Unit I

Community Health Nursing

Introduction

Community
The word community has been derived from two Latin words, namely ‘com’ means together and ‘munis’ means
to serve. Thus community means to serve together.

“A community is a social group determined by a geographical boundaries and/or common values and interests.
Its members know and interact with each other. It functions within a particular social structure and exhibits and
create certain norms, values, and social institutions. The individuals belongs to the broader society through his
family and community.” (WHO Expert Committee)

Community Health
According to WHO (1974)“Community health refers to the health status of the members of the community to
solve the problems affecting their health and to the totality of health care provided for the community”.

Community health nursing

• Community health nursing is one of the professions which operates within the domains of community
health and helps in meeting health and nursing needs of the community. It plays a very important and
challenging role in promoting and protecting health of people.

• Community health refers to the health status of the members of the community to solve the problems
affecting their health and to the totality of health care provided for the community. (American Nurses
Association 1980)

Public Health Nursing

It is the synthesis of nursing theory and public health theory applied to promoting and preserving health of the
population. The focus of practice is community as a whole and effect of community health status on the health
of individuals, family and the group.

Difference between Community health Nursing and Public Health Nursing

S Community Health Nursing Public Health Nursing

N
1. Deliver health services to individuals and families.
Assess population health needs.
2. Diagnosis is based on need of individuals and
Diagnose and develop policy in relation to
families community health needs.
3. Work to promote health and prevent illness in
Plan for community as a whole. Eg, After an illness
families. Eg, Meeting with group of young mother
outbreak, she will assess the need and develop
to provide information on Immunization program for an immunization Clinic.
4. Implementation is done as per individual's need
Implementation means resources are available to all
who need.
5. Evaluate whether health needs are met on Evaluate the health status of whole community and
 individual, family or group level. whether plan goals and objectives were met.
Goals of Community Health Nursing
 To prevent disease, illness and disability.
 To promote , maintain, and restore the community health
 To reduce morbidity and mortality rate among community

Objectives
 To provide antenatal, maternity and post natal care to ensure safe pregnancy, delivery and puerperium
for the mother and child.
 To provide under five clinics for
- Immunization
- Developmental assessment
- Advice on nutrition and child care
- Treatment for minor aliments
- Providing encouragement and support to mothers
 To perform Risk Assessment and identify High Risk/ Vulnerable groups
- Antenatal Cases
- Postnatal mothers
- Geriatric Population
- Under Five Children
 To provide clinics for treating adults and children for minor ailments and referral for major illness.
 To explain and promote the use of local health services in the community, advising people to seek health
care from safe, qualified health personnel.
 To promote projects in the community that will improve life for the people there, e.g. women’s
cooperative, literacy programs, Provision of safe water
 To assist in the prevention and control of communicable and non-communicable diseases.
 To work with government and other local organizations to promote health and welfare of individuals,
families and communities through close co operation.
 To increase capability of community to deal with their own health problems
 To conduct research and contribute to the further refinement and improvement of community health
nursing practice.

Principles of community health nursing

• The community health nursing service should be based on the needs of the client and there should be
proper continuity of services to the community.

• The community health nursing is community focused. It is therefore essential to know the defined
community, make a map and establish effective working relationship.

• The community health nurse should maintain professional dignity and never accept gifts and bribes
from the patients.

• The community health nurse should not belong to any one section or any political group.
 • The community health nurses should maintain professional relationship with all the leaders in the
community and maintain ethics at all times.

• Community health nurse should follow the policy of the agency, where she is appointed. She needs to
know, understand and follow the policies and accordingly plan and implement health care services.

• There should be proper facilities and job conditions

- Proper salaries to community health nurses according to their qualification and experiences and level
of positions, which is assigned to them.
- Proper accommodation
- Safe working condition

• Health Services should be available to the entire community regardless of origin, age, sex, culture or
social, political and economic resources.

• Community health Nurse should recognize the family and community as units of service.

• Health education and counseling for individual, family and community are the integral part of
community health nursing.

• Community health nurse should function as important member of health team so that she can provide
holistic nursing care, treatment of sick and can provide health counseling

• She should organize a periodic in-service education program and also continuous supervision and
guidance is needed to help the workers to produce high quality of work.

• Community health nurse should maintain the proper record and reports as they are the effective means
for continuous care for evaluation of what is being done and what needs to be done further.

Trend and development of nursing:

a) International Historical Review

Community health nursing is the product of centuries of responsiveness growth and its practice was adopted to
accommodate the need of a changing society, yet it has always maintained its initial goal of improved
community health. Community health nursing development has been influenced by changes in nursing, public
health and society that are traced through several stages.

Based on the historical time frame, the history of community and community health nursing can be broadly
classified into different eras which are:

 Pre-Christian era
In this period people’s health practices were based on magic and superstition rather than facts about the
cause and effects of certain events and action on health. Rudiments of community health can be traced to
the earliest recorded civilization. The Egyptians of about1000 B.C are considered to be the healthiest of
all early civilization. They developed a variety of pharmaceutical preparation and constructed earth
closets and public drainage systems. The mosaic health code of Hebrews which is clearly given in the
 Old Testament, discussed many aspects of individual, family and community hygiene which provided a
sound basis for practices to maintain health and prolong life.

 Greek era
Hippocrates, son of a Greek physician, transformed the superstitious healing magic to a great science
called medicine. The Greek saw health care delivery as the responsibility of civilized men and they paid
attention to personal cleanliness, exercise, diet and sanitation. Aristotle influenced the development of
Greek science during this era. The first acceptable evidence for acute communicable disease is recorded
in classical Greek Literature. The earliest community physicians were appointed during this era. These
physicians were paid from the funds raised from the Community.

 Roman Empire
Romans developed community health service with effective and systematic organization. In the
beginning, the Romans developed hospitals mainly to treat soldiers and slaves. Mature men and women
of good character and dignity helped in nursing the sick.

 Middle Age
During this era, disease was considered as punishment to sin. Initially little importance was given to
medicine. Later a progress was made due to terrible plaques that swept the land. Leprosy became the
major European epidemic. The rise of monasteries convents as the places of caring for the sick led to
the early existence of nursing activities. Health care during this time included both the physical and
spiritual needs of patients.

 Renaissance
Renaissance ushered in a new period in history during which community health as it is currently known
began. These changes supplemented the foundation laid for community health.

 Industrial Revolution
Increase in population and high Infant Mortality associated with it became significant. The growth of
hospital paralleled the development of Asylums.

 Colonial Period
In the early colonial period, community health efforts included the collection of vital statistics and
improved sanitation. This period provided evidence of exotic diseases brought in from trade routes. By
the end of 18th century, there were other developments such as Planting of trees and vegetables,
construction of masonry walls along the water from and interment of the dead.

 Nineteenth century America

During this period, the epidemics of small pox, yellow fever, cholera, typhoid and typhus were
prevalent, and hence threatens to health escalated. Housing and sanitation became a mojor problem.
Beginning from the year 1840, attention was focused on attacking community health problems to
improve urban living conditions. The new Orleans quarantine board decided to limit its activities to
hygiene, education, housing , preventable diseases, sale of poison and improving the general living
condition of poor people. During this century, several boards of health came into existence.
 The twentieth Century
As the 20th century begins with life expectancy was less than 50 years. The leading causes of death were
communicable diseases. Vitamin deficiencies disease and one of their contributing conditions, poor
dental health were extremely common in the slum districts of both Europe and America. There was
inadequate availability of prenatal and postnatal care.

 Health resource development period (1900 -1960)

This period of time is referred to as the health resources development period because of the growth of
health care facilities and providers. This period further divided into:

I. The reform phase (1900 -1920)

By the beginning of 20th century, there was a growing concern about many social problems like
immigrations, urbanization, industrialization or low wages.
The reform movement was board, involving both social, moral and health issues.
The reform movement finally took hold it when it became evident to the majority that neither the
discoveries of causes of many communicable disease nor the continuing advancement of
industrial production could overcome continuing disease and poverty.
Even by 1917, USA ranked 14 of 16 progressive nations in Maternal Death Rate.
Another movement that began about this time was that of public health nursing.
The first school nursing program was begun in1902. In 1918, the first school of Public Health
was established at Johns Hopkins University which was followed by establishment of another
school at Harvard University.

II. The 1920s

In comparison to the preceding period, the 1920s represented a decade of slow growth. However,
the first professional preparation program for health educators was begun at Columbia university
by Thomas D wood, MD, whom many consider the "Father Of Health Education."
During this period, community Health Nursing played a leading role in establishing standards for
Nursing practice.

III. World War I and CHN

The greater demand for nurses created by the onset of world war I in 1914 threatened the role of
CHN eventhough the number of each Nurses was insufficient to meet the needs. However,
American Red Cross helped to sustain CHN by the roster of Nurse who could be enlisted to
supply health care during this period .

IV. Between world wars I and II

During that time, CHN expanded its scope of practice. CHNs moved into rural areas and many
official agencies began to provide nursing case .The social security Act of 1935 marked the
beginning of government major involvement in social issue, including health. This Act provides
MCH and sanitary facilities and also turns their attention toward after health problem like cancer
by establishment of national Cancer Institute in 1937.
 Many of medical discoveries made during this period are Antibiotic Penicllin, used for treating
several bacterial like Pneumonia, Rheuma tic fever and insecticide DDT, used for killing insects
that transmit disease.

V. Post war Years (1945 -1960)

In 1946, the communicable Disease Center established to improve the distribution of medical
care and to enhance the quality of hospitals. From 1946 to1960s there were rapid improvement
of health care facilities and services like hospital construction, setting national health priorities.
In 1948,WHO was founded.

The two major health events were developed in 1950s, the Polio Vaccine was invented and
President Eisenhowers heart attack focused attention on the Nation's Number one killer Heart
Disease.
Communicable Disease center was set up in Atlanta during the war, now known as the center for
Disease control and prevention (CDC).

 Period of social Engineering (1960 -1973)

With the advance in preventive medicine and practices of public health, the patterns of disease began to change
in the developed world like non communicable disease. Eg cancer, cardiovascular disease. In 1965, congress
passed medicare and Medicaidbills. Medicare assists in payment of medical bills of elderly

 Period of health promotion (1974 – 1990)

Focus on the saving lives by education and lifestyle changes by individuals "Healthy People 2010" have defined
the National Health Agenda and guided its health policy which include vaccination, more vehicle safety, safer
work place, healthier mother's and babies.

 Community Health in Early 2000s (Health for All)

Most of the developed and developing countries enjoy all the determinants of good health like adequate income,
nutrition. In contrast, only 10 to 20 percent of population in developing countries has access to health services.
Death claims 60 to 250 of every 1000 live birth within first year of life and life expectancy is 30 percent lower
than developed country. There was the huge gas and against this back ground in 1981, the members of WHO
pledged themselves to an ambitious target to provide " Health for All by the year 2000 ",that is attainment of a
level of health that will permit all people to lead socially and economically productive life.

Health for All has been described as a revolutionary concept and a historic movement – a movement in terms of
its own evolutionary process .

Evolution of Community Health Nursing ( International)

1. The early home care nursing stage

It focuses to reduce suffering and promote healing. This began with religious and charitable groups. Babies
were delivered at home by midwives with little or no training . This stage was in the midst of these deplorable
conditions and response to them that Florence Nightingale began her work. Much of the foundations for the
modern community health nursing practices was laid through Florence Nightingales remarkable publishments.
Nightingales concern for population as well as her vision and successful efforts at health reform provided a
model for Community Health Nursing today.

2. The district nursing stage (visiting nursing)(1850-1900)

The next stage in the development of Community health nursing was the formal organization of visiting
nursing or District Nursing. Modern CHN laid by Florence Nightingale was founded in this era. During the
Crimean war she established competent nursing care and kitchens and laundries that saved 100s of lives. This
early emphasis on prevention and health nursing became one of the distinguishing features of district Nursing
and later of Public health nursing as a speciality.

3. The public health nursing stage (1900-1970)

By the 1920s public health nursing was acquiring a professional status in comparison to its earlier association
with charity. Industrial nursing expanded during this stage as well Lillian Wald was the first to use the term
“public health nursing” and promoted rural nursing and family-focused nursing. Her driving commitment was
to serve needy population, emphasis on illness prevention and help through health teaching and nursing
interventions as well as her use of epidemiological methodology established these actions as hallmark of Public
health nursing practice.

4. The community health nursing stage (1970 to present)

1978- Established Association of Graduate Faculty in Community Health Nursing / Public Health Nursing

In 1980- the ANA developed a Conceptual Model of Community Health Nursing

The term public health nursing and community health nursing were being used interchangeably and yet had
different meanings for many. The distinction between public health nursing and community health nursing was
done by the US Department of Health in 1984 and concluded that community health nursing was a broader term
referring to all nurses practicing in the community regardless of their education preparation.

1990 Association of Community Health Nursing Educators publishes Essentials of Baccalaureate Nursing
Education

Community Health Nursing in Nepal

History of community health nursing is no longer in Nepal. Before Rana regime (1903-2002 B.S), no record of
community health is available in Nepal. The record shows that one post was created as Director General of
Local Health Service (Dr. Raghubir Viadhya ) later on this local health service was changed into public health
service. At that time there were epidemic of various communicable disease like malaria, small pox , cholera,
tuberculosis and leprosy. Health care service was focused to eradicate the communicable disease in the country.
There was separated organization of small pox eradication, leprosy eradication, malaria eradication,
tuberculosis eradication. Eradication as a vertical project for providing service of those particular disease
separate individual health works from each organization use to be managed in each level of health care system
for providing those services.
Health Personnel before 1971 AD (2028/29 B.S.)

 Before 2010 B.S., there was no provision of public health nursing in Nepal, later on a team of nurses
from india and Bhutan were invited to Nepal for providing community health services. Some of those
nurses were Rup Kumari Gurung, Jimmi Tamsang , Barnadeti Rai and Ribika Ragain .

• 2015 B.S.: Jimmi Tamsang and Barnadeti Rai started Community Health Service in chitwan and
makwanpur . ANM school was established in bharatpur chitwan and Mrs Ribika Ragain took
responsibility of running school and Jimmi Tamsang worked as a community health nurse in central
level.

• 2017 B.S.: In support of WHO, department of health services sent some nurses to India and Lebanon for
Public health nursing study. Home visiting service was started by health workers at Bharatpur
Hospital(2019 B.S) along with the public health nurses. They have to work in both community and
hospital and used to give health teaching gathering patients in hospital OPD.

• 2018 B.S: to provide care for mother and child to support in controlling rapid growth of population,
family planning and MCH project came in support of donar agencies. At that time there were also
separate vertical projects(tb, leprocy, malaria, small pox and cholera) for providing service of those
particular diseases.

• 2028 B.S. : After the integration of all vertical projects, ANM were appointed in each health post and
Public health nurses in district public health office.

• History of Community Health Nursing after 1971 AD (2028/29 B.S.)

• 1971 A.D.: Zonal public health nurse post was created and allocated PHN in each zone and started
public health nursing activities.

• 1978 A.D.: The concept of Primary Health Care was developed. The slogan of Health for all by the year
2000 A.D. was passed in Alma Ata Conference in 1978.

• 1987 A.D.: Post basic bachelor in community health nursing was started in Mahabouddha nursing
campus

• 1993 A.D.: Implementation of all the health service including community health and training are run
through various division and centers within the DoHS.

• 1996 A.D.: Job description for public health of various level of health care system was prepared by
national health training centre (NHTC).

• 2008 A.D: BPKIHS, Dharan started M.Sc. Nursing, a 3 years course with speciality in community
health nursing.

• 2017: PAHS started MN in Community Health Nursing, a 2 years course

Current status, trend, socio-cultural issues and challenges related to community health
nursing

Current status:
Community health nursing has evolved into a focus on care of individuals, families and communities.
Community health nursing is a specific and specialized orientation to care that embodies principles of public
health as guiding precepts.

Community health nursing emphasizes on the personal and environmental health of the total population and not
just of selected individuals. Community health nursing focuses on promoting health related behaviors as well as
providing personal health services to members of populations or communities. Rather than serving only the
subgroups who need care, community health nurses anticipate, estimate, and design measures to interrupt the
onset of personal health problems.

Community health nursing pays attention to the influence of environment factors (physical, biological and
sociocultural) on the health of populations and priority is given to preventive and health maintenance strategies
rather than curative strategies.

The nurse today performs demanding tasks to meet the needs of the society. Her job is not only limited to the
sick but also to prevent diseases and to preserve and promote the health of the people. As a home care nurse,
they provide care to the patients at their home itself. Nurses provide antenatal, postnatal and child care services
in the MCH and family planning services. The school health nurse renders services to promote and protect the
health of the school children. They provide primary health care in the community, carry out immunizations,
conduct under five clinics, assess the social, environmental and nutritional needs of the community. Nurses are
employed in industries. They carry out the pre-employment and periodic health checkup, care of sick, first aid,
industrial sanitation, safety and rehabilitation.

Current trend:
The term “community health” has replaced the term “public health” in many countries. It is because of the
changing nature of public health, which focuses on individual responsibility and community participation. It has
generally been accepted that the term “community health nurse” has replaced the term “public health nurse”.
Health care and its delivery systems are changing rapidly in order to meet the needs and problems of the ever
changing society.

There have been tremendous and rapid changes during the past 150 years of historical developments in the field
of public health and public health nursing which are due to the growth and developments in the field of
physical, social, medical and technological sciences.

According to Dr. E.G. Mcgaveran, these changes are divided into four eras from middle of 19 th century to
middle of 20th century onwards. These are as follows:

1. Empirical Era (Upto 1850)

2. Basic Science Era (1850 to 1900)
3. Clinical Science Era (1900 to 1950)
4. Public Health/Community Science Era (1950 onwards)
One more era has been added by W.L. Barton from 1975-2000 AD and is called as Political Science Era which
is Health for All (HFA) era.

1. Empirical Era (Upto 1850)

The focus for this era was on relieving of symptoms. The objective was to make diagnosis and give
treatment of symptoms. Symptomatic treatment like use of poultices, ointments, cupping, leaches,
trepines, etc. to relieve variety of symptoms.

2. Basic Science Era (1850 – 1900)

The focus of this era was on curing of disease. The objective was to make diagnosis and give treatment
of disease and symptoms both. This change occurred due to invention of microscope and the discovery
of bacteria causing various diseases. It was also observed that treatment of symptoms did not necessarily
cure the patient and the symptoms and hence the disease and not the symptoms alone was considered.
This was the first scientific change from “Symptom Focus” to “Disease Focus”.
The change was not liked by the health professionals of the Empirical Era. They expressed resistance
and resentments. There were many practical problems. Health practices were much more complicated,
difficult and expensive. Health professionals required necessary knowledge and skills. The education
and training became very expensive. Research in laboratory investigations and disease became an
essential component of health practice. Traditional practices had to be discarded.

3. Clinical Science Era (1900 – 1950)

The focus of this era was “Total Patient”. The objective was not only the scientific diagnosis and
treatment of his disease but assessment of an individual as a whole which includes physical, emotional,
mental, social and spiritual self to identify his health status and health needs. This was a second
tremendous change in the field of public health.
The change from disease centered approach to patient centered approach was due to new knowledge and
skills in the field of behavioural sciences and observation of the fact that the correct treatment of disease
did not necessarily cure the patient.
Like the Basic Science Era, this era was also resisted and resented by environment health professionals
of that time. The health practices in this era were more complex, difficult and expensive than those in
the Basic Science Era.

4. Public Health or Community Health Science Era (1950 – 1975)

This era is community centered era. This was yet another tremendous change from patient centered
focus to community centered focus. The objective was scientific diagnosis and treatment of families,
groups and entire community. This era emerged due to new knowledge and advancement in health
science which has helped to recognize that each community has a distinct entity comprising of its
specific geographic boundaries, physical setup, and people living and interacting in this setup, having
common life style, social structure etc. and use of common resources.

During this era, man was considered in total context, in relation to his environment. Community
diagnosis and treatment gained greater importance rather than individual patients. The interdisciplinary
team approach was introduced in the delivery of health care. Therefore, there was a realization that the
health of a community is established not merely by the absence of disease but by considering the socio –
economic and socio – cultural factors which play a significant role in the maintenance of health.
 Community centered approach is challenging but threatening to medical professionals and not much
recognized by them. Gradually this approach is getting matured, recognized and accepted. It required
attitudinal change not only of health professionals but also of people to take care of their health and get
involved in their care.

5. Political Science Era or Health for all Era (1975 onwards)

This is people centered era. WHO conceived the goal of “Health for All (HFA)” in the 30 th World
Health Assembly in 1977. It was decided that main social goal of the Government and of the WHO
should be the attainment by all the people of the world by the year 2000 AD, of a level of health that
will permit them to work productively and to participate actively in the social life of their community.
Primary health care was declared as the strategy to attain this goal by WHO and UNICEF jointly during
the International Conference at Alma Ata in 1978. Health for all is a social goal and is considered as
integrated part of socio-economic development of the community. Major emphasis is laid on preventive
and promotive aspects of health, well integrated with curative, rehabilitative and environmental
measures.

Health now is the community’s concern and possession. The community is responsible for providing all
facilities and total care to all. Community health nursing practice primarily rests outside the therapeutic
institution. However, community health nursing links the hospital and the community. Community health and
community health nursing draws knowledge from other sectors such as medicine, surgery, pediatrics, obstetrics,
gynaecology, dentistry, health education and vital statistics.

Societal Influences on the Development of Community Health Nursing:

1) Demographic Changes and the Pole of Women:
The changing demographics in the country and the changing role of women have profoundly affected
community health nursing. In the 20th century, the women’s rights movement made considerable
progress; women achieved the right to vote and gained greater economic independence by moving into
the labor force.
Salaries for nurses compare favorably with those for other workers who have four years of education in
fields other than health care, such as education, human services (social work), and business. When
compared with other workers in the health care field, nurses make a lower salary.
Changing demographics, such as shifting patterns in immigration, varying numbers of births and deaths,
and a rapidly increasing population of elderly persons, affect community health nursing planning and
programming efforts. Monitoring these changes is essential for relevant and effective nursing services.

2) Advanced Technology:
Advanced technology has contributed in many ways to shaping the practice of community health
nursing. Technological trends that currently influence health and health care delivery include such things
as the knowledge explosion, the increased ability to prolong life, environmental pollution, increased
pace of life. For example, technologic innovation has greatly improved health care, nutrition, and has
caused a concomitant increase in life expectancy. Consequently, community health nurses direct an
increasing share of their effort toward meeting the needs of the elderly population and addressing
chronic conditions.
 Advanced technology also has been a strong force behind industrialization, large-scale employment, and
urbanization. Community health nurses face a challenge to demonstrate the physical and economic value
of technology for wellness-oriented care.
As we move deeper in to the 21 st century, we move to “mobile care”, using handheld, wireless
technology tools that are nurse friendly and compatible with the nurses’ role. We have the ability to
“tele-visit” our clients, and we regularly use smaller and smaller laptop computers for video
conferencing.

3) Progress in Causal Thinking:

Relating disease or illness to its cause is known as causal thinking in the health sciences. Progress in the
study of casualty, particularly in epidemiology, has significantly affected the nature of community
health nursing. The germ theory of disease causation established in the late 1800s, was the first real
breakthrough in control of communicable disease. At that time it was established that disease could be
spread or transmitted from patient to patient or from nurse to patient by contaminated hands or
equipment. Nurses incorporated the teaching of cleanliness and personal hygiene into basic nursing care.

4) Changes in Education:
Changes in education, especially those in nursing education, have had an important influence on
community health nursing practice. The wealth of information relevant to CHN practice means that
nursing students have more content to assimilate, and practicing community health nurses have to make
greater efforts to keep abreast knowledge in their field. In contrast to earlier times, when nurses were
trained to work as apprentices in hospitals or health agencies and to follow orders perfunctorily, today’s
educational program, including continuing education, prepare nurses to think for themselves in the
application of theory to practice.

CHN has always required a fair measure of independent thinking and self-reliance; now, community
health nurses need skills in such areas as population assessment, policy making, political advocacy,
research, management, collaborative functioning, and critical thinking. As the result of expanding
education, community health nurses have had to reexamine their practice, sharpen their knowledge and
skills and clarify their roles.

5) Consumer Movement:
The consumer movement also has affected the nature of community health nursing. Consumers have
become more aggressive in demanding quality services and goods; they assert their right to be informed
about goods and services and to participate in decisions that affect them regardless of sex, race, or
socioeconomic level. This movement has stimulated some basic changes in the philosophy of
community health nursing. Health care consumers are viewed as active members of the health team
rather than as passive recipient of care.
They may contract with the community health nurse for family care or group services, represent the
community on the local health broad, or act as ombudsmen by serving as representatives or advocates
for their community con – (e.g. to investigate complaints and report findings to protect the quality of
care in a local nursing home). The consumer movement also has contributed to increased concern for the
quality of health services, including a demand for more humane, personalized health care.
 6) Socio-cultural Trends:
 Health is taken as a right rather than a privilege.
 National health insurance policies have been introduced.
 Provisions for hospitalization, ambulatory care, and health maintenance are provided.
 Health as a positive state rather than the absence of disease.
 Increasing use of mass communication techniques.

7) Economic Forces:
Global economic forces also influence community health nursing practice. As the United States
experiences increasing interdependence with foreign countries for trade, investment, and production of
goods, the population has experienced a growing mobility and increased immigration, particularly
among Hispanic and Asian groups.

Community Health Nursing has responded to these economic forces in several ways. One is assuming
new roles, such as health educators in industry or case managers for government and privately sponsored
programs for the elderly. Another is by directly competing with other community health service
providers, particularly in such areas as ambulatory care or home care. Still another is by developing new
programs and service emphases. Elderly day care, respite care, senor fall-prevention programs, teen
pregnancy and drug prevention projects, and programs for the homeless are a few examples of the
response by community health nursing to the changing community needs created by demographic and
economic forces.
 The rising cost of health care causes the people to seek cost effective facilities in the community
hospitals rather than the private hospitals.
 Self care by individuals is another consideration in the provision of health care in today’s
economy due to maldistribution of health care services.

CHANGING PRACTICES
From these historical developments and evolutionary changes in the field of public health, the following
changing practices are identified since eighteenth century onwards.

The practice of public health during the period from 18 th century to early 19th century was limited to care of the
sick and control of communicable diseases through some restrictive measures like isolation, quarantine and by
having control over selected component of environmental sanitation through legislation. Care of the sick was
done by family members and religious men and women.

During the second half of 19th and the 20th century, the modern concept of public health laid its foundations. It
was felt that sufferings could not be relieved and diseases could not be prevented through laws. There are
certain responsibilities which must be taken care of by the individual, family and the community to control
diseases and to attain health. This idea initiated with the services to mothers and children to reduce morbidity
and mortality among them and health education of people to practice hygienical measures.

Public health nursing is the direct outgrowth of these public health services when the need for trained personnel
was felt for providing service to mothers and children including school children. These services were rendered
to poor people and not to the community at large.
Gradually, the value of healthy individual in terms of health as an asset for industrial production and for
economic growth was realized by the industrialists and the Government. Public health included in its preview
industrial and occupational health, accident prevention and control, mental health services etc. There was also
shift in focus from poor sick to all the people in the community.

For the last four to five decades, the area of public health activities broadened and included in its horizon
prevention and control of chronic illnesses like heart diseases, metabolic disorders, cancer, etc., social and
behavioural problems like alcoholism, drug dependence, etc., environmental pollution and genetic problems,
etc.

Public health today encompasses all those activities which contribute to health promotion, health protection,
health improvement and health maintenance of all the people. The services are provided with the organized
efforts of the Government and community so as to achieve the goal of health for all.

As is evident, the practice of public health nursing started with the services to mothers and children, industrial
workers and elderly during the second half of 19th century onwards. The services were initially rendered by lady
health visitors and later from 1930 onwards with the support of trained public health nurses. From 1952
onwards Auxiliary nurse midwives have been trained and included for providing primary health care services in
the villages under the supervision and guidance of lady health visitors and public health nurses.

Community health nursing practice is continuing, comprehensive, directed towards all age groups, takes place
in wide variety of settings. The practice includes evaluation of health status, providing direct care, health
education, guidance and counselling to individual, family and community according to their needs and level of
dependency. It lays major emphasis on preventive and promotive health care service which are community
focused rendered through individual, family and groups. It is practiced within the domain of public health and
includes all public health activities in its preview.

WORLD PLANNING FOR THE 21ST CENTURY

World health leaders recognized the need to plan for the twenty-first century at the 30 th world health assembly
of the World Health Organization (WHO), held in 1977. At that assembly, delegations from governments
around the world set as a target “that the level of health to be attained by the turn of the century should be that
which will permit all people to lead a socially and economically productive life”. This target goal becomes
known as “Health for all by the year 2000”.

The following year in Alma – Ata, USSR, the joint WHO/UNICEF International Conference adopted a
Declaration on Primary health Care as the key to attaining the goal of “Health for all by the Year 2000”. At the
34th World Health Assembly in 1981, delegates from the member nations unanimously adopted a “Global
Strategy” and that same year, the United nations General Assembly endorsed the “Global Strategy” and urged
other international organizations concerned with community health to collaborate with World Health
Organization. The underlying concept of “Health for All by the 2000” was the health resources should be
distributed in such a way that essential health care services are accessible to everyone.

As we now know, the lofty goal of health for all around the world by the 2000 was not reached. That does not
mean that the goal was abandoned. With the passing into a new century, the program was renamed Health for
All (HFA). HFA continues to seek “to create the conditions where people have, as a fundamental human right,
the opportunity to reach and maintain the highest level of health. The vision of are newer HFA policy builds on
the WHO Constitution, the experience of the past and the needs for the future”.
Even though the “Health for All by the year 2000” goal was not reached, some progress was made, overall
global health, as measured by life expectancy at birth, did improve.

Current Issues:
1) Ethical issues:
Nurses have always been concerned about professional ethics and moral codes. Values may be
considered to be a set of beliefs and attitudes that influence perceptions, guide our actions and have
desirable consequences in our interactions with others. No one can consider ethics without appreciating
the nature of values.
An ethical conflict will develop when there is a conflict between moral values. The main responsibility
of a nurse is to reduce these types of ethical issues in the basic moral principal that are to be followed in
professional life such as autonomy (self determination), beneficence (doing good), non-maleficence
(avoiding harm), fidelity (keeping promises), truthfulness and justice (treating people fairly). To
overcome these issues, the following steps should be taken into consideration:
 Provide nursing care with respect for the human dignity of all who require nursing care,
regardless of socio-economic status and other parameters.
 Safe guarding the client’s right to privacy and confidentiality.
 Providing safety to the individual, group, and community.
 Assuming responsibility and accountability for nursing judgements and actions.
 Protect the public from misinformation and misrepresentation.
 Accepting responsibilities, seeking consultation and delegation nursing activities based on
individual competence and informed judgment, etc.
 To promote community and national effort to ensure the availability and accessibility of high
quality health services.

2) Legal issues:
To avoid legal issues, a community health nurse must be technically competent and well versed in
nursing process. Community health nurse must be aware of laws affecting community health nursing
practice. The common laws are always influenced by justice and traditions of the community.
Community health nurses must be competent enough to understand the public and their problems. They
should be able to manage the current issues effectively and try to prevent the same through healthy
interaction.

3) Professional issues:
i. Environmental Health:
 Various types of pollution (water, air, noise pollution and radiation)
 Hazardous materials at home, school and office e.g. highly dangerous chemicals in
household machines, asbestos insulation and noise induced deafness, lack of proper
ventilation in laboratories, inefficient handling of chemicals.
 Other occupational hazards that may induce communicable diseases, cancer, TB, skin
ailments, etc.
 The community health nurse should be capable of bringing in awareness among the public
about the hazards and help them to reduce such hazards, so that the problem may not become
a social issue.

ii. Cost, access and quality issues over health care system:
 Public health care should be easily accessible to all and should be maintained following
high standards of quality. Such programmers will require high cost of maintenance, else
such programmes will fail.
 Failure of such good programmes would lead to negative impact on the minds of people
regarding the feasibility of the system.
Hence, the main responsibility of a community health nurse is to find adequate resources to
ensure that they provide easily accessible and quality health care to people.

4) Socio-cultural issues:
The numerous global, social, demographic, economic, and political changes in recent years have alerted
health care professionals to the need to provide attention to the increasing diversity in our society and
the effect of that diversity on people’s health.
Nepal is one the most culturally diverse nation in the world.
Culture influences our expectations and perceptions of symptoms, the way we label sickness. Health and
illness are shaped by cultural factor; sociocultural influences affect not only the individual’s health
status but also the entire health system.
Nursing has traditionally been a female dominated profession. It is clear that nurses must be sensitive to
cultural differences to be able to provide the best possible care to individuals, families and communities.
 Learning about different cultures helps to prepare community health nurses to competently care
for clients from diverse cultures.
 Culturally competent nursing care means that the negotiated treatment protocol reflects client’s
experiences.
 Nurses may use cultural preservation, cultural accomodations, cultural repatterning, and cultural
brokering to provide culturally competent care.
 The needs of clients vary based on variable, such as age, education, religion and socioeconomic
status, each client should be assessed to determine his/her specific cultural needs.
 Nurses should complete a cultural assessment on every client with whom they interact.
 Cultural competence means that the nurse has attained cultural awareness, has cultural
knowledge, uses cultural skill and has cultural encounters with culturally diverse clients.
 A major trend in this category is the rise of social conscience. Health as a right rather than a
privilege has become an issue.
 National health insurance is another issue.
 Description of benefits provided. These includes provisions for hospitalization, ambulatory care
and health maintenance.
 The redefinition of health as a positive state rather than the absence of disease.
 Increasing use of mass communication techniques.
Challenges:
1. Nurses’ mindset that the proper role of a nurse is at the bedside or at the client’s side, the direct care
role.
2. The structures within which nurses work and the process of role socialization that occurs within those
structures.
3. Relatively few nurses receiving graduate level preparation in the concepts and strategies of disciplines
basic to community health (e.g. epidemiology, biostatistics, community development, service
administration, and policy formation).
4. With few exceptions within the graduate programs in community health nursing, there is no aggressive
effort to develop population focused skills commensurate with the need. The bias of many nurses seems
to be that these skills are less important than clinical skills.

5. There is no standing order for the nurses. Community health nurse encounter different situation while
working in the community so, to handle the problem there should be the right for the standing order for
the nurses so that they can act independently. This is also the one of the challenges for the nurses
working in the community.
6. As there is no nursing division, nurses are bound to work under doctors and the issues related to nursing
are still unsolved. There is no any professional organization in nursing that can act solely considering
the rights and the welfare for the nurses.
7. Greater life expectancy of individuals with chronic and acute conditions is challenging the health care
system’s ability to provide efficient and effective continuing care even after being discharged from
hospitals in their own homes.

8. The educated consumer despite some information gaps, today’s patient is a well-informed consumer
who expects to participate in decisions affecting personal and family health care. With advances in
information technology and quality measurement, previously unavailable information is now public
information, and consumers are asked to play a more active role in health care decision making and
management. There is heightened demand for more sophisticated health education technology.

9. The public is becoming better informed and more assertive about health services, sometimes challenging
the professional decisions. At the same time, concerns with human rights, equity, accountability and
ethical issues will come to the forefront of debate and action.
10. Changing disease pattern and challenges of infectious diseases, emerging and re-emerging diseases,
chronic and non-communicable diseases, injuries and violence, new or re-emerging conditions is
challenging today’s nurses to think and react in sophisticated way.

11. Greatly reducing the burden of excess mortality and morbidity suffered by the poor. This means shifting
the ways in which governments all over the world use their resources. It also means focusing on those
interventions that enable the greatest health gain possible with the available resources so that the
diseases that disproportionately affect the poor, like tuberculosis, malaria, and HIV/AIDS, can be less of
a burden.
Scope of Community Health Nursing practices
The scope of community health nursing includes health promotion, illness prevention and restoration of health
of individuals, families and communities. The scope of community health nursing is wide; there is still a much
wider scope for a nurse. The concept that nursing is only for the care of patients in the hospital is wearing out. A
nurse today functions in a complex situation and performs demanding task. But now nurses’ job is not limited
only for the care of sick, she has equally important responsibilities in the prevention of disease, promotion and
preservation of health. Nurses’ service are not confined to hospital only but also in the clinics, industries and in
the community. The scope of nursing is as wide as the community.

Nurses can work in different places;

1. Home care
2. Nursing homes
3. School health nursing
4. MCH and family planning
5. Domiciliary midwifery services.
6. Public health nursing services
7. Industrial nursing services
8. Mental health nursing services
9. Geriatric nursing services
10. Rehabilitation centres

1. Home care

Extended nursing care services are received by number of patients at home when hospitals are overcrowded for
admitting the patients who require indoor care or when a patient is in need of isolate treatment. Even preventive
and promotive services are provided to the people at their home to maintain and achieve health. A hospital
based home care program provides personnel and equipment from the hospital, or through community agencies.
The hospital usually assumes the responsibility for co-ordinating these services. The visiting nurses require
additional skill such as history taking, recognition of physical signs and interpretation of same towards a
rational treatment. Nowadays, home care is also flourishing in Nepalese context for long term care, care for
paralyzed and disabled clients.

2. Nursing homes

The nursing homes are privately run. They have better medical care facilities because they charge more
fees. The nursing component in nursing homes is generally well catered.The nursing homes are privately
run. They have better medical care facilities because they charge more fees.

3. MCH and family planning

Mother and children are our priority groups for providing health care. The public health nurse is the main
person of all activities of MCH/FP centers. The health care services that a woman receives during pregnancy, at
birth, and soon after delivery is important for survival and wellbeing of both the mother and the child. Nurses
have also major role to play in family planning. During pregnancy or illness people are in a more receptive
mood to accept suggestion for their welfare. Nurses provide services such as immunization, maintenance of
growth chart, detect minor disease and treatment, provide health education for mother such as nutrition, breast
feeding, baby care, hygiene, supplementary food, follow up visit and family planning for spacing.

4. School health nursing

School health is an important branch of community health. According to modern concepts, school health
services is an economical and powerful means of rising community health and it is more important for
future generation. The school health services is the personal health services. It has developed during the past
70 years from the narrower concepts of medical examination of children to the present day broader concept
of comprehensive care of the health and wellbeing of children throughout the school years. The scope of
nursing is vast in a school health program. The school health nurse provides health service to promote and
protect health. The broad areas in which the school health nurse functions are early detection of disease,
health teaching, immunization, personal hygiene, nutrition, first aid, dental health, safe drinking water,
school sanitation, maintenance of health records, follow up and referral service etc.

5. Public health nursing service

Public health is defined as “what we, as a society, do collectively to assure the conditions in which
people can be healthy”. The mission of public health was “to generate organized community efforts to
address the public interest in health by applying scientific and technical knowledge to prevent disease
and promotion of health.(IOM, 1988;Williams 1995)

Public health nursing is comprehensive and includes nursing care of the family in sickness and health.
Public health nurse should be able to:

i. Treat many patients in their homes.

ii. Attend nursing aspects of maternal health and family planning that is to carry out routine of antenatal
and postnatal care of women including family planning and conducting normal deliveries as and when
required.

iii. Promote child health by organizing “under five clinics” and referring those cases to the doctor which
seem to require medical care.

iv. Carry out routine immunization

v. Assess the social environment and nutritional needs of individuals in the community health and direct
the attention of social workers to such needs.

6. Industrial nursing service

Nurses are also employed in industries. There is provision for appointment of medical and nursing staff
in factories where 500 or more workers are employed. The broad areas of nursing in an industrial setting
are:

 Care of sick and injured

 First aid

 Pre placement and periodic health check-up

 Industrial sanitation and safety

  First aid

 Industrial safety

 Organization of services to women and children

 Rehabilitation of ill and disable workers.

7. Domiciliary nursing service

Since domiciliary midwifery is not practiced and focus on institutional delivery, we as a community
health nurse should have knowledge and skills on domiciliary nursing services. There are 3 main areas
where domiciliary nursing is practiced in this country:

 Maternity services
 Health supervision and disease prevention service among newborn, infant, toddler, children as well
as services for illness and accidents.
 Since shortage of nursing personnel is an important limiting factor, domiciliary nursing service is
made available to carefully selected families or individuals.

8. Family planning center

Family planning is not just birth control. It includes many more family welfare planning. The nurses
activities and responsibilities in family planning are

 spacing of pregnancy

 Advice and counseling of sterility and infertility

 Education for planned parenthood

 Sex education

 Screening of cancer of cervix and breast

 Genetic counseling

 Preparation for pregnancy and delivery

 Marriage counseling

9. Rehabilitation center

Rehabilitation implies restoration of all treated cases to the highest level of functional ability physically,
mentally and also socially. Nursing is an important component in the rehabilitation of the disables. Community
health nurse needs to assist the parent to care their children and refer into such institution.

10. Mental health nursing

Mental health services comprises early detection and treatment rehabilitation group and individual, mental
health education, the use of special drugs and after care services. Psychiatric or mental health nursing services
are available in very few area in Nepal. There is one government hospital in LagankhelPatan and one at TUTH
where people can get treatment from health post, PHCC.

11. Geriatric nursing

Geriatric is that term which denotes “old age”. The old people need more care than younger age groups.
Hospitalization and treatment is costly. The old people need psychological support, love and attention. Health
care services for old are being provided in many countries through visiting nurses and other health workers.

Extended and expanded roles of a nurse

Expanded role of nurse involves enhancing the nursing profession and responsibilities assumed by a nurse
within the field of practice. A nurse plays a vital role at the fore front of health care battles. The contributions
made by nurses have always made significant difference for improving health care quality. Nurse’s role has
always been extended and expanded with the changing trends. Innovations in health care, expanding health care
systems and practice settings & the increasing needs of patients have been as stimulus for new nursing
roles. Nursing is the largest of all health care professions. As far as traditional role of nurses are concerned the
focus was on curative aspect whereas expanded role of nurse is assumed by virtue of education & experiences
and extended role includes the services to the people and community.

Importance of   Extended & Expanded role of nurse

 It provides variety of services for the patients of all age groups which may be part of hospital or
community.
 It enhances clinical decision skills.
 It provides expert knowledge and high level of job satisfaction.
 Health is considered as fundamental right of individual. To provide the population with broad access to
basic health services, nurses have to carry out wide range of functions especially in underserved areas
like rural sector, remote regions & urban areas. The transition of health care systems from a disease
oriented model to health oriented model is an emerging trend.

Some of the extended roles of nursing are;

1. Hospice Nursing
Hospice is a type of care that focuses on palliation of terminally ill patient.
2. Nurse epidemiologist
Nurses are in main role to enforce infection control practices. She is also called “infection control nurse”
monitor standard and procedure for prevention and control if infectious diseases or nosocomial
infections.
3. Tele nursing
Uses telecommunication and information technology in the provision of nursing services.Exists when
there is large physical distance between patient and nurse.
4. Disaster nursing
It is the adaptation of professional nursing skill in recognizing and meeting the nursing physical,
emotional, social needs results from disaster.
5. Aerospace Nursing
A nurse who provide comprehensive nursing care for all types patients during aero medical evacuation
and airlift flight.
DETERMINANTS OF HEALTH
Health is multifactorial. The factors which influence health lie both within the individual and externally in the
society in which he or she lives. It is a truism to say what diseases he may fall victim depends on a combination
of two set of factors - his genetic factors and the environmental factors to which he is exposed. These factors
interact and these interactions may be health promoting and deleterious. Thus, conceptually, the health of
individuals and whole communities may be considered to be the result of many interactions.

1. Biological Determinants
The physical and mental traits of every human being are to some extent determined by the nature of his
genes at the moment of conception. The genetic makeup is unique in that it cannot be altered after
conception. A number of diseases are now to be of genetic origin, e.g. chromosomal anomalies, errors of
metabolism, mental retardation, some types of diabetes, etc. The state of health, therefore depends partly
on the genetic constitution of man.

Thus, from the genetic stand-point, health may be defined as that "state of the individual which is based
upon the absence from the genetic constitution of such genes as corresponds to characters that take the
form of serious defect and derangement and to the amount of chromosomes material in the karyotype or
stated in positive terms, from the presence in the genetic constitution of the genes that corresponds to the
normal characterization and to the presence of a normal karyotype.

The positive health advocated by WHO is possible only when the person is allowed to live in healthy
relationship with his environment- an environment that transforms genetic potentialities into phenotype
realities.

2. Behavioral and socio- cultural conditions

The term lifestyles is rather a diffuse concept often used to denote " the way people live" , reflecting a
whole range of social values, attitudes and activities .It is composed of cultural and behavioral Pattern
and lifelong personal habits (e.g. smoking, alcoholism) that have developed through processes of
socialization. Lifestyles are learnt through social interaction with parents, peer groups, friends and
siblings and through mass media.

Health requires the promotion of healthy lifestyles. Many current- day health problems especially in the
developed countries (e.g. coronary heart disease, obesity, lung cancer, drug addiction) are associated
with life styles changes. In developing countries where traditional lifestyles still persist, risk of illness
and death are connected with lack of sanitation, poor nutrition, personal hygiene, elementary human
habits, customs and cultural patterns.

It may be note that not all the lifestyle factors are harmful. There are many that can actually promote
health. E.g. adequate nutrition, enough sleep sufficient physical activity etc. Inshort, the achievement of
optimum health demands adoption of healthy lifestyles.

3. Environment
Environment is classified as ' internal' and 'external'. The internal environment of man pertains to each
and every component part, every tissue, organ and organ – system and their harmonious functioning
within the system. The external or macro- environment consists of those things to which man is
 exposed after conception. It is defined "all that which is external to the individual human host. It can be
divided into the physical, biological and psychological components, any or all of which can affect the
heath of man and his susceptibility to illness. Some epidemiologists have used the term" micro-
environment"(or domestic environment) to personal environment which includes the individual's way of
living and lifestyles. (e.g. Smoking or drinking), use of drugs, etc.

It is an established fact that environment has a direct impact on the physical, mental and social wellbeing
of those living in it. The environmental factors range from housing, water supply, psychological stress
and family structure through social and economic support systems to the organization of health and
social welfare services in the community.

4. Socio- economic condition

The majority of the world's people, health status is determined primarily by their level of socio-
economic development. The major important socio- economic conditions are;

a) Economic condition- The economic status determines the purchasing power, standard of living, quality
of life, family size and the pattern of disease and deviant behavior in the community. It is also important
factor in seeking health care.
b) Education- A second major factor influencing health status is education (esp. female education).The
world map of illiteracy closely coincides with the map of poverty, malnutrition, illness and high infant
and child mortality rates, to some extent. The education to some extent compensates the effect of
poverty on health.
c) Occupation- The very states of being employed in productive work promotes health, because the
unemployed usually shows higher incidence of illness and death. For many loss of work may mean loss
of income and status. It can cause psychological and social damage.
d) Political system-Often the main obstacles to the implementation of health technologies technical, but
rather political. Decision concerning resource allocation, manpower policy, choice of technology and the
degree to which health services are made available and accessible to different segments of the society.
The WHO has set the target of at least 5 per cent expenditure of each country's GNP in health and family
welfare.

5. Health Services
The term health and family welfare services cover a wide spectrum of personal and community services
for treatment of disease, prevention of illness and promotion of health. The purpose of health services is
to improve the health status of population. For e.g., immunization of children can influence the
incidence/ prevalence of particular disease .Provision of safe water can prevent mortality and morbidity
from water – borne disease. The care of pregnant women and children would contribute to the reduction
of maternal and child morbidity and mortality.

6. Ageing and the Population

By the year 2020, the world will have more than one billion people aged 60 and over and more than
two- thirds of them living in developing countries. A major concern of rapid population ageing is the
increased prevalence of chronic disease and disabilities.
 7. Gender
The 1990's have witnessed an increased concentration on women's issues. In 1993. The Global
Commission on Women's Health established. The commission drew up an agenda for action on women's
health covering nutrition, reproductive health, the health consequences of violence, ageing, lifestyles
related condition and occupational environment .It has brought about an increased awareness among
policy – makers of women's health issues and encourages their inclusion in all development plans as a
priority.

8. Other factors
The development of the technologies contribute to dissemination of information worldwide serving
needs of many physicians , health professionals, biomedical scientists and researchers, the mass media
and the public.

Other contributors to the health population derive from systems outside the formal health care system,
i.e. health related systems (e.g. Food and agriculture, education, industry, social development) as well as
adoption of policies in the economic and social fields that would assist in raising the standard of living.

DIMENSIONS OF HEALTH

The dimension of health as documented in WHO definition of health and endorsed by Blum's force-field and
wellbeing paradigm are physical, mental, social and spiritual wellbeing.

1) Physical wellbeing or Health

Physical wellbeing or health is related to the body structure and its physiology. It refers to normal
functioning of all the tissues, organs and systems of the body resulting in harmonious functioning of the
body. All the vital signs are in normal range. The chemistry of all the body fluids is within normal range.
The skin is clear and firm, eyes are bright and hair are lustrous. There is good appetite, sound sleep and
regularity of bowel and bladder. The body movements are coordinated.

2) Mental wellbeing or Mental health

Mental health is related to mind and refers to normal functioning of mind and not merely the absence of
mental illness. It is rather abstract.

There are three major characteristics of mentally healthy individuals which are identified. These are:
1. He is free from internal conflicts and tensions. He knows himself and neither underestimates nor
overestimates, accepts his shortcomings. He feels comfortable about himself. He is self-confident.
He has self-identity and strong sense of self-esteem. He does not have spells of depression or elated
mood.
2. He is able to feel a part of others and has harmonious relations with others.
3. He is well adjusted and able to meet the demands of life and able to solve problem intelligently.
Because of abstract nature of mental health, there are no precise tools to assess the state of mental
health. Some mental health inventories have been developed to assess mental wellbeing and mental
diseases. There are some standardized test to carry on some specific test. E.g. IQ testing, personality
test, thematic appreciation tests, etc.
 3) Social wellbeing or Social health
It is difficult to define social health. It refers to abilities that enable the individual to become a whole
person in existing social structure. He is able to make lasting friendship that is satisfying, accomplishes
success and happiness from day to day task of living effectively with others and be able to live in
harmony with a surrounding.

Man is a social being. He learns from his society about socio cultural and economic aspects of life and
develops social values. He also contributes to society in enriching socio-cultural and economic aspects.
Social health of an individual is influenced by social systems of society.

It is equally difficult to assess social health of people. There are some indirect measure of social health.
The assessment tools and techniques which are developed and used are sociometery, attitude scales, and
socio-economic scales.

4) Spiritual wellbeing or spiritual health

It pertains to soul or spirit of man. There is no concrete/substantial definition so far. The concept is very
abstract. It refers to beliefs in super natural aspects of universe which help individual to seek meaning
and purpose in life, to resolve both internal as well as external conflicts. It is associated with religious
beliefs of an individual which provide philosophy of life, directions, ethical values and principles of
integrated and high living. This gives strength and determination to face realities of life and live
gracefully and meaningfully.

References:
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20
2. Gulani, K.K. (2008)" Community Health Nursing; Principles and Practices". New Delhi. Kumar
Publishing House. P 15 – 16.
3. Mary Jo Clark," Nursing in the community", 3rd edition, library of congress cataloging in –
publication
4. Basavanthappa, BT(2011). "Community Health Nursing", (2nd edition), Jaypee Brothers
5. Dr Rao, S (2010), "Principles of Community Medicine", 5th edition, Aitbs Publishers India
6. Ghimire, B.(2012) "A Textbook of Community Health Nursing", 2nd edition, Heritage Publisers
and Distributers P.Ltd
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