MODULE 1
COMMUNITY Health Nursing (PPT)
COMUNITY HEALTH NURSING
• “synthesis of nursing practice and public health
practice applied to promoting and preserving the
health populations”
HIERARCHY OF PRACTICE NURSING FIELD
Why do you think Community & Public Health
Nursing is in the apex of the hierarchy ?
• Nurses impact to population
• Unique Task is to transform technical knowledge
from all fields of nursing into service for the
people
KEY CONCEPT OF COMMUNITY & PUBLIC HEALTH
NURSING
COMMUNITY AS A CLIENT
• Community & Public Health Nursing requires
understanding & respect for culture .. Introdue
gealth info & influence people to embrace the
culture of health
HEALTH AS A GOAL
• Community & Public Health Nursing foster multi-
disciplinary efforts to address core determinants
of health
NURSING AS THE VEHICLE OR MEANS TO
ACHIEVE ITS AIMS
1. Nursing as a means of ensuring that people are
placed in optimum condition where NATURE can
contribute to healing & wellness. FNightingale
2. Nursing as a way to help people achieve self-reliance
in health allowing them to do things on their own efforts;
unique function is to assist individual , sick or well.
VHenderson
• Nursing as the art & science of caring
LEVEL OF CLIENTELE
The following are the specific clients of the nurse
1. INDIVIDUAL
• specific clients/patients in various conditions of
health & illness
• from healthy/well to the dying
• all ages from birth to senescence
2.FAMILY
• 2 or more individual joined or related by ties of
blood, marriage or adoption
• w/ respective familial roles & maintain a common
culture
3. GROUP/AGGREGATES
• These are the population with common unique
health needs
E.g. child bearing women, infants
• Group that are at risk of developing or have
developed certain health problems
E.g. pre-diabetic clients
4. COMMUNITY
• Share common interest, needs, ethnic or cultural
ties
E.g. squatters community of Metro Manila
• Place w/ spatial boundaries, physical &
environmental characteristics w/ natural & man-
made resources
E.g. Barangay, vilage/barrio, town, province,

The three (3) characteristics basic to positive
concept of health are as follows :
1. Reflects concerns for the individual as a total
person rather than as merely the sum of various
part;
2. place health in the context of the environment;
3. equates health w/ productive & creative living.
HEALTH AS A SOCIAL PHENOMENON
.HEALTH affects physical well-being of people in the
society,social, economic, political, intellectual and
spiritual development of the community and the country
• Example:
Ecomic globalization and privatization of hospital
& health facilities --- disrupted the health of the
people since it causes the increase of medical
expenses which prohibit the society to avail
regular health services.
HEALTH AS A BASIC HUMAN RIGHTS
.Health accessibility and equality are essential human
rights. It is a reflection of society’s commitment to equity
and justice. Health should prevail over economic and
political concerns.
• Example is the commitment of the Philippine
government in creating an interim agencies such
as the Inter-Agency Task Force (IATF) to
alleviate the people’s condition or eradicate the
COVID 19 .
.Health should not be discriminatory and should not be
limited to groups regardless of their race, religion,
gender, age and socio-economic conditions.
HEALTH AS PERSONAL & SOCIAL RESPONSIBILITY
.Health a collective effort to ensure that everyone gets
every health care due to them
Being a responsible member of society, one should
consider the welfare of others besides ourselves.
DOH ensures the access to public health services &
establish health care programs to regulates activities of
the Filipinos.
• Example is that the people should refrain from
indulging himself to reckless and inconsiderate
habits/vices since the cost of health care is
becoming expensive everyday.
FIELDS OF COMMUNITY & PUBLIC HEALTH
NURSING
1. Occupational Health Nursing
2. Correctional Nursing
3. Faith Community Nursing
4. School Health Nursing
COMMUNITY & PUBLIC HEALTH NURSE
LAW - basis of the role and functions is embodied in
Republic Act 9173 otherwise known as the Philippine
Nursing law
Defined by the different professional organizations :
• Philippine Nurses Organization (PNA), Inc.,
• Occupational Health Nurses Association of the
Philippines (OHNAP)
• National League of Philippine Government
• Nurses (NLPGN)
• Department of Health
• Department of Education (DepED).
ROLES OF COMMUNITY & PUBLIC HEALTH NURSE
Healthcare Provider: Use of nursing process in the
natural environment of the client.
• Example :Occupational Health Nurse conducting
physical assessment to an employee School
nurse providing first aid to the students.
Health Educator: Communicating information to assist
clients with informed choice
Goal; Awareness to impact people’sbehavior to achieve
health in their own hands
• Example :Healthy lifestyle program for
seniorsInstructions to take medications among
diabetic patients
Program Implementer: Deliver health care to the
grassroots in collaboration with LGU
Execution of DOH programs at all levels of clientele
Collaborate with RHM & BHW
Submit reports per standards of documentation
• Example :
- EPI records
- Database for those who received Sinovac,
Pfizer for COVID 19 prevention
Community Organizer: Working with people in the
communities & providing ownership of their healthcare
needs to act collectively on their issues
• Example :
Addressing the pressing of the community on
potable water supply
5.Knowledgeable of spiritual beliefs and practices of the
faith community
• w/ specialized knowledge and skills to enable
implementation of Faith Community Nursing
Scope and Standards of Practice (Scope and
Standards 2017)
• unique expertise concentrates on intentional
care of the spirit

Manager/ Leader: Employs principles of management S/he may offer:

to maximize resources effectively & efficiently 1. Integration of faith and health
2. Health promotion, education, and counseling
• Example : 3. Referrals, volunteer coordination, support group
- Budgeting development
- Inventories 4. Advocacy for individuals and the
- Scheduling & staffing congregation/community
- Conducting training sessions

Researcher/ Epidemiologist: Keep tracking of illnesses
encountered in the area
- Submits reports to health authorities
- Investigation to identify etiology of epidemics &
potential solutions
Correctional Nurse:
- Assigned to perform routine health care of inmates with
certain pre-existing medical conditions
- Common illnesses of inmates : high blood pressure,
diabetes, seizure disorders ,acute or chronic illnesses,
ranging from influenza to AIDS

• Example : • Must be prepared to handle injuries such as

Collection of data ( actual research) stabbings and broken bones
* prisons and correctional facilities can be
dangerous places, and injuries – unintentional or
Client Advocate: otherwise – are not uncommon
-Engages with stakeholders to promote health of the
people
- Lobbying for policies that impact the health of the PUBLIC HEALTH NURSE
community Roles
- Establish linkages to health related agencies • Management
• Training
• Supervision
FAITH COMMUNITY NURSE • Provision of Health and nursing care
• Health education
• specialized practice of professional nursing that • Coordination
focuses on the intentional care of the spirit as
well as on the promotion of wholistic health and
prevention or minimization of illness within the OCCUPATIONAL HEALTH NURSE
context of a faith community. (Faith Community Roles
Nursing Scope and Standards of Practice 2017). • Curative/palliative
• Preventive
• Educative
• Administrative functions
FAITH COMMUNITY NURSE : QUALIFICATIONS
1. Registered nurses with a current license
(baccalaureate or higher degree preferred) SCHOOL NURSE
Roles
2. With Academic preparation in community-focused or
1.health and nutrition assessment, screening and case-
population-focused care
findings
3. Experienced as a registered nurse using the nursing 2. treatment of common ailments and attending to
process emergency cases
3. counseling and health education
4.Knowledgeable of healthcare assets and resources in perform nursing procedures
the community 4. supervision of health and safety of school personnel
5. referrals and follows of pupils/students and personnel
seeking health services to the clinic.
DETERMINANTS OF HEALTH AND DISEASES

The attainment of community’s health status is affected

by numerous factors. Specifically, the following are the
determinants of health with corresponding explanation
on how they affect the health.. There are examples given
in each factor.

1. INCOME & SOCIAL STATUS

• the greater gap between the richest & the
poorest people, the greater the difference in
health

2. EDUCATION
• low education levels are linked w/ poor health ,
more stress & lower self-confidence

3. PHYSICAL ENVIRONMENT
• safe water, clean air, healthy workplaces, safe
houses, communities and roads may contribute
to good health

4. EMPLOYMENT & WORKING CONDITIONS

• conducive working conditions lead to a healthier
employee

5. SOCIAL SUPPORT NETWORKS

• families, friends & communities support is linked
to better health

6. CULTURE
• Customs, traditions & beliefs of family &
community may affect health

7. GENETICS
• inheritance plays part in determining lifespan,
healthiness & likelihood of developing diseases

8. PERSONAL BEHAVIOR & COPING SKILLS

• Good nutrition, indulging to physical activities,
cessation of smoking & alcohol drinking
connotes better health outcome

9. GENETICS
• inheritance plays part in determining lifespan,
healthiness & likelihood of developing diseases

10. PERSONAL BEHAVIOR & COPING SKILLS

• Good nutrition, indulging to physical activities,
cessation of smoking & alcohol drinking
connotes better health outcome

11. HEALTH SERVICES

• equitable & accessible health services
contributes to health promotion & disease
prevention

12. GENDER
• men & women experience disease at different
stages in life
 MODULE 2 (PPT)
ASSESSMENT OF COMMUNITY HEALTH
NEEDS
COMMUNITY
As PRIMARY CLIENT :
• Direct influence on health of the
individual, families & sub-group
• Most service health provisions occur
POPULATION
• General public or society or collection
of communities
• NO social action among each members
• SUBGROUPS: Aggregate, Neighbor,
• General
Community
public or society or
AGGREGATES
• With common characteristics &
concerns
• Interact or work together to address the
concerns
• EX : high risk of diabetes, hypertension
NEIGHBORHOOD
• Homogenous
• With common language & cultural,
tradition
• May not have specific physical or
geographical location
COMMUNITY
– Collection of people, place& a social
system
COMMUNITY DIAGNOSIS (CDx)
• As a Profile – Health status
• As a Process- working relationship
• between the nurse & the community
TYPES OF CDX.
1. COMPREHENSIVE CDX
– aims to obtain general information
about the community.
2. PROBLEM ORIENTED CDX
– an assessment of community that
responds to a particular need.
When we talk of a comprehensive CDx, its
intention is to determine;
• Health condition & risk factor (
epidemiologic)
• Socio-economic condition
• Lifestyle behaviors & attitude affecting
health
COMPREHENSIVE CDX
Aims to Determine
• Prevalent health condition and risk
factor (epidemiology)
• Socio-economic condition
• Lifestyle behaviors & attitude that affect
health (behavioral approach)
ELEMENTS: COMPREHENSIVE CDX
1. Demographic variables
2. Socio-economic & cultural
3. Health & Illness patterns
4. Health resources
5. Political/Leadership patterns
A. DEMOGRAPHIC VARIABLES
• Size, Composition & Geographical
distribution of the population :
1. Total population & geographical
distribution ( urban-rural index & population
density)
2. Age & gender composition
3. Household size
4. Vital indicators – growth rate, CBR,CDR,
Life expectancy
5. Patterns of migration
6. Population projections
B. SOCIO-ECONOMIC & CULTURAL
VARIABLES
1. Social Indicators
• Education
• Housing
• Social classes
2. Economic Indicators
• Poverty level income
• Employment status - wage earners
• Occupation
• Communication network
• Transportation system
3. Environmental indicators
• Physical/ Geographical/topographical
• Water supply
• Waste disposal
• Air, water & land pollution
4. Cultural Factors
• Variables –Ethnicity, Social class,
Language ,Religion
• Beliefs & practices affecting health
• Concept on health & illness
C. HEALTH & ILLNESS PATTERNS
Leading causes :
• Mortality
• Morbidity
• Infant & Child Mortality
 • Maternal Mortality
• Hospital admission
• Nutritional status
D. HEALTH RESOURCES
MANPOWER RESOURCES:
• Categories health personnel
• Manpower –population ratio
• Health facilities & organization
• Quality of services
MATERIAL RESOURCES:
• Health budget & expenditures
• Sources of funding
• Health institutions available
• Hospital bed-population ratio
• Health services available
E. POLITICAL/LEADERSHIP PATTERNS
• Power structure
• Attitudes to authority
• Conditions/events: cause social conflict
Practices/approaches: settle issues
PROBLEM-ORIENTED CDX,
• Assessment of particular need of target
population
Example of this is an outbreak of a certain
illness like measles or COVID-19.
• Use of hard instruments such as
cameras, or videotapes
• OCULAR SURVEY or windshield
survey
• Participant Observation
2. RECORD REVIEW
• Hard copies of written information
• Database retrieved/accessed
3. INTERVIEWS
• Asking & answering questions following
a systematic procedures
• Most common & widely used method
TYPES OF INTERVIEW:
1. Face to face interview
• Seek clarification on questions
• Pick up non- verbal cues
2. Telephone interview
• Gather voluminous data
• Text messages provide limited data
3. Individual interview
• Conversation bet respondent &
Interviewer
• Use in sensitive issues

4. Key Informant Interview

STEPS IN CONDUCTING CDX
• Interviewee is expert or authority on
specific subject
1. DETERMINE THE OBJECTIVES.
• Present health conditions of the
5. Group Interview
community
• Specific problems causing the • Interviewer & 10-15 participants
condition/s • Skilled interviewer ensure equal
• Roots of the problem participation
• Solution/s to address the problem
APPROACHES: INTERVIEW
2. DEFINE THE POPULATION 1. Structured Interview
• Entire population • “script” during interview
• Subset of the target population • Possible responses in the interview
schedule
3. DETERMINE THE DATA TO BE • Interview adhere to & not after
COLLECTED sequence of questions
• Data Collection Plan
o Primary 2. Unstructured Interview
o Secondary • Collect qualitative data
• Use of open-ended questions
4. COLLECTION OF DATA • Interviewer- skillfull in evoking
• Generate relevant data responses

DATA COLLECTION METHOD 4. Focus Group Discussion (FGD)

1. OBSERVATION • This is a qualitative research
• Check validity of many verbal technique used for its value in
statements understanding and documenting human
behavior. (Tan and Dalisay, 1999).
 • A very popular method appropriate in
the community to elicit opinions of
people, determine their attitudes and
practices regarding a limited set of
concepts.
• Define characteristics common to &
differentiate the participants
FOCUS GROUP DISCUSSION
In conducting FGD, make sure to set the
characteristics of the participants in terms of:
1.Those characteristics that will be common to
them, and
2.Those characteristics that will differentiate
them from each other
TYPES OF FGD
1. Natural Group- consists of multiple
participants who belong to a pre-
existing informal or formal group.
(Family or kin, co-workers, elderly
group, women’s self-help group etc.)
2. Expert groups- consist of several
people who are particularly good and
broad expert knowledge and
experience of the research topics
PPT
USE OF FGD IN HEALTH RESEARCH
1. Exploration- perform in the beginning
of the research to detail preliminary
issues
2. Monitoring- Perform in the midst of
research to control or supervise the
corresponding processes
3. Evaluation- Perform at the end or
during the phase-out stage
4. Gathering and Assessing Outcomes-
after the completion of the investigation
or intervention
SAMPLING AND RECRUITMENT
• Purposive Sampling- participants are
selected based on their knowledge, life
experiences, particular characteristics,
or role in a group/ community
• Compose of 6 to 12 participants
• General rule of thumb: The more
experience and knowledge the
participants on the given subject, the
smaller the group can be
MEMBERS OF FGD RESEARCHER GROUP
1. Moderator- facilitates the FGD process
2. Recorders- Video or audiograph
recording
ROLES OF THE MODERATOR
1. Ensures that the discussion topic is
clearly understood and discussion is
balanced and inclusive
2. Should avoid dominating the groups
and expressing his or her own
judgments
3. He should be alert, probing and
encourage everyone to take part in the
discussion
4. She should be able to establish a good
dynamic in which participants discuss
topics from the discussion guide among
themselves
STEP IN FGD PROCESS
1. Start the discussion with an ice-
breaker e.g. introduction of participants
2. Introduce the main topic and the overall
research question
3. Ask specific questions listed in the
discussion guide
4. Thank participants and say goodbye
PHASES OF ANALYSIS OF DATA
1. Transcribing recorded statements-
so that a detailed written document is
available about who said about a
particular question
2. Coding the Transcription- Used
codes that labels or summarize
bookmarks
a. Deductive code- specified before data
collection, based on the research question
b. Inductive codes- those that emerged from
the analyzed text itself (analysis)
3. Reviewing memos- review again the video or
audio graph, the transcribed data and the codes
formed
4. Analyzing and Interpreting qualitative data-
a. look at the people as a group rather than the
individual is the unit of analysis
“ the majority of the participants agreed…” “
there were several contradictory opinions
about….” “ almost no one mentioned….”
b. Interpret what people said
ESTABLISHING VALIDITY AND RELIABILITY
1. Conducting respondent check- go back
to the participants and verify results
2. The researcher must not allow his
personal beliefs, and opinions affects
the interpretation of findings
3. Compare results with other results-
(survey)
 MODULE 3
STEPS IN CDX
5. DEVELOPING THE INSTRUMENTS
• Tools or instruments depend on data
gathering method
PPT
INSTRUMENTS
• Instruments or tools facilitate the
nurse’s data gathering activities
• to be used depend on the method of
data gathering needed to supply the
information for the community
diagnosis.
COMMON INSTRUMENTS
1. Survey questionnaire
• also called the survey instrument
• is the form one uses to document the
data being collected
• maybe in the form of interview schedule
or a self-administered questionnaire.
FORMS
• Interview schedule: Nurses read
questions & record responses
• Self-administered Questionnaire:
respondents read the question and
write down their responses
INTERVIEWS
• Asking & answering questions following
a systematic procedures
• Most common & widely used method
TYPES OF INTERVIEW:
2. Face to face interview
• Seek clarification on questions
• Pick up non- verbal cues
3. Telephone interview
• Gather voluminous data
• Text messages provide limited data
4. Individual interview
• Conversation bet respondent &
Interviewer
• Use in sensitive issues
5. Key Informant Interview
• Interviewee is expert or authority on
specific subject
6. Group Interview
• Interviewer & 10-15 participants
• Skilled interviewer ensure equal
participation
2. Focus group discussion guide
• Facilitate the direction & flow of
exchange of ideas
• Content: Specify objectives &
characteristics of participants
3. Key Informant Interview guide
• Direct/guide the interviewer using set of
questions
• Interviewee (person being interviewed)
-selected due to expertise/ know how/
concern to the issue or subject matter
4. Observation Checklist
• List of DATA – manifestations or
indicators of health needs or problems.
STEPS IN CDX
6. ACTUAL DATA GATHERING
• the nurse meets the team of people
who will be involved in the data
collection process
• The instruments are discussed and
analyzed
• the instruments maybe modified or
simplified
• Pre-testing of instruments is highly
recommended
• The data collectors must be given an
orientation and training
• The nurse can ask the data collectors
to role-play an interview scene
• The nurse can teach data collectors
participatory tools and techniques
ROLE of the NURSE :
1. Orientation of the Data Collectors
2. Facilitate Role Play of an Interview scene
3. Teach the Participatory tools & technique
PARTICIPATORY TOOLS FOR DATA
GATHERING
1. Semi-structured Interviews
• Informal
• Guided interview sessions
• Some pre-determined questions
• New questions or lines develop
2. Analytical Games
• Quick means of finding out individual’s
or groups list of priorities or
preferences
• Example : “Pinoy Henyo”
3. Stories & portraits
• Short, colorful description encountered
by the nurse
• Stories recounted by the people
• Example : “ Ang Kwento…”
4. Diagrams
• Simple, schematic representation in
understandable visual forms
• Analytic procedures to communicate
between & among the people
Example:
Non-utilization of slippers among children
Parasites (worms)
Worms eats the nutrients taken from the food
Signs of MALNUTRATION
5. Workshops
• Bringing people together & outsiders for
their skills & experience
• Purpose: review, analyze & evaluate
information gathered
STEPS IN CDX
7. DATA COLLATION
– Putting together all facts & figures to
generate information on health status
TYPES of DATA :
• Numerical- demographic profile
• Descriptive- Observable
PPT
Categories of data
1. Mutually Exclusive- this includes
choices that do not overlap. Responses
can only in one category from a set of
choices. This type is both for numerical
and descriptive data.
Exhaustive Categories
– anticipate all possible answers that a
respondent may give:
What family planning methods/ are you
using?
• Lactational Amenorrhea method
• Natural
• Basal Body Temperature
• Cervical Mucous method
• Standard days method
• Thermal method
8. DATA PRESENTATION
• Descriptive Data – Narrative reports
EX. : history, beliefs
• Numerical Data - - Tables or graphs
EX. Mortality rate, prevalence of disease
POPULATION PYRAMID
– In making the population pyramid,
distribute the age-sex of the
respondents according to:
Example:
Demographic data:
In barangay Malaya there are 501
number of population. There are 124 children
aged 0-5 years old (80 female & 44 male), 85
individuals aged 15-24 (62 female &23 male),
180 adult aged 25-39 years old.( 70 F & 110 M) ,
67 individual aged 40-59 (27M & 40 F) years old.
There are 45 older persons aged >60 (32 M &
23 F).
In making the population pyramid, distribute the
age- sex of the respondents according to:
Age criteria (0-5, 6-14, 15-24, 25-39,40-59,
65up)
Construct sample population pyramid.
X- % of population
Y- Age in year
Male (left of the bar graph)
Female (right of the bar graph)
Young Population
• Broad base
• Majority of population
belongs to young
population (starting
form 0-12 mos to14
y/o and below)
Inverted Population Pyramid
• Majority of the population belongs to
old age (60-65 years old and above)
LESSON 3: (10) IDENTIFY CHN PROBLEMS
CATEGORIES OF CHN PROBLEMS
• HEALTH STATUS – increase or
decrease morbidity, mortality, fertility,
or reduced capability for wellness

• HEALTH RESOURCE – lack or

absence of manpower, money,
materials or institutions necessary to
solve problems

• HEALTH –RELATED – existence of

Ideal
Population Pyramid
• Japanese lantern like
• Majority of the population belongs to
reproductive years (14/15 y/o- 45 y/o)
social, economic , environmental, &
political factors
11. PRIORITY-SETTING
1. NATURE of the CONDITION
• Classification of problem as health
status, health status or health
resources

2. MAGNITUDE of the PROBLEM

• Severity measured in terms of
proportion of population

3. MODIFIABILTY of the PROBLEM

• Probability of reducing, controlling or
eradicating the problem
TYPE of GRAPH DATA FUNCTION
Line Graph Shows trend or 4. PREVENTIVE POTENTIAL
changes w/ time or age • Probability of controlling or reducing the
w/ respect to other effects posed by the problem
variables
Bar graph or Comparison of absolute 5. SOCIAL CONCERN
pictograph or relative counts & • Perception as they are being affected
rates between
categories SCORING
Histogram or Graphic representation
frequency of frequency distribution
polygon or measurement
Proportional or Breakdown of a group
component bar or total where number
graph or Pie chart of categories is not too
many
Scattered diagram Correlation between 2
variables

9. DATA ANALYSIS
• Most crucial stage
• Quantification, description & Interpretation:
classification of data – The problem with the highest possible
• Use of TRIANGULATION scores is given the highest priority of
• Role of the Nurse : facilitate simplified the nurse.
analysis technique
EX. : Problem Tree Analysis
Fish Bone Analysis
Formula Example Solution Tree
– Score/highest possible score x
weight
Problem Tree Analysis
– provides an overview of all known
causes and effect to an identified
problem.
– involves writing causes in negative form
(e.g. lack of knowledge, not enough
money etc.)

Example Problem Tree:

A problem tree analysis:

1. Helps in the planning of project or
community health plans
2. Provides a guide to the complexity of a
problem by identifying the multiple
causes
3. Identifies particular lines of intervention
and other factors that may need to be
tackled with complementary projects/
plan
4. Provides an outline of the projects/
plans, including the activities that need
to be undertaken, the goals and the
outcomes of the project

Solution Tree
• Reversing the problem tree, by
replacing negative statements with
positive ones, creates a solution tree.
• A solution tree identifies means-end
relationships as opposed to cause-
effects.
• provides an overview of the range of
projects or interventions that need to
occur to solve the core problem.
 MODULE 2
LESSON 1 THE COMMUNITY HEALTH
ASSESSMENT TOOLS
Assessing Community Health Needs
If you work as a community health
nurse, you will have to work with different types
of client. You may work with families,
populations or sub-groups. Each one has distinct
characteristics and distinctions;
The interrelationship of these elements will
explain the health and illness patterns in the
community.
Freeman and Heinrich (1981), said that it is
based on three interdependent, interacting and
constantly changing conditions:
1. The health status of the community,
including the population’s level of

POPULATION – refers to the general public or

society or a collection of communities. Within the
population are smaller subgroups referred to
as aggregate, neighborhood, and community.
This will give rise to communities that
Sanders (1958) and Cassells (1993) define as a
collection of people, a place and social system.
Knowing the defining characteristics of
a community will set the stage in understanding
the different aspects that directly or indirectly
influence the health status of a the community.
Thus being a community health nurse, vulnerability.
we regard the community as our primary client.
2. Community health capability or the
ability of the community to deal with its
THE COMMUNITY DIAGNOSIS
● an in depth process of finding out the
profiles, health status of the community and
the factors affecting the present status.
● we are use in the cliché that the heart of
nursing is caring, and caring for the
community as a client starts with
determining its health status.
● there are two important parts in community
health diagnosis (Muecke 1989)
1. Collection of data to identify the factors
that influence the health of the
population, and health problems.
2. Analyze and seek explanation for its
occurrence of health needs and 3. Community action potential, or the
problems. patterns in which the community is
This process is called community likely to work on its health problems.
assessment, considered to be the keystone of
community health process (Freeman and
Heinrich 1981; Muecke 1989).

ECOLOGICAL APPROACH TO COMMUNITY

HEALTH DIAGNOSIS (Payne,1965) recognizes
the health status of the community is a product
of the various interacting elements;
● Population
● Physical and topographical
characteristics
● Socio-economic
● Cultural factors
● Health and basic social services
● Power structure within the community
LESSON 2 THE PROCESS OF COMMUNITY ● Water supply
DIAGNOSIS STEPS 1-3 ● Waste disposal
● Air, water & land pollution
The Process of Community Diagnosis Steps 4. Cultural Factors
1-3 ● Variables –Ethnicity, Social class,
Language ,Religion
There are two types of Community ● Beliefs & practices affecting health
Diagnosis: ● Concept on health & illness
1. Comprehensive CDx C. HEALTH & ILLNESS PATTERNS
- aims to obtain general information about ● Leading causes :
the community. ● Mortality
● Morbidity
2. Problem- Oriented CDx ● Infant & Child Mortality
- an assessment of community that ● Maternal Mortality
responds to a particular need. ● Hospital admission
When we talk of a comprehensive CDx, its ● Nutritional status
intention is to determine; D. HEALTH RESOURCES
● Health condition & risk factor ( MANPOWER RESOURCES:
epidemiologic) ● Categories health personnel
● Socio-economic condition ● Manpower –population ratio
● Lifestyle behaviors & attitude affecting ● Health facilities & organization
health ● Quality of services

The following are elements of a MATERIAL RESOURCES:

comprehensive CDx; ● Health budget & expenditures
1. Demographic variables ● Sources of funding
2. Socio-economic & cultural ● Health institutions available
3. Health & Illness patterns ● Hospital bed-population ratio
4. Health resources ● Health services available
5. Political/Leadership patterns E. POLITICAL/LEADERSHIP PATTERNS
● Power structure
COMMUNITY HEALTH ASSESSMENT TOOL ● Attitudes to authority
(PPT) ● Conditions/events: cause social conflict
A. DEMOGRAPHIC VARIABLES ● Practices/approaches: settle issues
● Size, Composition & Geographical
distribution of the population : WHEN WE TALK OF A PROBLEM-ORIENTED
1. Total population & geographical CDX,
distribution ( urban-rural index & population Spradley (1990;) and Clark (2003)
density) describes the problem-oriented community
2. Age & gender composition diagnosis as the type of assessment that
3. Household size responds to a particular need of a target group.
4. Vital indicators – growth rate, CBR,CDR, Example of this is an outbreak of a certain
Life expectancy illness like measles or COVID-19.
5. Patterns of migration
6. Population projections COMMUNITY DIAGNOSIS: THE PROCESS
B. SOCIO-ECONOMIC & CULTURAL ● The community diagnosis consists of
VARIABLES collecting, organizing, synthesizing,
1. Social Indicators analyzing and interpreting health data.
● Education
● Housing ● The community is an active partner not
● Social classes a passive recipient of care. Meaning
2. Economic Indicators the nurse works with and not for the
● Poverty level income community.
● Employment status - wage earners
● Occupation
● Communication network
● Transportation system

3. Environmental indicators
● Physical/ Geographical/topographical
The Figure below summarizes a model of
community diagnosis process adapted from F.J.
Bennet (1979).

HOW DO WE CONDUCT COMMUNITY

DIAGNOSIS? HERE ARE THE STEPS;
1. Determining the objectives
2. Defining the study population
3. Determining the data to be collected
4. Collecting the data
5. Developing the instrument
6. Actual data collection
7. Data collation
8. Data presentation
9. Data analysis
10. Identifying community health nursing
problem
11. Priority setting

1. Determining the objectives

This should answer the following;
– What are the present health
conditions?
– Why are they in such conditions?
– What are the roots of these problems?
– What solutions will address the
problem?

2. Defining the study population

Identify the target population, it could be the
entire community or focused only on a specific
population group.

3. Determining the data to be collected

Need to develop a data collection plan; can be
categorized as;
– Primary, directly obtained by the nurse.
– Secondary, existing data obtained by
other people.
LESSON 3 THE PROCESS OF COMMUNITY
DIAGNOSIS STEP 4
STEP 4: DATA COLLECTION
There are different methods in which the nurse
may utilize to generate relevant data.
These are as follows;
1. OBSERVATION- you will extract information
from subjects by observing their behavior and
the environment.
● This way the will have the opportunity
to check validity from the verbal
statements of the community people.
● OCULAR SURVEY or windshield
survey is used to have a bird's eye
view or a "feel"of what the community
looks like. It consists of walking around
the community or in the case of
windshield survey, driving through the
community appreciating what can be
seen and perceived as the people go
along with their daily lives.
● The nurse may investigate lifestyle
patterns that likely to affect the people
they are observing and can cause
"artificial" behavior among them. She
may need to live and be fully integrated
with the community to understand what
is happening in the community, this is
called participant observation.
2. RECORDS REVIEW
● Hard copies of written information-
these are kept in folders, files or books.
May also be kept on tape or electronic
form as database to be
retrieved/accessed for specific purpose.
● Compiled by health or non-health
agencies from the government or other
sources. Examples are the barangay or
municipal records.
3. INTERVIEWS
● Most common and widely used data
collection.
● Follow systematic procedures
TYPES OF INTERVIEW:
1. Face to face interview
● Seek clarification on questions
● Pick up non- verbal cues
2. Telephone interview
● Gather voluminous data
● Text messages provide limited data
3. Individual interview
● Conversation bet respondent &
Interviewer
● Use in sensitive issues
4. Key Informant Interview
● Interviewee is expert or authority on
specific subject
5. Group Interview
● Interviewer & 10-15 participants
● Skilled interviewer ensure equal
participation
THE INTERVIEW MAY BE:
1. Structured Interview
● This follows a list of questions which
becomes the “ script” in the conduct
of interview
● Possible responses in the interview
schedule from which the participants
will choose from.
● Interview adhere to & not alter
sequence of questions.
2. Unstructured Interview
● This is useful in collecting qualitative
data that seek to describe opinions or
perceptions of people focusing on a
particular issue, problem or
phenomenon.
● Use of open-ended questions.
● Interviewer- skillful in
evoking responses.
4. Focus Group Discussion (FGD)
● This is a qualitative research technique
used for its value in understanding and
documenting human behavior. (Tan
and Dalisay, 1999).
● A very popular method appropriate in
the community to elicit opinions of
people, determine their attitudes and
practices regarding a limited set of
concepts.
● The participants are selected based on
the variables that are being studied.
Example: You wish to determine what
factors in the child feeding practices in the
community will likely contribute to the
incidence and prevalence of malnutrition.
The mothers and the other child
care providers are the participants for the
FGD.
● Note that the focus group discussion
will need a highly skilled facilitator with
deep understanding of the issues being
discussed. Be able to ensure that
everybody contributes into the
discussion. The facilitator will
summarize and synthesize the
discussion.
LESSON 1 :THE COMMUNITY HEALTH NURSING
COMMUNITY HEALTH NURSING (CHN)
- is one of the fields of nursing. The term is used
interchangeably with public health nursing in the
Philippine settings. It indicates similarities yet
presents distinctive ideologies, visions and
philosophies utilized in the practice. You were
introduced with this term in the course CHN 1
which is pre-requisite of this course CHN 2.
Experts defines CHN in different perspective.
The American Nurses Association (in
Famorca, et.al. , 2013) defines community health
nursing as a “ synthesis of nursing
practice and public health practice applied to
promoting and preserving the health populations”.
The underlined words focus on the use of nursing
knowledge in providing service to society.
The emphasis on this course CHN 2, is the
community as a client or the general public.
Therefore, public health nursing will be highlighted on
the following discussions. Public health nursing is
defined as “ field of professional practice in nursing and
in public health in which technical nursing ,
interpersonal, analytical and organizational skills are
applied to public as they affect the community (
Freeman, in Famorca et.al., 2013). It is an organized ,
legislative and tax-support efforts that served all people
through health department and other related government
organizations. The purpose of which is to improve the
health of the public.
Specifically, Public health nursing deals is anchored
on the following activities :
• preventing disease
• prolonging life
• promoting health & efficiency through
organized community effort
The core public health functions are as follows :
1. Assessment
• regular collection, analysis & information sharing
on health conditions, risk & resources of
the community
2. Policy development
• gathered information as a basis of local & state
health policies
3. Assurance
• Ability of public health agencies & private
providers to manage health concerns & respond
to critical situations & emergencies
SETTINGS FOR CHN SERVICES
You were given an opportunity to explore the
community during the exposure CHN 1 course . I
believe you have met a community health nurse from
which, in the Philippines and other developing countries
is usually employed by a public health agency which
could either be a government, semi-government or
private institutions. She is usually assigned in a
community, usually a town, city or municipality with
spatial boundaries. The nurse implements varied roles
in practice settings and provide range of services
with the goal of promoting the health of the different
level of clientele.
The nurse’s work base is usually a health
center where she provides services to clients and
patients like pre-natal check-up, well-baby or general
clinic for sick cases. In addition to clinic/health center
services, the nurses deliver services in the following
venues :
1. clients/patients’ homes
2. schools
3. industrial establishment or place of works such
as factories
4. other setting where services is needed such as
market or rice fields where accidents may occur.
LEVEL OF CLIENTELE
The following are the specific clients of the nurse
1. INDIVIDUAL
• specific clients/patients in various conditions of
health & illness
• from healthy/well to the dying
• all ages from birth to senescence
2.FAMILY
• 2 or more individual joined or related by ties of
blood, marriage or adoption
• w/ respective familial roles & maintain a common
culture
3. GROUP/AGGREGATES
• These are the population with common unique
health needs
E.g. child bearing women, infants
• Group that are at risk of developing or have
developed certain health problems
E.g. pre-diabetic clients
4. COMMUNITY
• Share common interest, needs, ethnic or cultural
ties
E.g. squatters community of Metro Manila
• Place w/ spatial boundaries, physical &
environmental characteristics w/ natural & man-
made resources
E.g. Barangay, vilage/barrio, town, province,
CONCEPT OF HEALTH AS A
COMMUNITY PERSPECTIVE
Since the firs professional course in nursing in level 1,
you were introduced with various definitions of health as
an evolving concept. The World Health Organization
(WHO) defines health as “ a state of complete physical,
mental and social well-being and not merely the absence
of disease or infirmity”. It describes health in social
dimensions rather that medical terms. Social
health pertains to community vitality and is a result of
positive interaction among groups within the community
with emphasis on health promotion and illness
prevention. An example of which is a community groups
that sponsor a feeding program for the children in a day
care center with the purpose of alleviating hunger and
malnutrition among pre-school children.
The three (3) characteristics basic to positive
concept of health are as follows :
1. Reflects concerns for the individual as a total
person rather than as merely the sum of various
part;
2. place health in the context of the environment;
3. equates health w/ productive & creative living.
HEALTH AS A SOCIAL PHENOMENON
You have seen in your the community during
your previous community exposure that health affects
primarily the physical well-being of people in the society.
The social, economic, political, intellectual and spiritual
development of the community and the country may
affect the people’s life regardless of their health
condition. An example of which is economic globalization
and privatization of hospital & health facilities that
disrupted the health of the people since it causes the
increase of medical expenses which prohibit the society
to avail regular health services.
HEALTH AS A BASIC HUMAN RIGHTS
Health accessibility and equality are essential
human rights. It is a reflection of society’s commitment to
equity and justice. Health should prevail over economic
and political concerns. An example is the commitment of
the Philippine government in creating an interim
agencies such as the Inter-Agency Task
Force (IATF) to alleviate the people’s condition or
eradicate the COVID 19 . Health should not be
discriminatory and should not be limited to groups
regardless of their race, religion, gender, age and socio-
economic conditions.
HEALTH AS PERSONAL & SOCIAL RESPONSIBILITY
Health is a collective effort to ensure that
everyone gets every health care due to them. Being a
responsible member of society, one should consider the
welfare of others besides ourselves. The individual is
responsible to one’s state of health, to family & society.
Meanwhile, the government represented by the
Department of Health ( DOH) ensures the access to
public health services & establish health care programs
to regulates activities of the Filipinos. An example is that
the people should refrain from indulging himself to
reckless and inconsiderate habits/vices since the cost of
health care is becoming expensive everyday .
CONDITIONS IN THE COMMUNITY AFFECTING
HEALTH
There are various conditions that affect the health of the
community as a whole. These are as follows :
1. PEOPLE
• demographic profile of the population affects
health
• population variable : size, density, composition,
rate of growth or decline, cultural characteristics,
mobility, social class & educational level
• g. A population composing of bigger working
groups ( ages 21- 45 years old) has the high
probability achieving economic development
2. LOCATION
• natural & man-made variables
• geographic features, climate, flora & fauna
• community boundaries whether it is urban or
rural, the quality of air, soil & water
• g. Environment conditions of people living in the
rural areas is better that that of people living in a
slum congested area in the rural community.
3. Social System
• patterned series of interrelationship existing
between individuals, groups and institutions
• pertains to the family, economic, educational
level, communication, political and legal system,
religion, recreational, health system
• g. A community with recreational facilities such
as basketball court or playground for children
more likely for the population to exhibit good
health
DETERMINANTS OF HEALTH AND DISEASES

The attainment of community’s health status is affected

by numerous factors. Specifically, the following are the
determinants of health with corresponding explanation
on how they affect the health.. There are examples given
in each factor.

1. INCOME & SOCIAL STATUS

• the greater gap between the richest & the
poorest people, the greater the difference in
health

2. EDUCATION
• low education levels are linked w/ poor health ,
more stress & lower self-confidence

3. PHYSICAL ENVIRONMENT
• safe water, clean air, healthy workplaces, safe
houses, communities and roads may contribute
to good health

4. EMPLOYMENT & WORKING CONDITIONS

• conducive working conditions lead to a healthier
employee

5. SOCIAL SUPPORT NETWORKS

• families, friends & communities support is linked
to better health

6. CULTURE
• Customs, traditions & beliefs of family &
community may affect health

7. GENETICS
• inheritance plays part in determining lifespan,
healthiness & likelihood of developing diseases

8. PERSONAL BEHAVIOR & COPING SKILLS

• Good nutrition, indulging to physical activities,
cessation of smoking & alcohol drinking
connotes better health outcome

9. GENETICS
• inheritance plays part in determining lifespan,
healthiness & likelihood of developing diseases

10. PERSONAL BEHAVIOR & COPING SKILLS

• Good nutrition, indulging to physical activities,
cessation of smoking & alcohol drinking
connotes better health outcome

11. HEALTH SERVICES

• equitable & accessible health services
contributes to health promotion & disease
prevention

12. GENDER
• men & women experience disease at different
stages in life
LESSON 2: PHILOSOPHICAL & THEORETICAL
FRAMEWORK IN CHN PRACTICE
Community health nursing utilizes practice-
based and evidenced-based strategies and approaches
in its practice. The philosophy and theoretical framework
guides to and bases for a well-directed, purposive, and
systematic engagement of a community health nurse. In
order to understand fully these concepts, the definitions
of each term is established.
PHILOSOPHY focuses on the nature of human
life and reality (Mc Ewen, Willis, 2019). It is a set
of system of beliefs that provides basis and guide
for action.
THEORETICAL FRAMEWORK refers to the basic
structure of ideas, beliefs and principles being
followed in the practice of a profession (Bailon-
Reyes, 2006). CHN is the totality of its philosophy
and theories to maintain the high standard of
practice.
THE PHILOSOPHICAL AND THEORETICAL BASES
OF CHN PRACTICE
Bailon-Reyes ( 2006) provides the discussion of
the philosophical beliefs that guide the practice of
CHN . These are as follows:
1. Nursing is unique and distinct components of
health care. The nurse in the community shares
its discrete roles and functions to other members
of the health team in caring for the different
levels of clientele particularly, the individual
clients/patients, families, aggregates and the
community. The uniqueness of CHN aims to
achieve a better heath outcome of the clients.
2. CHN is interdependence among health
professions. CHN deals with the multi-faceted
health problems of the clients. She/he works
collaboratively with members of the health team
and multi-sectoral teams in the spirit of team
work using team approach to provide quality
health services.
3. As a special filed of nursing, CHN shares the
humanistic beliefs and values of the nursing
profession. The nurses in the community
believes in the dignity of human beings and
respects the rights of every individual clients and
families.
4. CHN believes in the primacy of health as a goal
and as an essential element that affects the
quality of life of individuals, families, groups and
communities.
5. The goal of nursing care is independence and
self-reliance in health care for the different levels
of clientele. The nurses in the
community believes in the capacity of the people
to change for the better provided that they will be
given the proper information, motivation and
assistance.
6. CHN as field of nursing recognizes the
relationship of non-health problems to health
problems, and the role of non-health
interventions in the solution of health problems.
An example of this is the occurrence of poverty
that may lead to malnutrition due to inability of
the families to secure nutritious food and
inaccessible information due to infrastructure
problems.
7. The community health nurse works with, not for,
the different clientele. She/he considers the
people as active participant for decision making
and care process, and not as a passive recipient
of care.
8. Nursing goals and standards of care should
consider constraints imposed by clients, health
agency and community resources. Basically,
concerns of nurses in the community pertains to
resources. The use of indigenous resources in
the community particularly in the rural areas is
one of the competencies of community health
nurses.
9. CHN practice is not a body or set of the same
repeating tasks. The content, approach and
priorities in practice of a community health nurse
is based on client needs and setting where
health services are being delivered.
10. Nurses have the responsibility to keep their
knowledge and skills current and up to date
according to development in nursing, health and
related sciences. Nurse should be life- long
learner where they should attend seminars and
conferences on trends and issues confronting
the nursing practice and the community.

F1. Theoretical Framework for CHN Practice ( Bailon-
Reyes, 2006)
Community health nursing utilizes the concept and
principles of nursing and public health in practice. The
proposed theoretical framework ( Figure 1) defines the
following :
1. THE LEVEL OF CLIENTELE OF THE COMMUNITY
HEALTH NURSE
• The care focused on the needs of the individual,
family, groups and the
2. THE OBJECTIVES OF CARE
• The practice of CHN focuses on prevention.
3. THE METHODOLOGY OF PRACTICE
• The nursing process is utilized in the care of four
level of clientele.
4. PRIORITIES FOR CARE
• The community health nurse utilized the risk
approach to identify the priorities of care. It
pertains to delivering the care to those at greater
risk of developing the disease or other health
problems
5. APPROACH TO HEALTH CARE DELIVERY
• The community health nurse is part of the health
team with specific roles and functions in the
achievement of the goal for community health
development.
EXPERT CARING IN COMMUNITY HEALTH NURSING
The science of nursing has grown and
developed over the years. You have learned from the
theoretical foundation of nursing during your first- year
level in the BSN program that caring is the core of the
nursing practice. Expert nursing care provided by a
professional nurse is a combination of the competence
and character that pertains to compassion, human
kindness, concern and empathy.
The following are some features and
characteristics of expert caring in nursing practice :
1. Expert caring is both an art and a science.
Nursing as an art reflects the innate creativity of
the nurse while performing the nursing
interventions. Meanwhile, science-based nursing
practice utilizes a methodological and logical
approach in the care of clients. An example is
the use of nursing process.
2. Expert caring demonstrates the humanistic
aspects of care that form the core of nursing
philosophy which are universally accepted as
basic element of good quality care. A nurse
employs the personal touch, human kindness,
courtesy, respect, compassion, empathy and the
TLC ( tender, loving, care). angels of mercy”.
3. Expert caring in nursing is comprehensive in
scope. The care of the clients encompass health
promotion, preventive, curative and rehabilitative
nursing actions.
4. Expert caring is individualized. It considers the
uniqueness of the clients in the practice of
nursing care.
5. Expert caring provides holistic care. Nursing
focuses on the totality of clients’ needs based on
physical, psycho-social and spiritual dimensions.
6. Expert caring demonstrates skillful ministration
in practice. The nurse is adept and demonstrate
dexterity in the performance of nursing and
related medical procedures.
7. Expert caring involves a mutual, dynamic and
active interchange of meaning, concerns,
perceptions, emotions, biases, knowledge and
skills between the clients/patients and the nurse.
8. Expert caring is efficient. The nurse is expected
to provide a quality care to client despite of the
limitations in resources.
9. Expert caring focuses on nursing concerns and
responsibilities as a profession, on its’
independent functions and put primacy in the
performance of nursing care rather than just the
implementation of medical plan of care.
10. Expert caring includes maintenance of high
standard of acre and delivery of quality nursing
services to the public at all times.
11. Expert caring realizes the collaborative effort
with other members of the health team and to
other intra/intersectoral teams.
12. Expert caring appreciates the importance of
leading an exemplary personal and family life,
practicing what one preaches and providing a
role model of healthful living to the community.
The mentioned features and characteristics of expert
caring is important for the realization of the community
health nurse’s roles and functions in the care of the
different level of clientele.
LESSON 3 : FIELDS OF COMMUNITY HEALTH
NURSING
Different Fields of Community Health Nursing in the
Philippines
In the Philippine setting, majority of community
health nurses works in the health centers as public
health nurses, industrial companies as occupational
health nurses and school nurses.
The law as a basis of the role and functions is
embodied in Republic Act 973 otherwise known as the
Philippine Nursing law. Likewise, it is defined by the
different professional organizations such as the
Philippine Nurses Organization (PNS), Inc.,
Occupational Health Nurses Association of the
Philippines (OHNAP) and the National League of
Philippine Government Nurses (NLPGN) and agencies
such as the Department of Health and Department of
Education (DepED).
PUBLIC HEALTH NURSING (PHN)
The PHN , together with other members of the
health team, are the implementers of the local
government unit’s mandate in promoting and protecting
the health of their constituents.
Specifically, the following are the functions and activities
of the PHN :
A. MANAGEMENT
1. Plans and organizes the nursing unit of the
RHU/BHC.
2. Participates in the preparation of the municipal
health plan.
3. Participates in the implementation of the
municipal health plan.
4. Implements the nursing care plan.
5. Monitors and evaluates the implementation of
the nursing service plan.
6. Initiates changes for the improvement of
services.
7. Manages the RHU in the absence of the Rural
health physician (RHP).
B. TRAINING
1. Participates in meeting the training needs of
midwives, student affiliates and other trainees.
2. Prioritizes the needs of the Rural health
midwives (RHM) that can be addressed by
training.
3. Conducts a staff education program or caching
sessions.
4. Evaluates effects of trainings on work
performance.
C. SUPERVISION
1. Formulates the supervisory plans for RHM.
2. Implements the supervisory plan.
3. Monitors and evaluates the midwives’
performance in the implementation of public
health programs.
4. Maintains records and reports.
D. PROVISION OF HEALTH AND NURSING CARE
1. Identifies the health needs and problems of
individual, families and communities.
2. Formulates the nursing/ health care plan.
3. Coordinates with individual, groups and
agencies for resource assistance in
implementing the health care plan.
4. Implements the health care plan.
5. Evaluates the nursing interventions and other
components of care provided to the individual,
families and communities.
E. HEALTH EDUCATION
1. Identifies the client’s needs for education.
2. Conducts health education activities.
3. Assesses the effects of health education
activities on the capabilities of the clients.
F. COORDINATION
1. Identifies person, groups, organizations, other
agencies and communities whose resources are
available within and outside the community and
which can be tapped in the implementation of
individual, families and community health care.
2. Refers to other health personnel, health facility
or government agency.
OCCUPATIONAL HEALTH NURSING (OHN)
The duties and responsibilities of OHN are grouped
according to the following :
• curative/palliative
• preventive
• educative
• administrative functions
The major areas of concerns includes the following :

• emergency and palliative care

• family planning
• nutrition counseling
• immunizations
• environmental sanitation
• disaster preparedness and control
• work safety
• orientation of the new employees
• dissemination of health information

SCHOOL NURSING

This field of CHN practice aims to promote the

health of the school personnel and pupils/students.
Majority of the role of school nurses focus on health
advocacy, health promotion, disease prevention and
early detection of disease.

Specifically, the school nurse performs the

following :

1. health and nutrition assessment, screening and

case-findings

2. treatment of common ailments and attending to

emergency cases

3. counseling and health education

4. perform nursing procedures

5. supervision of health and safety of school

personnel

6. referrals and follows of pupils/students and

personnel seeking health services to the clinic.