Target Client List
iii.
Reporting forms
iv.
Output Reports
ii.
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.
iii.
iv.
Community
a group of people with common characteristics or interests living together within a territory or
geographical boundary
place where people under usual conditions are found
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)
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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)
Health
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
health.
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
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Aims:
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)
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 practice.community nursing is certainly not
confined to public health nursing agencies.
2.
3.
4.
5.
6.
7.
8.
10.
Standards in CHN
Theory
Applies theoretical concepts as basis for decisions in practice
Data Collection
Gathers comprehensive, accurate data systematically
Diagnosis
Analyzes collected data to determine the needs/ health problems of IFC
Planning
At each level of prevention, develops plans that specify nursing actions unique to needs of
clients
Intervention
Guided by the plan, intervenes to promote, maintain or restore health, prevent illness and
institute rehabilitation
Evaluation
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
practice
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
9.
Research
Indulges in research to contribute to theory and practice in community health nursing
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.
Collaboration
Coalition building
Community organizing
Advocacy
Social marketing
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.
II
III
IV
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
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
assigned.
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b. The PHN collaborates with other health care providers, professionals, and community
representatives in assessing, planning, implementing and evaluating programs for community
health
5. NURSING PROCESS
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
diagnoses.
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.
6. HEALTH PROMOTION AND HEALTH EDUCATION
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
properly
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
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1919
16
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.
1923
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.
1927
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.
1928
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.
1930
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.
1933
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.
1941
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.
1942
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
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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
Chief.
1948
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.
1950
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
Office.
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.
1953
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).
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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)
1957
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.
1958-1965
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.
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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.
1974
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.
1975
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.
1976-1986
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
reorganization.
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.
1986
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
20
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.
1987-1989
Executive Order No. 119 reorganized the Department of Health and created several offices and services
with the Department of Health.
1990-1992
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.
2005-2006
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.
HISTORICAL BACKGROUND
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
1912
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.
1915
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.
1932
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
22
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.
1942
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
Philippines.
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
Secretary.
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.
1970
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
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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.
1999-2004
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
financed.
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
policies.
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Ensure the highest achievable standards of quality health care, health promotion and health
protection.
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.
VISION
The DOH is the leader, staunch advocate and model in promoting Health for All in the Philippines.
MISSION
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
(MMR).
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.
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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
levels.
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.
26
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
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
systems
SPECIFIC GUIDELINES
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
trauma;
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;
and
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;
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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
Government
UNIVERSAL HEALTH CARE (2010-2016)
FOURmula One for health (2005-2010)
Health Sector Reform Agenda (1999-2004)
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
effects.
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
ailments.
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
areas.
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.
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.
TRADITIONAL AND ALTERNATIVE HEALTH CARE
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
Lagundi
(Vitex Negundo)
Yerba Buena
(Mentrha
Cordifelia)
solution as gargle.
Toothache
Sambong
(Blumea
balsamifera)
Insect bites
Pruritus
Anti-edema/antiurolithiasis,
diuretic
Tsaang Gubat
(Carmona retusa)
Diarrhea, stomachache
Niyug-niyogan
(Quisqualis indica)
Anti-helminthic
Bayabas
(Psidium guajava L)
Akapulko
(cassia, alata L)
Ulasimang
bato/pansitpansitan
Bawang
Ampalaya
(mamordica
charantia)
in 2 glasses of water.
Hypertension.
Lower cholesterol,
Focus client
Focus of care
Decision-making process
Outcome
Setting for services
Goal
Individual
Curative, provided by health
professionals
Health worker driven
Reliance on health professionals
to restore/regain health
Mostly urban-based; hospitals,
clinics
Absence of disease
HEALTH PROMOTION
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
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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
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:
38
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
characteristics.
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
education.
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
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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
environments
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
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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
expectations:
How to use it: Provide both knowledge-based training and skill-based training to intervention
participants
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:
goal-setting
self-monitoring
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
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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
participants.
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
behavior.
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
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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.
Concept
Perceived susceptibility
Perceived severity
Perceived benefits
Definition
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
Cues to action
Self-efficacy
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
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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.
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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
needs.
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
objectives.
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)
PRECEDE PHASES
Phase 1-Social Diagnosis
Phase 2-Epidemiological Behavioral & Environmental Diagnosis
Phase 3-Educational & Ecological Diagnosis
Phase 4-Administrative & Policy Diagnosis
PROCEED PHASES
Phase 5-Imlementation
Phase 6-Process Evaluation
Phase 7-Impact Evaluation
Phase 8-Outcome Evaluation
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.
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.
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
program.
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.
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
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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 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.
2. contemplation
3. preparation
4. action
5. maintenance
Decisional balance
Pros
Cons
DESCRIPTION
.
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
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.
1. PRIMARY PREVENTION (HEALTH PROMOTION AND SPECIFIC INTERVENTION)
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
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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
COMMUNITY ORGANIZING
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.
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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
action.
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.
CORE PRINCPLES IN COMMUNITY ORGANIZING
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
lives.
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.
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1.
2.
3.
4.
Pre entry involves preparation on the part of the organizer and choosing a community for
partnership.
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?
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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?
2. ENTRY PHASE
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.
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.
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.
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
characteristics:
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.
4. ACTION PHASE
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.
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4. EVALUATION PHASE
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
Program-based
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?
organizational
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
organization?
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?
5. EXIT AND EXPANSION PASE
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.
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.
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
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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
community.
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
emphasis
COPAR
Bottom-up
Community-driven process
Roles
Methodology
Output
Community members as
researches: the nurse is a
facilitator and recorder.
Data analysis is done collective
by the community.
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
recommendations.
Methods
Transect walk
Mapping
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
community.
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.
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I-
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
ASSESSMENT
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
coping.
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:
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individual and family health records: laboratory and screening tests and physical examinations of
individual.
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
confidentially.
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
technology.
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
client.
SECOND LEVEL ASSESSMENT
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.
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COMMUNITY DIAGNOSIS
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
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
community
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
CONTENTS OF COMMUNITY DIAGNOSIS
A. INTRODUCTION
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
instrument
Limitation of the study: state any limitations that exist in the reference or given population/area
of assignment.
B. TARGET COMMUNITY PROFILE
1. Geographic identifiers
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b.
c.
d.
e.
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
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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.
DEMOGRAPHIC COMPONENTS
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
DEMOGRAPHIC PROCESS
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
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
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
births.
VITAL STATISTICS
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
69
event. (Numerator) must come from the total population exposed to the risk of same event
(Denominator).
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
population
CDR=
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
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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.
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
character.
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
population.
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.
AGENT
Environment
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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.
Fungi
Rickettsia
Viruses
Geology, climate
Density
Sources of food, influence as source
of agent
C. Socio-economic environment
Occupation
Exposure to chemical agents
Urbanization
Urban crowding, tension and pressures
Disruption
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
value.
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
75
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
infection.
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
infection)
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;
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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.
Epidemics
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
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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)
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
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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.
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.
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Breastfeeding
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
Parenting
Breastfeeding
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
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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
polio)
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
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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,
specifically:
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).
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B. DATA ANALYSIS
sort data
cluster/group related date
distinguish relevant from irrelevant data
identify patterns
89
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.
TYPES OF COMMUNITY DIAGNOSIS
1. COMPREHENSIVE COMMUNITYDIAGNOSIS aims to obtain a general information about the
community.
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
need.
PROCESS OF COMMUNITY DIAGNOSIS:
Collecting
Organizing
Synthesizing
Analyzing and interpreting health data
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
NURSING PROCEDURE
CLINIC VISIT
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
I.
Registration/Admission
5. Great the client upon entry and establish rapport.
6. Prepare the family record the client and record it accordingly.
II.
Waiting time
5. Give priority number to client.
6. Implement the, first served policy except for emergency/urgent cases.
IIITriaging
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.
IV-
Clinic evaluation
1. Validate clinical history and physical examination
2. The nurse arrives at evidence-based diagnosis and provides rational treatment based on DOH
program.
Identify the patients program.
formulate/write the nursing diagnosis and validate
93
VVI-
VII-
1.
VIII1.
2.
3.
HOME 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
health
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
family.
c. The acceptance of the family for the service to be rendered , their interest and the
willingness to cooperate
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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.
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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
Percent
protected
TT2
Minimum age
interval
As early as possible
during pregnancy
At least 4 weeks later
TT3
95%
TT4
99%
TT5
99%
TTI
Duration of protection
-gives initial protection
80%
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:
Target
Pregnant
women
Post-partum
women
delivery
TARGET
Pregnant
women
Lactating
women
Post-partum bleeding
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
suspected)
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
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malaria
Check
every
4
hours
for
fever,
pulse,
more)
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
fluid.
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,
visible)
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
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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
women.
11. Inform, teach and counsel the women on important MCH messages:
Birth
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
Referral
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
Zones)
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
o
o
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101
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
nipple).
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.
B. THE FAMILY PLANNING PROGRAM
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
methods
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
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Vasectomy
Tubal ligation
103
The symptothermal method is more effective than either the BBT or the cervical mucus
method alone.
Advantage; no cost
Disadvantage: requires motivation and cooperation
6. OVULATION DETECTION
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.
7. LACTATION AMENORHEA METHOD (LAM)
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.
8. COITUS INTERRUPTUS/WITHDRAWAL
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
vagina.
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.
9. POST-COITAL DOUCHING
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
(COC)
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
effectiveness.
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1.
o
o
o
2.
o
o
Various preparations are available including gels, creams, sponges, films, foams and
suppositories.
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)
GELS OR CREAMS
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.
FILMS
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.
3. VAGINAL SUPPOSITORIES
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.
4. SPONGES/FOAM
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)
1. DIAPHRAGM
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.
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o
o
107
3. MALE CONDOM
Description/Uses:
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
Advantages:
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
Disadvantages:
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
cell
% of Effectiveness:
Perfect Use: 98%
Typical Use: 85%
4. FEMALE CONDOMS
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
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o
o
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
injection.
1. PILLS
Decription/Uses
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:
Nausea
Weight gain
Headache
Breast tenderness
Breakthrough bleeding (bleeding outside the menstrual period)
Monilial vaginal infections
Mild hypertension
Depression
Advantages:
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
Disadvantage:
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
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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
day.
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
2. INJECTABLES/(DMPA-DEPO MEDROXY PROGESTERONE ACETATE)
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
Advantages:
Reversible
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
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% of Effectiveness
Perfect Use: 99.7%
Typical Use: 97.0%
3. TRANSDERMAL ROUTE
Refers to patches that slowly but continuously release a combination of estrogen and
progesterone.
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)
Abdomen
Buttocks
Side effects:
Mild breast discomfort
Irritation at the application site
Considerations:
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.
5. VAGINAL INSERTION
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.
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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.
6. IMPLANTATION/CONTRACEPTIVE IMPLANT
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.
Advantages:
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
Depression
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.
112
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.
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
Ideally:
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
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Advantages:
Permanent method of contraception. A single procedure leads to lifelong, safe and very effective
contraception
Nothing to remember, no supplies needed, and no repeated clinic visits required
Does not interfere with sex.
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Advantages:
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
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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
NATIONAL OBJECTIVES FOR 2011-2016
OVERALL GOAL: Improve maternal health and ensure the survival, health and well-being of mothers and
their unborn.
STRATEGIES FOR 2011-2016
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
authorities.
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
9%
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.
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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
malnutrition
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
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
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.
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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
months.
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.
NUTRITION PROGRAM
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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.
Objectives:
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
Strategies;
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
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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.
Goal:
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.
Objectives:
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)
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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
breastfeeding
Dental check-up as soon as the first
tooth appears and every 6 months
thereafter
Supervised tooth brushing drills
Oral urgent treatment OUT)
- Removal of unsavable teeth
- Referral of complicated cases
- Treatment of post extraction
complications
Application of Atraumatic Restorative
Treatment
(ART)
Oral examination
Supervised tooth brushing drills
Topical Fluoride Therapy
Pits and Fissure Sealant application
Oral Prophylaxis
Permanent Filings
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
Referrals
Oral examination
Extraction of unsavable tooth
Gum treatment
Relief of pain
Health instruction and advice
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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
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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.
Storage Temperature
DPT/Hep B
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
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.
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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.
Vaccine
# of
dose
s
1
DPT
Minimum
age at
first dose
Birth or
any time
after birth
6 weeks
OPV
6 WEEKS
measles
9 months
Hep B
At birth
MMR
12 months
Pentavalent
6 weeks
BCG
Administration of Vaccines
Route,Dosage, Interval
Site
Type/form of
vaccine
Storage
temperature
2-80C body of
ref.
D-weakened toxin
P-killed bacteria
T-toxin
Live attenuated
virus
Freeze dried, live
attenuated virus
2-80C body of
ref.
6 wks interval
from 1st dose to
2nd dose, 8 wks
interval from 2nd
to 3rd dose
None
RNA recombinant
2-80C body of
ref
Live attenuated
2-80C body of
ref
4 weeks
Hep B-RNA
recombinant
D- Weakened
toxin
P- killed bacteria
T- toxin
Hibpolysaccharide
CHON conjugate
Live attenuated
2-80C body of
ref
ID, 0.05 ml at
Right arm
IM, 0.5 ml at
vastus lateralis
Oral, 2 drops by
mouth
SQ, 0.5 ml outer
part of upper
arm
IM, 0.5 at vastus
lateralis (thigh)
None
4 weeks
4 weeks
none
Rota6 weeks
2
oral
4 weeks
virus
Tetanus
IM, 0.5 ml at
Toxoid
deltoid region
Procedures in the giving of vaccines:
Reconstituting the freeze dried BCG Vaccine:
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-15 to -25 C
(freezer)
-15 to -25 C
(freezer)
2-80C body of
ref
a. Always keep the diluents cold by sustaining with BCG vaccine ampoules in refrigerator or vaccine
carrier.
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
skin.
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.
Measles
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.
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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
133
Identify and actively search cases and death of EPI target diseases following standard case
definition.
NEWBORN SCREENING
Newborn Screening Act of 2004 RA 9288
When:
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
Where:
In participating Newborn Screening Facilities that includes hospitals, lying-in centers, RHUs
and health centers
How:
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)
Results:
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.
Remarks:
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
screened
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
1.
2.
3.
4.
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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
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
135
2. Convulsions
3. Unable to drink/breastfeed
4. Abnormally sleepy
Evaluation based on information gathered is utilized to improve community health nursing services as part
of the total community health services.
138