Community Health Nursing:

Definitions:
1.) World Health Organization:
a. Special field of nursing that combines skills of nursing public
health
b. Function as part of total public health program for:
i. Promotion of health
ii. Improvement of condition
iii. Rehabilitation of illness and disability
2.) Jacobsen
a. Learned practice discipline with ultimate goal of contributing as
individuals to promote clients optimum level of functioning
through teaching and delivery of care
3.) Dr. Ruth B. Freeman
a. CHN is a unique blend of nursing and public health practice
aimed at developing and enhancing health capabilities of
people. It is involved in entire spectrum of health services for the
community
4.) Tinkham and Voorhies, 1972
a. CHN is a field of nursing in which family and communities are
patients
b. Unique blend of nursing and public health practice woven into
human service
c. The hallmark of CHN is that it is population or aggregate-
focused.
Philosophy of CHN
Dr. Margaret Shetland:
Philosophy is based on the worth and dignity of man.
Ultimate Goal
To raise level of health of the citizenry.
Objectives of CHN
1.) Participate
2.) Conduct researches
3.) Coordinate
Concepts of CHN

emphasis on importance of greatest good for the greatest number

assessing health needs, planning, implementing and evaluating impact
of health services on population group
 priority of health promotive and disease preventive strategies over
curative interventions
tools for measuring and analyzing community health problems
application of principles of management and organization of the
delivery of health services to the community
Basic Principles of Community Health Nursing

family is the unit of care, community is the patient and the four levels
of clientele of CHN are:
o individual
o family
o group
o community
goal of improving community health involves multidisciplinary effort
CHN works not for individual patient, family, group or community. The
latter are active partners, not passive-recipients of care
Practice of CHN is affected by changes in society in general and by
developments in health field in particular
CHN is part of community health system, which in turn is part of the
larger human services system
Barangay Health Centers
1 doctor, 1 nurse, midwives, 2 barangay health workers. 1 nurse= 5000 people
Wednesday: check-up and free immunizations

Roles and Functions

Planner: e.g. IMCI = Integrated management of childhood illnesses

Provider of Nsg Services: direct nursing care of sick; provides patient
continuity of care
Manager/Supervisor: formulates individual, family, group and
community centered care of plan; organize work force
Coordinator of Services: coordinates with individuals, family, group for
health related services provided by GOs and NGOs
Trainer/health educator/counselor: identifies and interprets training
needs of RHMs, BHWs and hilots; resource speaker; IEC materials
Health Monitor: detects deviation from health of individual, family,
group and community through contact visits with them; use of
systematic and objective assessment
Role model: provides good example/ model of healthful living to public
Change agent: motivates changes in health behavior of individual,
family, group and community including lifestyle to promote and
maintain health. most difficult role.
 Recorder/reporter/statisticiain: prepares and submits records and
reports
Researcher: participates/assists in conduct of surveys
Community Health Nursing:
History:

Early Christian era: virgins, noblewomen and plebeians took care of

sick
Phoebe: 1st visiting nurse
Mr. William Rathbone:
o Philanthropist who first thought of public health nursing
o District nursing service in Liverpool in 1859
o More emphasis on midwifery
o Forerunner of public health nursing system
In the USA:
o Public HN developed from visiting nursing service under
missionary societies and visiting nursing associations
o 1877: womens board of NY mission established 1st visiting
nurses
History of Public Health

Babylonians
o Understood need for hygiene
o Developed medical skills
Egyptians
o Developed variety of pharmaceutical preparations
o Constructed earth privies and public drainage system
Hebrew Mosaic Law
o Maternal health, communicable disease control, protection of
food, water, waste and sanitary disposal
Greeks
o Linked health to environment
o Wealthy people value personal cleanliness, exercise, diet and
sanitation
Romans
o Viewed medicine from a community health and social medicine
perspective
o Emphasized regulation of medical practice
o Provision of pure water
o Sewage systems, public food preparation
o Women visited and cared for the sick
Christianity
o Brought idea of personal responsibility
o Started the care for the sick
 Middle Ages
o Poor sanitary conditions
o Increase in communicable diseases (cholera, bubonic plague,
smallpox)
o Religious convents and monasteries established hospitals
o Started movement of health education and personal hygiene
Renaissance
o Health practices were influenced by recognition of human
dignity and worth
o Elizabeth Poor Law: established 1601, guaranteed medical
services to poor and lame individuals
Industrial Revolution
o Advances in transportation
o Religious women started to provide nursing care in institutions
and homes
Milestones in history of public health

1601- Elizabeth Poor Law

1617- Sisterhood of Dames de Charite organized by St. Vincent de
Paul
1789- Baltimore Health Department
1798- Marine Hospital Service, nuns visited poor
1813- Ladies Benevolent Society of Charleston, South Carolina
founded
1836- Lutheran deaconesses provided home visits in Germany
1851- Nightingale visited Kaiserwerth, 3 months of nursing training
1855- Quarantine Board, established in New Orleans; beginning of
tuberculosis campaign in US
1859- district nursing established by William Rathbone
1860- Florence Nightingale Training School for Nurses established in
St. Thomas Hospital in London
1864- Beginning of Red Cross
Community Health Nursing Historical Background in Philippines

1901- Act 157, est. Board of Health of Philippines

1905- Act 1407, est. Bureau of Health, under Department of Interior
1912- Fajardo Act (Act 2156) Sanitary Division, forerunner of present
Municipal Health Offices; President of Sanitary division took charge of
2 to 3 municipalities. Philippine General Hospital sent 4 nurses to Cebu
1914- School of Nursing rendered by Filipino Nurse employed by
Bureau of Health in Tacloban, Leyte
1915- Philippine Health Service; Reorganization Act 2462 created.
Office of Inspector General and Office of District Nursing headed by
Dr. Rosario Pastor, a nurse and physician
 1915-1918- Ms. Perlita Clark took charge of Public Health Nursing
Works
1919- 1st Filipino Nurse Supervisor was appointed, 84 PHNs assigned
in 5 health stations
1927- Office of District Nursing abolished and changed to Section of
Public Health Nursing
1930- Section for Nursing
1941- Outbreak of war, PHNs were assisted to take care of sick and
wounded
1942- 31 nurses as POWs at Bilibid Prison, released to Director of
Bureau and Health, Dr. Eusebio Aguilar
1948- 1st training center of Bureau of Health organized in cooperation
with Pasay City Health Department
1950- Rural Health Demonstration and Training Center by DOH
1958-1965- RA 977 abolished Division of Nursing
o Annie Sand= nursing consultant, Office of Secretary of Health
Founded DOH National League of Nurses Inc.
o RA 977created 8 regional offices in country increased to 11 then
to 16

Primary Health Care (Basic Health Care)

Definition
1.) World Health Organization: essential health care made
universally accessible to individuals and families by means
acceptable to them, through full participation and at cost that the
community and country can afford at every stage of
development.
Conceptual Framework

Goal: Health for all Filipinos and Health in the hands of th epoeple by
the year 2020
Mission: to strengthen the health care system by increasing
opportunities and supporting conditions wherein people will manage
their own health care.
Concept: Primary Health Care (PHC) characterized by partnership and
empowerment of people shall permeate as core strategy in effective
provision of essential health services
Legal Basis

Letter of Instruction (LOI) 949: signed on Oct. 19, 1979 by then Pres.
Ferdinand E. Marcos
Historical Background
o 1974- WHO and UNICEF conducted a joint study
o 1975- World Health Assembly passed a resolution giving priority
to the development of PHC
o 1977- World Health Assembly decided that main target of
government and WHO is the attainment of the level of health
that would allow or permit them to lead a socially and
economically productive life by year 2000
o September 6-12, 1978- 1st International Conference on Primary
Health Care in Alma Ata, USSR
o 1979- WHA launched global strategy to attain health for all
o 1980- PHC endorsed for implementation by respective regional
community
Why Philippines Adopted PHC
1.) magnitude of health problems
2.) inadequate and unequal distribution of health resources
3.) increased cost of medical care
4.) isolation of health care activities from other developmental activities
Principles of PHC
1.) Accessibility, acceptability, availability, and affordability of health
services
a. Health services are delivered where people live and work
b. Development of indigenous or resident volunteer health workers
to provide health care with an ideal ration of 1:10-20 households
c. Use of low cost, appropriate technology sustainable by
community
d. Combined utilization of traditional medicines and essential drugs
2.) Partnership between community and health agencies in provision of
quality, basic and essential health services
a. Community needs and priorities are basic for planning health
services and activities
b. Training curriculum of community health workers I based on
community health problems and task analysis of community
health workers
c. Regular supervision and periodic evaluation of community
health workers performance by health staff to community
d. Development of promotive, preventive, curative and
rehabilitative care
e. Recognition of role and traditional healers in delivery of health
services
 3.) Community Participation
a. Awareness building and consciousness raising on health and
developmental issues
b. Community building and organizing
c. Planning, implementation, monitoring and evaluation done by
community
d. Community discussions done through small group discussions
e. Selection of community health workers by community
f. Foundation of health committees
g. Establishment of community health organizations
h. Mass health campaigns and community mobilization
4.) Self-reliance
a. Community generates support for health care
b. Mobilization of health resources
c. Training of community leaders on leadership and managerial
skills
d. Income-generating projects
5.) Recognition of interrelation of health and development
a. Convergence of health, food, nutrition, water, sanitation and
population services
b. Integration of PHC into national, provincial, municipal and
barangay development plan
6.) Social Mobilization
a. Establishment of effective health referral system
b. Multi-sectoral and inter-disciplinary linkages
c. Integration, Education, Communication (IEC) support using
multimedia channels
d. Collaboration among government agencies, non-government
organizations and community groups
7.) Decentralization
a. Reallocation of budgetary resources
b. Advocacy for political will and support
c. Re-orientation of health profession
Strategies of PHC
1.) reorientation and reorganization by local government code of 1991 or
RA 7160
2.) effective preparation and enabling process for health action at all levels
3.) mobilization of people to know their communities and identify basic
health needs
4.) development of utilization of technology
5.) organization of communities arising from needs
6.) increase opportunities
Essential Components of Primary Health Care
1.) Multi-Sectoral Approach
a. Intrasectoral linkages
b. Intersectoral linkages
2.) Community participation
a. Identify problem
b. Identify solution
c. Mobilizing resources
d. Barriers
i. Lack of motivation
ii. Indifference on part of community
iii. Resistant to change
iv. Bureaucracy of government
v. Lack of managerial skills
vi. Dependence on part of community
3.) Appropriate Technology
a. 6 criteria:
i. effectiveness and safety
ii. less complex
iii. less costly
iv. broader scope of technology
v. acceptability to local culture
vi. feasibility
4.) Community involvement
a. Involvement level:
i. Individual
ii. Family-monitor growth and development of child and able
to address to problems in government
iii. Community- organizations formed to promote health
development
Concepts of Primary Health Care
1.) PHC represents supplementary health system
2.) Equip community with capability to solve its own problems by
conducting trainings
3.) Come into being only when community recognizes and accepts
problems
4.) Government officials dont work in place of community and vice versa
5.) Community involvement is the heart and soul of PHC
6.) Good health is related to living conditions and lifestyle
7.) Provide opportunity to underprivileged majority to develop to an
acceptable level
a. Basic minimalistic needs:
i. Food
ii. Clothing
 iii. Shelter and clean environment
iv. Health
v. Education and information
vi. Security of life
vii. Means of livelihood
8.) Community must take its role and responsibility to develop basic needs
9.) PHC activities must be in harmony with existing institution
10.) PHC activities must be flexible in its application
11.) Must be related to public health services and technical support
levels of public
Elements of Primary Health Care
1.) Education
2.) Locally Endemic Diseases
a. Filariasis
b. Schistosomiasis
3.) Essential basic drugs
a. Cotrimoxazole
b. Amoxicillin
c. Rifampicin
d. Isoniazid
e. Ethambutol
f. Paracetamol
g. Pyrazinamide
h. Oresol
i. Nifedipine
4.) Maternal and Child Health Care
5.) Expanded program of immunization
a. BCG- bacillus calmette guerin
b. OPV- oral polio vaccine
c. AMV- anti-measles vaccine
d. DPT- dyptheria pertussis tetanus
e. Anti-Hep B
6.) Nutrition
a. IDD- iodine deficiency disorder
b. IDA- iron deficiency anemia
c. PEM- protein energy malnutrition
7.) Treatment of common diseases
8.) Safe water supply and sanitation
9.) Prevention and control of leading communicable diseases
10.) Promotion of dental health
11.) Elderly and disableds physical and mental health
The Philippine Healthcare Delivery System

Health Care System- organized plan of health services

Health Care Delivery- rendering services to people
Health Care Delivery System- network of health facilities and
personnel which carries out task of rendering health care to people
Philippine Health Care System- complex set of organizations
interacting to provide an array of health services
RA 7160
o Local Govt Code of 1991
o Provides for decentralization
o Places in local govts to manage health care system
Levels of Health Care Facilities
1.) Primary level
a. Composed of barangay, municipal and medicare health facilities
b. 1st contact emergency care
c. rural health units, chest clinics, malaria eradication units,
schistosomiasis control units, puericulture units, private clinics,
company clincis
d. early symptomatic stage
2.) Secondary level
a. Consists of district health care institutions with capabilities and
facilities for cases with hospitalization
b. Smaller non-departmentalized hospitals including emergency
and regional hospitals
3.) Tertiary level
a. Highly technological and sophisticated services
b. Specialized centers, regional health care institutions and
provincial health care centers
Multi-Sectoral Approach to Health

Intersectoral
o Sectors most closely related to health
o Agriculture, education, public works, local governments, social
welfare, population control, private sectors
Intrasectoral
Restructured Healthcare Delivery System
Rationale

healthcare system serves only small portion of rural population

diseases do not require sophistication
some problems can be handled by other positions besides MHO
(Municipal Health Officer)
 Solutions

3 levels of health care provided by RHU (rural health unit) staff, with
referral and supervisory system support
redefinition of roles and relationships among RHU staff
establishment of satellite health centers in selected barangays
Features of DOH reorganization

1958- RA 1082
o 1st Rural Health Act
o employment of more physicians, dentists, nurses, midwives and
sanitary inspectors assigned to RHUs
o 1st 81 rural health units
1972- RA 5435
o defined authorities of regional directors for more meaningful
decentralization
o 13 regional health offices
1974
o IBRD- RHCDS implemented RHM were sent to BHS to man
BHS
o Midwives were trained and roles expanded
1982- EO 851
o integrated public health and hospital systems with emphasis on
importance of putting together promotive, preventive, curative
and rehabilitative components of health care
o utilization of BHW
o implementation of DOH impact programs
Role of Society in RHCDS

participation in information drive of HCDS

identifying problems
identify sources
Local Health Board

propose annual budget

identify problems
identify what programs
Chairman, vice-chairman, chairman of committee on health, DOH
representative, NGO representative
Two-way referral system
Referral- intervention to direct client to another healthcare facility to continue
his/her treatment
Population
BHS Midwife BHS BHW
Sanitary Inspectors RHU Midwife PHN
Physician
Secondary Health Care Facility
Tertiary Health Care Facility

Types of Health Care Systems

1.) Traditional
a. E.g. client provider
2.) Non-Traditional
a. Holistic Health Centers
i. Believes that time, space and encouragement can help
people find strength to deal with problems confronting them
ii. Spiritual, physical and psychological care
iii. Acts:
1. Pastoral counseling
2. Stress reduction
3. Parenting
4. Dietary conditioning
b. Faith Healing
i. Believes that disease is a state of mind so one can alter his
state of mind so he will be healed
c. Chiropractic
i. System of manipulation treatment which teaches that all
diseases are caused by impingement on spinal column and
corrected by spinal adjustment
ii. Daniel Palmer- founder
d. Acupuncture
i. Insertion of needles into selected body parts to control pain
e. Acupressure
i. Finger pressure to control pain in body parts
f. Kinesiology
i. Study of movement which applies principles of anatomy to
movement
g. Reflexology
 i. Systematic massage of soles of feet
ii. Applies same principles as applied in acupressure
h. Massage
i. Relieves tension, enhances flexibility and creates
coordination between mind and body
i. Homeopathy
i. Use of variety of herbs, drugs and chemicals that when used
in small quantities can cure or prevent disease caused by
same substance in larger doses

Health Promotion, Health Maintenance, and Disease Prevention

Health Promotion

Definition
o WHO- Health promotion includes encouraging healthy
lifestyles, creating supportive environments for health,
strengthening community action, reorienting health services to
place primary focus on promoting health and preventing
disease, and building healthy public policy.
o Pender, 1996- Health promotion is a behavior motivated by the
desire to increase well-being and actualize human health
potential.
Health promotion includes any activity that helps people to change or
maintain lifestyles that support a state of optimal health or balance of
physical, emotional, social, spiritual and intellectual health.
Prominence of health promotion came about as a result of changing
patterns of health and corresponding emphasis on lifestyle as a
factor.
PHE (Public Health Education) can only have impact on PH only if
joined other sectors and brought multiples social forces to bear.
Green- Behavioral changes that health education is able to effect can
only be maintained if supportive environment were provided via:
political, economic, social, biological and other sectors.
1st use of term, health promotion- 1945, Henry E. Sigerist
o Defined 4 major tasks of medicine
Promotion of health
Prevention of illness
Restoration of the sick
Rehabilitation
o Sigerist: Health is promoted by providing a good labor
condition, education, physical culture and means of rest and
recreation.
 Concepts used and found in Ottawa Charter for Health
Promotion which occurred 40 years later
1986, WHO, Health and Welfare Canada and Canadian Public Health
Association organized an International Conference on Health
Promotion
o later known as Ottawa Charter
o Guiding principle in health promotion efforts currently
Ottawa Charter for Health Promotion

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 realized
aspiration; to satisfy needs and to change and cope with environment
Health promotion is not just a responsibility of the health sector, but
goes beyond healthy lifestyles to well-being.
Prerequisites for Health
o Peace
o Shelter
o Education
o Food
o Income
o A stable eco-system
o Sustainable resources
o Social Justice
o Equity
In order to operationalize the concept of Health Promotion, the Charter
recommended the following areas.
o Build Health Public Policy
Coordinated action that leads to health, income and
social policies that foster greater equity
o Create Supportive Environment
Societies are complex and interrelated
Overall guiding principle is the need to encourage
reciprocal maintenance to take care of each other, our
communities and our natural environment
Conservation of natural resources throughout world
should be emphasized as a global responsibility
Changing patterns of life; work and leisure leave a
significant impact on health
Systematic assessment of health impact of rapidly
changing environment, especially in areas of technology,
works, energy production and urbanization
o Strengthen Community Action
Setting priorities, making decisions, planning strategies
and implementing
 Heart of this process is Empowerment of communities
Community development helps to enhance self-help and
social support, to develop flexible system for
strengthening public participation in and direction of
health matters
o Develop Personal Skills
Through providing information, education for health and
enhancing life skills
Enabling people to learn throughout life, to prepare
themselves for all of its stages and to cope with chronic
illnesses and injuries
o Reorient Health Services
Health services are shared among individuals;
community groups, health service institutions and
government