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Community and Public Health Nursing

Conceptual Literature

Community-based nursing deals with working outside hospital. Community

health nurses provide care to individuals and families, rather than populations. Public

nursing renders population based assessment, planning, and evaluation. However,

implementation of health programs are catered to individuals, families, groups, and

communities. Community and public health nurses are dedicated for the development of

healthy communities. They give unique contributions to fulfill their commitments by

providing equal distributions of health care; forming an environment that is safe to

promote health and protect the clients; educating preventive measures for clients to

avoid themselves to any disease or dysfunction; giving treatment to patients without

bias related to age, gender, socioeconomic status, religion, and cultural predispositions;

encouraging clients to commit themselves to strive for well being (Maurer & Smith,


Family Health
Every human being has the right to have good health. The national development

requires healthful people. The Department of Health uses the life span approach to

conduct programs and help in the delivery of health services to a narrow range of age

groups. It views health care of individuals within the context of the family. The term

‘family’ is defined as the basic unit of the community. All the family members are given

the right to maintain and improve their health status. They must be free from any
disorders and infections with no disabilities. In public health perspective, the health of

the family is considered as a while, not by individual.

The Family Health Office has the duty to conduct health programs equipped towards the

health of the family. It is concerned with the health of the mother and a child that is not

yet born, the newborn, the infant, the child, the youth and adolescent, the adult men and

women and seniors.

Specific aims of Family Health Office are to lengthen the lifespan, survival and

the well being of mothers and the unborn through health services for the pre-pregnancy,

prenatal, natal, and post natal stages; reduce the death rate for children 0-9 years old;

reduce mortality from preventable causes among adolescents and young people; lower

the rate of death among Filipino adults and improve their state of living; lengthen the life

span of senior citizens and improve the quality of life. Public Health Nurses have

important roles in making sure that the health of the family in not at risk. Every effort has

to be made to provide holistic approaches of health services to the family for a better

state of living (Cuevas, 2007).

Role of the Nurses as Educator

Health education deals with giving knowledge that guides to positive health

behavior. Community health nurses give information and insights that guide them

regarding on making decisions for their health concerns. They often set health facts to

individuals, families, and groups; and they usually involved to the improvement

population-based health education programs (Clark, 2008).

Organizations ruling and influencing nurses in practice have identified teaching

as a responsibility of all of them in caring ill and well patients. For nurses to fulfill the

duty of an educator whether the audience is patients, family, nursing students or staff,

or other personnel, they have the right to have a strong foundation in teaching and

learning. The prerequisites for patient education consist of a collaborative effort among

healthcare team members, all of whom play more or less significant roles in teaching.

However, physicians are first and foremost prepared “to treat, not to teach”. Nurses,

apparently, are ready to provide a clarifying approach to care delivery. The teaching

duty is part of our professional structure, because, customers entrust their lives to the

nurses with respect. That makes the nurses to be in an ideal position to provide holistic

information and make something out of nothing. Amidst a fragmented healthcare

delivery system involving many providers, the nurse has the role of a coordinator of

care. By making sure of the consistency of the information, nurses can support clients in

their efforts to achieve their goal of optimal health. They also can assist their peers and

workmates in gaining knowledge and skills needed for the delivery of professional

nursing care (Bastable, 2008).

Research Literature

Community health needs assessment with precede-proceed model: a mixed

methods study

Health services in community gives people with a more convenient and faster

medical service and lessen the pressure on large hospitals. In the Chinese health sector

reform, the government has prioritized developing community health services

encourage citizens to use it instead of private hospital services. The main question of

health promotion planning is to realize what does the community want, what is actually

needed, and, what can actually be done. The three areas intersected represent what

can be done. However, resources, time and other restrictions do not permit everything

to be referred and so areas must be prioritized. In the PRECEDE-PROCEED model,

thorough needs assessment implicated five phases should be made before planning a

health promotion intervention. Currently, needs assessments are inadequately

conducted prior to community based health promotion activities in China, resulting in

short impact and hapless use of resources. Most health centers have limited funds and

qualified health staff. Health needs assessment can help community participation in

health programs, prevent wasting limited resources and supply baseline for program

analysis. Take to consider that the resources available for health care are limited, health

needs assessment is one of the ways for successful community based health promotion

in China. However, little is known about the health needs of community members and

what community health stations can provide.

By using Green and Kreuter's PRECEDE-PROCEED model, this study looks at

to identify the main health problems having a negative impact on the wellbeing of

community members, identify the key risk factors associated to a disease or health

problem prioritized by the community, and analyze the resources for health promotion in


In agreement with the PRECEDE-PROCEED model, the needs assessment

includes the identification of health problems (Phase 1 and Phase 2), behavioural and

environmental risk factors (Phase 3), factors affecting behaviour (Phase 4) and
resources in terms of policy and organizations (Phase 5) . In this study the researchers

accomplised the five phases of the assessment to identify community health problems,

risk factors and existing resources.

A health program cannot be based upon what the professionals decide on what

the public should know or not know about a specific issue. Planning, the solution to any

successful health promotion project must include a radical needs assessment using

literature reviews and investigations. Health project planning should target diseases and

their risk factors. Strategies for health promotion should take these factors into

consideration. Policy, organization and manpower need further fortification. (Ying Li et

al, 2009).

Health promotion services for lifestyle development within a UK hospital –

Patients' experiences and views
UK public health policy demand hospitals to have impose health promotion

services which let patients to improve their health by means of adopting healthy

behaviours in help of health education. Key to the idea of health promotion is

"empowerment" of individuals, social groups and communities; a process wherein

people obtain greater control over decisions and actions related to their health. Health

promotion interventions within healthcare can encourage people through "self-

reproduction": supporting patients be responsible for self-care physically, mentally and

socially; through "co-production": involvement of the patient in their therapy;

empowering health promotion services for disease management (usually part of

integrated care and beyond the hospital boundaries); and empowering health promotion

services for lifestyle improvement: people are reinforced on a healthy lifestyle by

preventing risk (e.g. not smoking or excessive alcohol intake) or uplifting lifestyles (e.g.

becoming more physically active).

The outcome of study indicate that hospital patients look at hospitals as an ideal

place for the giving of health education for all risk factors. While there was clear

reinforcement for screening all adult hospital patients for risk factors, reported screening

was not appropriate for any of the risk factors, especially for diet and physical activity.

There was also considerable demand for health education, but poor provision. Patients'

memory may be dissembled by the emotional state they were in when information was

supplied, potentially results to attentional narrowing or state-dependent learning.

Memory may also be tingled by the perceived importance of information (diagnosis is

viewed as very important and treatment less so), and age-related cognitive disorders.

The communication style of healthcare professionals delivering health promotion

services also affects recall, with patients more likely to remember medical information if

healthcare professionals give simple to follow, specific written guidelines (rather than

general/verbal instructions). Medical information is least likely to be remembered, and

therefore acted upon, if it is spoken verbally compared to written/pictorial presentation

or a combination of written and verbal presentation, yet the most usual form health

education took was verbal advice.

The timing of health education has importance to patients. While the many of

them felt that the time around discharge was the most ideal period for health education,

those receiving health education reported that it was frequently delivered on admission.

This may be because admission is the common time for screening of risk factors.

However, it is likely that this is not necessarily the best time for health education as
patients may be in an unreceptive state due to their condition and their primary concern

may be the immediate development in health.

As the purpose of health promotion is to enable people to change a behavior, it is

significant to assess whether the different potential forms of health education have

accomplished this. This was evaluated by asking patients how "helpful" the health

education services they received were. While more patients look at the services as

"helpful" than "unhelpful", given that so few patients received any form of health

education, it is impossible to draw definitive conclusions concerning the "helpfulness" of

the different services. It is recommended that this question remains as it could give

valuable information about health education services when they are delivered to a larger

number of patients. (Haynes, 2008).

Compliance and Non-compliance

Conceptual Literature
Compliance, in medicine describes the degree to which a patient correctly

follows medical advice. Most commonly, it refers to medication or drug compliance, but

may also mean use of medical appliances such as compression stockings, chronic

wound care, self-directed physiotherapy exercises, or attending counseling or other

courses of therapy. Both the patient and the health-care provider affect compliance, and
a positive physician-patient relationship is the most important factor in improving


Additional problems may arise when patients do not comply with their prescribed

treatment regimens, these people may not get over their sickness or injury. They may

get even sicker or increase the severity of their present condition(Trisha Torrey,2008).

Experts agree on seven main reasons for non-compliance: Denial of the problem;

Treatment costs; the Regimens difficulty; the Unpleasant outcomes of treatment; Lack

of trust; Apathy; and Previous experience.

Denial of the problem. Asymptomatic diseases and conditions are easy to

ignore, even when they have been diagnosed. Pride may also be a cause of non-


The cost of the treatment. The more money\resources a patient has to

consume the more the level of compliance decreases.

The difficulty of the regimen. This is a barrier simply because patients

sometimes do not know how to do the treatment, patients have difficulty in following

certain procedures.

The unpleasant outcomes or side-effects of the treatment. All, if not most

apparent negative side effects or factors such as an unpleasant taste of a medicine, or

the pain of physical therapy may keep the patient from complying to treatment.
Lack of trust. When patients don't believe in the potential of success, they are

less likely to follow through. In this case, they don't trust that compliance will really

recover their health.

Apathy. The importance of the treatment is very vital. Patients with little or no

knowledge about the treatment and\or their illness, this is a ground for non-compliance

Previous experience. Cases of chronic or repetitive conditions explain this

factor, patients will sometimes decide that a treatment didn't work in the past, so they

are either reluctant or unwilling to try it again.

There are additional reasons patients do not comply; regardless, when a

treatment decision has been reached collaboratively, then patients need to follow

through with those decisions. In such cases of non adherence to treatment, patients are

advised to talk to their physicians or doctors and discuss the reasons for non-


Research Literature

Compliance and Non-compliance

To deliver the topic about therapeutic non-compliance, it is prioritized as the most

significant way to have a clear and meaningful definition of compliance. According to the

Oxford Dictionary, compliance has the denotation as the practice of obeying rules or

request made by the people in authority (Oxford Advanced Learner's Dictionary of

Current English). In healthcare, the most commonly used definition of compliance is a

connotation known as "patient's behaviors (in terms of taking medication, following

diets, or executing lifestyle changes) coincide with healthcare providers'

recommendations for health and medical advice" (Sackett, 1976). Therefore,

therapeutic non-comliance occurs when a person's health-seeking or maintenance

attitude lacks equality with the recommendation as prescribed by a healthcare provider.

Other terms have been used instead of compliance, and the meaning is more or less

congruent. For example, the word adherence is often used interchangably with

compliance. It is defined as the ability and willingness to abide by a prescribed

therapeutic regimen. Recently, the word "concordance" is also suggested to be used. It

makes the patient the decision maker in the process and defines patients-prescribers

agreement. Although there are differnences between those terms, they are used

interchangably (Jin et al, 2008).

Levels of Compliance

The most common way for dealing with constantly changing levels of

compliance is what is known as a 'as-treated' breakdown of thoughts, which is

comparable to the people who participate with those who didn't. An 'as-treated' analysis

is equipped by biased estimates of the effect of participation because it is concluding

the effect by comparing two cultures of people; those who fully participate with everyone

and those who would have participated had they been in the treatment group, and those

who wouldn't have. Those who fully participate in the program are likely different from

those who do not, in both observed and unobserved ways. As an example, there's this

mother-baby intervention, there are some evidence that women who fully participated
had higher liftime risk of having a major depressive episode before entry into study.

That concludes that the benifits of random assignment are lost when an as treated

analysis is done, since groups being compared are now indifferent from each other.

Relevant to an as-treated breakdown of thoughts is the approach of inclusive of

the level of participation as a predictor in the model of the outcome, thus "controlling for"

participation. Inopportunely, this method is also equipped by biased estimates of the

effects, since it focuses on just the observed levels of participation and compares

individuals in the treatment and control groups with the same observed participation.

Nevertheless, people in the treatment group with an observed level of participation (e.g.,

non-participation) may not be indifferent from individuals in the control group with that

said participation. Special processes may lead to non-participation in the treatment

group and the control group, and in specific some of the apparent non-participants in

the control group would likely have participated if they had been in the other group. A

conclusion of casual effects need to be a comparison of effects among similar

individuals, which this approach does not do. This issue is broadly known in the

epidemiology literature as post-treatment selection bias.

Instead, the intuitive idea behind CACE analysis is that the investigators need to

have a comparison between the participants in the treatment condition with a similar

group of people from the control subgroup of the study--those who would have

participated had they been given the chance to do so. If there was a direct to the point

approach to identify those individuals, the investigators could simply have a comparison

of outcomes of the participants in both groups. Nonetheless, the investigators cannot

identify those individuals directly--the investigators do not know which control group
members would have participated had they been in the treatment group. CACE

methods instead use and indirect way to conclude the effect of interest (Stuart,



Ø Francis A. Maurer & Claudia M. Smith, Community/Public Health Nursing:

Health for Families and Pupolations, Forth edition, 2008

Ø Mary Jo Clark, Community Health Nursing: Advocacy for Population

Health, Fifth edition, 2008

Ø Frances Precilla L. Cuevas, Public Health Nursing in the Philippines, Tenth

edition, 2007

Ø Susan B. Bastable, Nurses as Educator: Principle of Teaching and

Learning for Nursing Practice, Third edition, 2008

Online Sources

Ø Elizabeth A. Stuart,Deborah F. Perry, Huynh-Nhu Le, Nicholas S. Ialongo,

Estimating intervention effects of prevention programs: Accounting for

noncompliance, Published October 9 2008, Retrieved January 15 2011,

Ø Jing Jin, Grant Edward Sklar, Vernon Min Sen Oh, Shu Chuen Li, Factors

affecting therapeutic compliance: A review from the patient’s perspective,

Published February 4 2008, Retrieved January 15 2011,

Ø Jason Van Dyke, 5 Ways to Improve Your Patient's Compliance, Published

April 2 2009, Retrieved January 15 2011,



Ø Ying Li,#1 Jia Cao, Hui Lin, Daikun Li, Yang Wang, and Jia He, Community

health needs assessment with precede-proceed model: a mixed methods

study, Published October 9 2009, Retrieved January 17 2011,

Ø Charlotte L. Haynes, Health promotion services for lifestyle development

within a UK hospital – Patients' experiences and views, Published August 13
2008, Retrieved January 17, 2011,