CHAPTER 1

COMMUNITY HEALTH NURSING: CONTEXT AND PRACTICE

Rosalinda G. Cruz-Earnshaw

Community health nursing (CHN) is one of the two major fields of nursing in the
Philippines; the other is hospital nursing. Some people use the terms community health
nursing and public health nursing interchangeably. However, the former is broader than
the latter; it includes public health nursing, occupational health nursing and school
nursing.

COMMUNITY HEALTH NURSING

Clark defines community health nursing as a "synthesis of nursing knowledge and

practice and the science and practice of public health, implemented via a systematic use
of the nursing process and other processes to promote health and prevent illness in
population groups" (2008:5). The other processes include management, supervision,
research, advocacy and political action. Annex A1 presents a model of community health
nursing practice which illustrates the relationship between nursing practice as science and
art, core community health functions and essential community health services.

The following statements characterize CHN: (1) Promotion of health and prevention of
disease are the goals of professional practice; (2) Community health nursing practice is
comprehensive, general, continual and not episodic; (3) There are different levels of
clientele-individuals, families and population groups and the practitioner recognizes the
primacy of the population as a whole; (4) The nurse and the client have greater control in
making decisions related to health care and they collaborate as equals; (5) The nurse
recognizes the impact of different factors on health and has a greater awareness of his/her
clients' lives and situations (Clark, 2008: 10-13).

CHN is the totality of its philosophy and beliefs, principles, processes and standards. As
one of the subsystems, it influences and is influenced by the health care delivery system.
CHN is practiced within a specific economic, political, socio-cultural and environmental
context. The roles and functions of CHNs directly contribute to the health of their clients.

The essence of nursing is the same even if practiced in different settings. Nursing is
defined as the science and art of caring. Nursing as an art is reflected in the nurses'
interactions and communication with clients that are geared towards the improvement not
just of their health but also their ability to deal with the determinants and consequences of
their health problems.

According to Parse, the responsibility of nursing to society is to guide individuals and

families "in choosing possibilities in changing the health process which is accomplished
by intersubjective participation with people" (George, 2002:439). The art of nursing is
demonstrated by nurses who can maintain the delicate balance between doing things for
their clients and doing things with them, thus co-creating a better or more meaningful
reality. The practice of community health nursing, therefore, entails active interaction and
partnership between the nurse and the client. Such partnership recognizes the autonomy
of both parties and the potential of each one in enriching their relationship.

Nursing is also a science, which means that community health nurses should use practice-
based and evidence-based methods and tools. They also need to engage in generating
evidence to support their practice through research. Quantitative research is needed to
describe or quantify variables of interest to community health nurses or to evaluate the
effectiveness of existing practices, procedures or interventions. Qualitative research can
be done to understand specific human response phenomena such as client-partners' lived
experiences on poverty and adaptation.

The roles of CHNs are grouped by Clark (2008: 14-22) into client-oriented roles
(caregiver, educator, counselor, referral resource, role model and case manager);
delivery-oriented roles (coordinator, collaborator and liaison); and, population oriented
roles (case finder, leader, change agent, community mobilizer, coalition builder, policy
advocate, social marketer and researcher). In recent years, the case manager role in the
community setting is gaining importance as an innovative strategy to provide high quality
care in a financially restricted environment. As the case management concepts of client
independence, control, advocacy and coordination are already reflected in current nursing
models and philosophies, nurses are considered the most appropriate professionals to fill
the role of case managers(Knollmueller, 1989; Bergen, 1992). As a CHN practice option
in many countries, community-based case management is discussed at length towards the
end of this chapter.

FRAMEWORK FOR COMMUNITY HEALTH NURSING

The practice of nursing, particularly in CHN differs from one geographic area (country or
region) to another. It is influenced by a number of factors primarily the scope of practice
as defined by the nursing law, policies and standards of the Department of Health and
organizations where CHNs work and the health needs and problems of the people.

The macro framework for CHN practice has four components: (1) the health care
delivery system, with its CHN subsystem; (2) the clients (individual, family, population
group and community); (3) health which is the goal of the health care delivery system
(HCDS); and, (4) the economic, sociocultural, political and environmental factors that
affect the HCDS, the practice of community health nursing and the people's health. These
constitute the context of community health nursing practice in the Philippines

This chapter elaborates on the different components of the framework.

CLIENTS OF COMMUNITY HEALTH NURSES

There are different levels of clientele in community health nursing-the individual, family,
population group and community, with the latter as the primary client.
Individual
The CHN deals with individuals-sick or well-- on a daily basis. Since the heart problems
of individuals are intertwined with those of the other members of the family and
community, they are also considered as an "entry point" in working with these clients.

Family
From a systems perspective, a family is defined as a collection of people who are
integrated, interacting and interdependent (Hunt, 1997:126). Just like other systems, the
parts (family members) interact with each other and the action of one affects the other
members. The family has a boundary which means that other people can recognize its
members and those who are not. In fact a person may be identified primarily as a member
of a particular family.

There have been many changes in the social context of the Filipino family and these may
have modified how it performs its health tasks and its capacity to remain as the primary
source of support to its members.

Population group
A population group is a group of people who share common characteristics,
developmental stage or common exposure to particular environmental factors, and
consequently common health problems, issues and concerns. Allender and Spradley
(2001) identified population "aggregates" with developmental needs (such as: maternal,
prenatal and newborn populations; infant, toddler and preschool populations; school aged
and adolescents; adults and working populations; and, older adult populations) and those
that are vulnerable (rural clients, the poor, migrant workers, minority populations
experiencing health disparities, those with mental health issues, those living with
addiction, those in correctional facilities and those in long-term care settings). Population
groups are the usual targets or beneficiaries of social services and health programs.

Community
A community is a group of people sharing common geographic boundaries and/or
common values and interests within a specific social system. This social system includes
health system, family system, economic system, educational system, religious system,
welfare system, political system, recreational system, legal system and communication
system (Allender and Spradley, p. 360). Behringer and Richards describe a community as
"webs of people shaped by relationships, interdependence, mutual interests and patterns
of interaction (Leonard, 2000:93).

Although all communities are the same (according to the general systems theory), each
one is unique because it functions within a specific sociocultural, political, economic and
environmental context. They also vary in terms of community dynamics--citizen
participation, power and decision making structures and community collaboration efforts
(Allender and Spradley, 362-364).
A community is regarded as an organism with its own stages of development and it
matures through time. Development is facilitated by some catalysts from within and
outside the community.

Anderson and McFarlane (Anderson, 2000:157) developed the community-as- client

model which later on was renamed to community-as-partner model. The two elements of
the model are: focus on the community as partner and the use of the nursing process. At
the core of the assessment wheel are the people of the community their demographics,
values, beliefs and history. The people are affected by, and also influence eight
subsystems of the community-physical environment, education, safety and transportation,
politics and government, health and social services, communication, economics and
recreation.

HEALTH

Health is a basic human right. On the 6th Global Conference on Health Promotion in
2005 the United Nations affirmed its recognition that the enjoyment of the highest
standard of health is one of the fundamental rights of every human being (The Bangkok
Charter for Health Promotion, 2005).

Health which is viewed as a continuum, is considered as the goal of public health in

general, and community health nursing, in particular. It is an important prerequisite (and
consequence) of development. By promoting health and preventing disease, CHNs,
therefore, contribute to the country's economic and social development.

There are a number of definitions highlighting the different dimensions of health and
basically focusing on the individual. These should guide nurses in identifying areas for
assessment and interventions. The most frequently cited is that of the WHO: "Health is a
state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity" (WHO, 1995).

Dunn (1959, in Pender, 1987:21), on the other hand, emphasized high-level wellness
which he defined as: "an integrated method of functioning which is oriented toward
maximizing the potential which the individual is capable. It requires that the individual
maintain a continuum of balance and purposeful direction within the environment where
he is functioning".

Rene Dubos in his book Man Adapting (1965) defined health as "a quality of life,
involving social, emotional, mental, spiritual and biological fitness on the part of the
individual, which results from adaptations to the environment (Butler, 2001:2).

Florence Nightingale looked into health and illness in relation to the environment
ventilation, noise, light, cleanliness, diet and restful bed. She prescribed ways to improve
health by manipulating the environment. Dorothea Orem, on the other hand, defined
health as a "state characterized by soundness and wholeness of human structures and
bodily and mental functions"(1985 in Pender, 23).
FACTORS AFFECTING HEALTH
There is a strong link between a society's health and its economic development, which in
turn is determined by its social and political structures and processes. The link between
inequalities in income and wealth and inequalities in health is well-established
(Wilkinson, 1996 in Naidoo and Wills, 2000:12). Culture and environment which impact
on people's health are also affected by the country's politics and economy.

The different international conferences on health promotion identified the determinants

of, or prerequisites for health such as peace, food and shelter, clean water, education,
adequate economic resources, a stable ecosystem, sustainable resources, social justice
and equity and access to basic human rights. In her keynote address during the 5 th
International Conference on Health Promotion in 2000, the UN Secretary General pointed
out that “many of the major determinants of better health lie outside the health system.
Knowledge made available to people. Clean environments. Access to basic services. Fair
societies. Fulfilled human rights. Good government. Enabling people to make decisions
relevant to their lives, and to act on them” (Proceeding of the 5 th International Conference
on Health Promotion, 2000)

In 2005, the Bangkok Charter for Health Promotion identified “critical factors” that now
influence health and these are: increasing inequalities within and between countries, new
patterns of consumption and communication, commercialization, global environmental
change and urbanization. The other factors that influence health identified by the Charter
are rapid and often adverse social, economic and demographic changes that affect the
working conditions, learning environments, family patterns and the culture and social
fabric of communities.

Poverty and health

Poverty is an indication of the continuing social injustice and failure of a country's
development efforts. It is a multidimensional construct that goes beyond income
measurements. The United Nations (UN) Human Development Index (HDI) summarizes
a composite index of life expectancy, adult literacy rate, combined primary, secondary
and tertiary gross enrollment ratio and gross domestic product (GDP), among others
(MTPDP 2004-2010). The Philippines is the 90th among the 177 countries ranked by the
United Nations Development Program in terms of human development (Philippine Star,
2/28/08).

The poverty incidence in the country was estimated at 34% in 2000, up from 33% in
1997 (MTPDP 2004-2010). More than half of the total income flows to the richest 20%
of the population (MTPDP 1993-1998). According to the Social Weather Station (SWS),
almost 16 of every 100 survey respondents claimed to have experienced involuntary
hunger because they had nothing to eat in early 2008 (Mangahas, 2008).

The poor have poor health because they do not have the resources to afford the basic
requisites of health; they are not covered by health insurance; and they do not have the
capacity to effectively transact or negotiate with the health care system which seems to be
more responsive to the needs of those with the necessary financial resources.

Poverty, however, is a not a complete explanation for poor health. The poor are not a
homogeneous group. Martin and Henry point out that poverty is the only characteristic
that the poor share for their cultural orientations, values, beliefs, practices and needs vary
greatly (1991: 523).

Culture and health

Culture is, broadly speaking, a way of life; it is the totality of who we are as a people. It
is stable, which means that it endures over time and is passed on from one generation to
the next. As such, it is obviously an important influence on people's health. Culture
includes many things such as beliefs, values and customs or practices-how we socialize
or interact with others, how we relax and spend our free time, the food that we eat or do
not eat, how we prepare our food, how we treat and care for pregnant women, how we
deliver babies and take care of newborns, how we cope with our problems, how and
when we seek help, among many others.

Culture has positive effects on health. An example is the value that we Filipinos place on
close family ties and social relationships. Families, relatives and friends are a major
source of financial, emotional, instrumental and social support, especially during crisis
situations. These relationships contribute to our sense of emotional well-being and mental
health.
Some people have beliefs and practices that adversely affect health. It is, however,
difficult to isolate the effects of culture because of the concurrent influences of poverty
and ignorance, and the inadequacies of the health care delivery system.

Environment and health

The environment plays a direct influence on the health of people. For example, it
provides breeding sites for insect vectors of diseases like malaria, dengue and filariasis,
which are still major health problems in some parts of the country. An unsanitary
environment is also a major factor in the causation of diarrheal diseases such as cholera
and typhoid fever. It is the breeding ground of animals and insects that harbor and
transmit microorganisms. Malaria, dengue and filariasis are still major problems in many
parts of the country.

In the environment could be found toxic substances such as lead, mercury, asbestos,
pesticides, tobacco, solvents and PCBs. These could adversely affect human
reproduction, the brain and immune system and could cause cancer (Needleman and
Landrigan, 1994). Tobacco particularly is a major threat to health because it contains
over 4000 chemicals (including hydrogen cyanide, sulfur dioxide, carbon monoxide,
ammonia, formaldehyde, arsenic, benzene, chromium, lead, nitrosamines, benzopyrene,
nicotine, cadmium and carbon monoxides) many of which are irritants, carcinogens and
mutagens, toxins and substances that increase blood pressure, promote tumors, affect the
heart and brain, damage the lungs and cause kidney and reproductive malfunctions
(Framework Convention on Tobacco Control Alliance, Philippines).
The increase of carbon dioxide, methane and nitrous oxide (among other gases) in the
earth's atmosphere has depleted the ozone layer. The deterioration of the ecosystem has
been implicated in the rapid increase of cancer cases and other health problems
throughout the world. Specifically, there is a rise in cancer-causing ultraviolet radiation,
surface air temperature and carbon dioxide.

The denudation of our forests has directly and indirectly resulted in many health
problems. Rivers have dried up or are extremely polluted, thus depriving many people of
their major source of dietary protein.

The International Physicians for the Prevention of Nuclear War estimates that millions of
cancer cases will result from the nuclear testing conducted in the past. The WHO also
estimates about 20,000 deaths a year in the world due to pesticide poisoning alone
(Philippine Breast Cancer Network, 1997).

The so-called El Niño and La Niña phenomena which have been caused by insults to the
environment have caused thousands of deaths due to disasters (Nash, 1998).

The state of the world's environment is the direct result of the interaction of a number of
factors such as industrialization, government policies, poverty and an uncaring attitude
towards the environment.

Politics and health

Policies reflect the priorities of government and the value system of policy makers. The
health budget is the most concrete expression of the government's political will. Many
Filipinos do not have full access to basic health goods and services because of the
severely limited health care financing. In 1999, the amount spent for health was only
3.4% of the gross national product, lower than WHO-recommended 5%. This translates
to the fact that almost half of health expenditures is out-of-pocket; in other words, the
“financial burden on individual families is heavy, leaving access to care highly
inequitable” (NSCB, 2002). the severely limited health budget is also the biggest
hindrance to the full implementation of well-meaning policies such as national health
insurance.

There are a number of laws that impact on people's health directly (such as the salt
iodization law and food fortification law) and indirectly such as those that affect their
purchasing power (minimum wage, expanded value-added tax, energy law, etc.), family
and social relationships (e.g., laws protecting women and children), environment, and
access to education and employment opportunities.
There are also laws that affect the delivery of health services -- the Local Government
Code, National Health Insurance Act and the professional practice acts of the different
professions (nursing, midwifery and medicine).
HEALTH CARE DELIVERY SYSTEM

A health care delivery system is the totality of "societal services and activities designed
to protect or restore the health of individuals, families, groups and communities (Banta,
1986 in Cookfair, 1996:66). It includes both government and non-government health.
facilities (hospitals, clinics, diagnostic centers, health centers), programs, services and
activities (preventive, promotive, curative and rehabilitative). Preventive health care is a
major concern of the government-owned health centers while curative care is provided by
hospitals, both government and private.

The health care delivery system is affected by policies such as RA 9439 and RA 9502
(refer to Annex A2 for a listing of laws that impact on people' health and the health care
delivery system)

Public health
Public health is generally regarded as a responsibility of government. One of the most
quoted definitions of public health is that of Winslow (1920): "Public health is the
science and art of preventing disease, prolonging life, and promoting health and
efficiency through organized community effort; for the sanitation of the environment; the
control of communicable infections; the education of the individual in personal hygiene;
the organization of medical and nursing services for the early diagnosis and preventive
treatment of disease; and, the development of the social machinery to ensure everyone a
standard of living adequate for the maintenance of health, so organizing these benefits as
to enable every citizen to realize his birthright of health and longevity" (Hanlon and
Pickett, 1979:4).

Today public health could be defined in terms of its three core functions: assessment,
policy development and assurance. Assessment is the regular collection and analysis of
health data. These data are used for program planning and policy development. Policy
development involves advocacy and political action to develop policies in various levels
of decision makin Assurance is making sure that health services are effective, available
and accessible to the people (Institute of Medicine, 1988 in Clark, 2008:87-88).

Related to the core functions of public health there are ten essential health services
(ASTDN in Lundy and Janes: 2001: 875) which are: (1) monitoring health status to
identify community health problems; (2) diagnosing and investigating health problems
and hazards in the community; (3) informing, educating and empowering people about
health issues; (4) mobilizing community partnerships to identify and solve health
problems; (5) developing policies and plans that support individual, family and
community efforts; (6) enforcing laws and regulations that protect health and ensure
safety; (7) linking people to needed personal health services and ensuring the provision of
health care that is otherwise unavailable; (8) ensuring competent public health and
personal health care workforce; (9) evaluating effectiveness, accessibility and quality of
personal and population-based health services; and, (10) researching for new insights and
innovative solutions to health problems. Public health nurses should participate in these
essential health services.
The Philippine health care delivery system

This section presents some of the major components of the Philippine health care
delivery system that constitute the context of community health nursing-the Department
of Health, Millennium Development Goals, Medium- Term Philippine Development
Plan, Health Sector Reform Agenda, FOURmula One for Health, National Objectives for
Health and local health care system (devolution of health services).

Department of Health

The DOH leads in efforts to improve the health of Filipinos, in partnership with other
government agencies, the private sector, NGOs and communities. With the exception of a
few government agencies (such as the University of the Philippines and Armed Forces of
the Philippines) and affluent cities (such as Manila, Makati and Quezon City) operating
their own health facilities, the DOH remains to be the national government's biggest
health (particularly curative) care provider.

The DOH used to have control and supervision over all barangay health stations, rural
health units and hundreds of hospitals throughout the country (special and specialty
hospitals, medical centers, and regional, provincial, district and municipal hospitals).
Today, only the regional hospitals, medical centers, special and specialty hospitals and a
few re-nationalized provincial hospitals are directly under it.

The DOH exercises regulatory powers over health facilities and products. It takes the lead
in the formulation of policies and standards related to health facilities, health products
and health human resources. It provides LGUs the necessary support in managing their
local health system. It also implements a number of health programs (Refer to Annex A3
for a listing of DOH health programs).

The DOH has undergone transformation to be more responsive to its post-devolution

functions. One of the major changes at the Central Office is the creation of the Bureau of
Local Health Development, which is concerned with local health systems development,
health care financing programs, quality improvement programs, inter-sectoral (public
private) coordination and local projects.

The direction being pursued by the DOH is guided by the Millennium Development Goals,
Medium-Term Philippine development Plan, Health Sector Reform Agenda, FOURmula One
and National Objectives for Health

Millennium Development Goals (MDGs)

The concern to improve people's health is universal because there is a strong correlation
between health and development. Poor health is a consequence and cause of poverty and
underdevelopment. Poverty also breeds despair and turmoil. To address these problems,
the United Nations spearheaded the formulation of the MDGs with the corresponding
targets. These goals are: (1) eradicate extreme poverty and hunger; (2) achieve universal
primary education; (3) promote gender equality and empower women; (4) reduce child
mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria and other
diseases; (7) ensure environmental sustainability; and (8) develop a global partnership for
development.

Medium-Term Philippine Development Plan (MTPDP)

Chapter 12 of the Medium-Term Philippine Development Plan 2004-2010 spells out the
priority strategies to meet the basic needs of the poor. The following health priorities
were identified: (1) reduction of the cost of medicines; (2) expansion of health insurance
particularly for indigents through premium subsidy; (3) strengthening national and local
health systems through the implementation of the Health Sector Reform Agenda; (4)
improvement of health care management system; (5) improvement of health and
productivity through R and D; and, (6) establishment of drug treatment and rehabilitation
centers and the expansion of existing ones.

Specifically for public health, the plan provides for the strengthening of health promotion
and disease prevention and control programs: (1) achieve and maintain fully immunized
children coverage to 95% ; (2) achieve and maintain sputum positive TB case detection
rate of 70% and cure rate of 85% ; (3) widen the choice and reach of family planning
services and increase the prevalence rate of men and women/couples practicing
responsible parenthood using either modern, natural or artificial methods to 60% by
2010; (4) contain HIV/AIDS prevalence to 1% or less for groups at high risk for HIV
infection; (5) reduce malaria morbidity rate by 50% from 48 cases per 100,000
population in 2002 to 24 cases per 100,000 population by the year 2010; (6) implement
micronutrient fortification of foods; and, (7) heighten advocacy for the provision of
adolescent health services including sexuality education and counseling.

Health Sector Reform Agenda (HSRA)

Towards the end of the twentieth century, the DOH has come up with the HSRA 1999-
2004 that included the following reforms: (1) provide fiscal autonomy to government
hospitals; (2) secure funding for priority public health programs; (3) promote the
development of local health systems and ensure its effective performance; (4) strengthen
the capacities of health regulatory agencies; and (5) expand the coverage of the National
Health Insurance Program.

FOURmula ONE for Health (F1)

The FOURmula ONE which is the implementation framework of the HSRA, has three
goals: better health outcomes, more responsive health systems and equitable health care
financing. The elements of the strategy are: health financing, health regulation, health
service delivery and good governance. According to the Secretary of Health, F1 is the
guiding philosophy and strategic approach of the DOH (Foreword, NOH 2005:8).
National Objectives for Health (NOH)

The NOH 2005-2010 is an important document that reflects the MDGs, MTPDP, HSRA
and F1. It includes a statement of vision, mission, principles, goals and objectives, key
ideas, targets, indicators and strategies to bring the health sector to its desired outcomes
(http://www.doh.gov.ph/noh).

The vision of the NOH is "health for all Filipinos" and the mission is to ensure
accessibility and quality of health care to improve the quality of life of all Filipinos,
especially the poor. The basic principles are: (1) fostering a strong and healthy nation; (2)
enhancing the performance of the health sector; (3) ensuring universal access to quality
essential health care; and, (4) improving macro-economic and social conditions for better
health gains. The goals are: (1) better health outcomes; (2) more responsive health
system; and, (3) more equitable health care financing. The medium-term objectives are
to: (1) secure increased, better and sustained investments in health; (2) assure the quality
and affordability of health goods and services; (3) improve the accessibility and
availability of basic and essential health care for all; (3) Improve health systems
performance at the national and local levels.

Devolution of health services

One of the most significant laws that radically changed the landscape of health care
delivery in the country is RA 7160 or more commonly known as the Local Government
Code. The Code aims to: transform local government units into self reliant communities
and active partners in the attainment of national goals through a more responsive and
accountable local government structure instituted through a system of decentralization.

Throughout the country, there are about 79 provinces,113 cities, 1,496 municipalities,
and 41, 943 barangays. (http://www.doh.gov.ph/kp/ statistics/no_cities_prov).

In 1993, health services were devolved or transferred from the Department of Health to
the local government units all provincial, district and municipal hospitals to the
provincial governments and the rural health units (RHUS) and barangay health stations
(BHSs) to the municipal governments. In 1999 there were 2,381 RHUS and 11,393
BHSS (Bautista et al., 2002:19).

Each province, city and municipality has a Local Health Board (LHB). This body is a
good venue for making the local health system more responsive to the needs of the
people. It is mandated to propose annual budgetary allocations for the operation and
maintenance of health facilities and services within the municipality, city or province.

At the provincial level, it is composed of the: governor (chair), provincial health officer
(vice chair), chairman of the Committee on Health of the Sangguniang Panlalawigan,
DOH representative and NGO representative. At the city and municipal level, the LHB is
composed of the following: mayor (chair), municipal health officer (vice chair), chair of
the Committee on Health of the Sangguniang Bayan, DOH representative and NGO
representative.

At the municipal level, many public health nurses have been appointed as DOH
representatives. This means that they have been retained by the DOH. Many of them,
however, perform dual functions--those of a public health nurse and those of a DOH
representative. Many of the local government units "cannot afford" to hire a replacement.
The DOH has, therefore, allowed this set-up as a form of support to the income
municipalities.

The shift in the leadership in health care from the national government to the LGUs has
resulted in both the improvement and deterioration of health care delivery. Some LGUs
have the political will and financial capability to support their own health care system
while others do not. Some LGUs give their PHNs SG 15 salaries in accordance with RA
9173 while most do not.

It has been established that an LGU’s financial capability, a dynamic and responsive
political leadership and community empowerment are the important ingredients of an
effective local health system.

Almost two decades after the devolution of health services, there us a need to look into its
impact on people’s health. It is also important to know how PHNs performed their jobs,
how they perceive their roles and how they view their professional development in a
developed set-up.

THE NATIONAL HEALTH SITUATION

The national health situation gives us an idea of the health situation in the communities
where nurses work. Because the different conditions prevailing in these communities,
their health picture expectedly varies. For example, goiter is highly prevalent in the
Mountain Province while schistosomiasis is endemic in Leyte. The local health situation,
therefore, needs to be established for each province, city, and municipality.

The next section gives a general demographic and health profile of Filipinos. It must be
recognized, however, that the regional differences in many important socioeconomic and
physical factors are translated to differences in the regional health picture.

Demographic profile

The Philippines ranked 12th in the world in terms of total population which was 88.6
million in August 2007 (http://www.census.gov.ph) This is projected to increase to 91,
868, 309 in 2010 (National Objectives for Health, 2005:21). According to the President in
her State of Nation Address in July 2008, the country's annual population growth rate is
2.04%, down from the 2.36% in the 1990s (The Philippine Star, 8/3/08).
In 2004, the average life expectancy at birth was 72. 8 years for females and 67.5 years
for males- up from the average of 61.6 years for both sexes in 1980. The country's
population is very young, with 21 years as the median age. The dependency ratio is 69
which means that 63 young dependents (0-14 years old) and 6 old dependents (65 years
old and above) are being supported by 100 people aged 15-64. Thirty-seven percent
(37%) of the total population are in the 0-14 age group while 3.8% are in the 65 and
above age group (NOH, 2005).

In 2000, there were about 255 people for every square kilometer of Philippine territory.
Metro Manila has the highest population density and CAR has the lowest (NOH, 2005).

The population in the urban areas is increasing very rapidly. From the 37% of the total
population in 1984 (UNICEF, 1986) the figure increased to 48% in 2004 (NOH 2005).

Health profile

One of the issues raised about health statistics in the country is their accuracy,
completeness and reliability. Different sources sometimes quote different figures. The
intention of including some statistics in this chapter is to give a general picture of the
epidemiological patterns and trends in the health of Filipinos.

Births and deaths

The crude birth rate (CBR) in 2000 was 23.1 per 1000 population while the crude death
rate (CDR) was 4.8 per 1000 population. Based on these figures, the rate of natural
increase in the country's population for the same year was 18.3 (23.1 minus 4.8) for every
1000 population (NOH, 2005).

Despite the decline in the fertility of women, the total fertility rate (TFR) in the
Philippines remains high (3.1 births per woman in 2004, according to the ADB)
compared to the neighboring Southeast Asian countries. Rural women have more.
children than urban women. Uneducated women also have more children than those who
are with college education. Those in the 25-29 age group have the highest fertility rate
(NOH 2005).

Between 1998 and 2003, the infant mortality rate (IMR) was 29/1000 live births, which is
within the WHO global goal for IMR of less than 50/1000 live births. This figure went
down to 26/1000 live births in 2004. The child mortality rate (CMR) between 1998 and
2003 was 12/1000 live births (NOH 2005). The maternal mortality rate (MMR) was
2/1000 live births (ADB, 2006). There are more deaths among males than females. This
expl the "feminization" of old age.

Causes of morbidity and mortality

The following are the leading causes of mortality among Filipinos: (1) heart disease; (2)
vascular system disease; (3) malignant neoplasms; (4) accidents (5) pneumonia; (6) TB,
all forms; (7) ill-defined and unknown cause of mortality;(8) chronic respiratory disease;
(9) diabetes mellitus; and, (10) certain conditions originating in the perinatal period
(Philippine Health Statistics 2004). Most of these diseases are highly preventable.

Despite the improvements in the field of public health, many of the common causes of
morbidity can be prevented easily by improving environmental sanitation and personal
hygiene and through health education. In 2004, the leading causes of morbidity were: (1)
acute lower respiratory tract infection (RTI) and pneumonia; (2) bronchitis and
bronchiolitis; (3) acute watery diarrhea; (4) influenza; (5) hypertension; (6) TB
respiratory; (7) chickenpox; (8) diseases of the heart; (9) malaria; and, (10) dengue fever
(PHS 2004).

Infants and children

The leading causes of infant mortality in 2004 were: (1) bacterial sepsis of newborn; (2)
respiratory distress of newborn; (3) pneumonia; (4) disorders related to short gestation
and low birth weight not elsewhere classified; (5) congenital pneumonias; (6) congenital
malformation of the heart; (7) neonatal aspiration syndrome; (8) other congenital
malformation; (9) intrauterine hypoxia and birth asphyxia; (10) diarrhea and
gastroenteritis of presumed infectious origin (PHS 2004).

Malnutrition is very common among children, particularly protein-energy malnutrition..

In 2001, 31% children under 5 years old were underweight (ADB, 2006). The Philippines
has one of the highest blindness rates in the world. It is estimated that 17 children become
permanently blind everyday and lack of Vitamin A is the primary cause of their blindness
(NOH, 1999). iodine deficiency which results in mental and growth retardation is
common in females seven years old and above, and in pregnant and lactating mothers
(National Nutrition Council, 1994).

An emerging serious health concern among the young, according to the WHO is the first
that almost 1 in every 3 Filipino adolescent aged 13 to 15 smoke cigarettes.

Maternal mortality
Maternal mortality is a major indicator of a woman's health status. It is defined by the
WHO as the death of a woman while pregnant or within 42 days of termination of
pregnancy irrespective of the duration and the site of the pregnancy from any cause
related to, or aggravated by the pregnancy or its management, but not from accidental or
incidental causes. The maternal mortality rate in 2000 was 2/1000 live births (ADB,
2006).

The leading causes of maternal mortality in 2004 were: (1) other complications related to
pregnancy occurring in the course of labor, delivery and puerperium; (2) hypertension
complicating pregnancy, childbirth and puerperium; (3) postpartum hemorrhage; (4)
pregnancy with abortive outcome; and, (5) hemorrhage in early pregnancy (2004)
Philippine Health Statistics).

Maternal mortality should be viewed within the greater context of women's health.
Analysis of women's poor health and maternal mortality should consider the overall
social, cultural, and economic environment. The woman who dies from pregnancy related
causes is more likely to be poor, with low educational status, a multipara, and anemic.
More likely she comes from an area where the antenatal services are inaccessible;
transport facilities are poor; supply of blood for transfusion is inadequate; vital drugs,
supplies and equipment are not available; and adequately skilled help in labor and
delivery is not available.

Elderly
Probably the most commonly documented problems of older people are those related to
their health. According to the DOH, the elderly suffer from the "double burden of
degenerative and communicable diseases. The leading causes of morbidity among older
people are influenza, pneumonia and TB. The leading causes of mortality are
cardiovascular diseases, pneumonia, malignant neoplasms, TB, COPD, diabetes mellitus,
gastrointestinal ulers, accidents and injuries, nephritis, nephrotic syndrome and nephrosis
and septicemia (PHS 2000 in NOH 2005).

The prevalence of nutritional deficiency disorders among older people is high: anemia,
45%; thiamine deficiency, 35%; and riboflavin, 12%. There are more older women (16%)
than older men (11%) who are underweight (National Health Objectives, 144). According
to the Food and Nutrition Research Institute (2001:21) the prevalence of chronic energy
deficiency is higher in females than in males, and the severity increases with age.

In 1995 there were 345,000 senior citizens (9.2%) with some type of disability. Low
vision was the most common especially among elderly women (44.1% as compared to
39.7% among elderly men). The other types of disability that older people suffer from
were: deafness (partial and total), poor hearing, blindness (partial and total) and paralysis
(NSO, 2001).

Lifestyle-related diseases
The patterns of morbidity and mortality have changed significantly. While infectious
diseases remain to be the main causes of morbidity, cardiovascular diseases, diabetes.
mellitus, cancer, and chronic respiratory diseases, the so-called lifestyle diseases, have
become the leading causes of deaths. WHO estimates that 60% of all deaths are due to
chronic diseases. Eighty percent (80%) of these occur in low- and middle-income
countries like the Philippines (WHO, 2005). By 2020, it is estimated that 73% of total
deaths will be attributed to the major non-communicable diseases (World Health
Assembly, 2004).

People's lifestyle (particularly their unhealthy diet, sedentary work and lack of exercise)
has been identified to be the major reason why they die from the diseases which used to
be associated with developed countries.

Cardiovascular diseases comprise 25% of the total deaths. Nine Filipinos die of
cardiovascular disease every hour Diabetes mellitus, which is regarded as "the biggest
health catastrophe the world has ever seen" (Castillo, 2003) is found in 4 out of 100
Filipinos. Not surprisingly, more diabetics are found in urban areas (6.8 %) than in rural
areas (2.5%) (FNRI).

Cancer is the most dreaded of all diseases because of its very high case fatality rate and
the long suffering that patients experience. The leading cancer sites among males are:
lung, liver, colon/rectum, prostate, leukemia, stomach, nasopharynx, non-Hodgkin's
lymphoma, oral cavity and larynx. ong females, these are: breast, cervix, colon/ rectum,
lung, ovary, thyroid, leukemia, liver, uterus and stomach. (Philippine Cancer Society,
2008). In addition to lifestyle, a major factor in the causation of malignant neoplasms is
the drastic change in the physical environment and greater exposure of people to
chemicals (such as polychlorinated biphenyls or PCBS), radiation and other carcinogenic
substances (Cone,2005; Needleman and Landrigan, 1994).

Infectious and communicable diseases

Although the number of deaths from infectious diseases has decreased, many of these are
still major public health problems in the country Cholera and typhoid fever is still a
common occurrence in many parts of the country. The number of paralytic shellfish
poisoning (more commonly known as red tide) continues to increase because of the
degradation of the country's bodies of water.

In the past few years, there were infectious diseases that have emerged such as the scary
severe acute respiratory syndrome (SARS). SARS has highlighted the fact that the
transmission of infectious diseases is facilitated by the increasing physical mobility of
people and ease in traveling from one country to another.

There is a steady increase, though relatively slow, in the number of HIV Ab seropositive
cases in the country-2,454 cases from January 1982 to February 2006. HIV/AIDS is no
longer just associated with homosexuality. About one-third of the cases were OFWs
(seafarers, domestic helpers, entertainers and health workers). About three-quarters
(74%) were males. The mode of transmission is primarily (93%) through sexual
intercourse (DOH, 2006).

The increase in other sexually transmitted diseases (STDs) such as syphilis and gonorrhea
is due to unhampered prostitution in many areas of the country. Prostitution has always
been identified as a consequence of poverty. STDs (and the newly emerging diseases)
further burden the health care system which at the moment could not cope adequately
with the leading causes of morbidity and mortality.

Tuberculosis which was the number one cause of mortality about 50 years to continue to
be a major killer of Filipinos. TB prevalence in 2003 was 458 per 1000,000 population
(ADB, 2006) and this problem is made worse by the resistant strains of the TB
microorganisms. Unfortunately, TB will not significantly decline over the next two
decades (ADB, 2004). Leprosy, too, is still a public health concern in some parts of the
country.
Schistosomiasis continues to affect hundreds of barangays in 24 endemic provinces.
Rabies incidence in the Philippines is one of the highest in the world. It is estimated that
about 12% of the population are chronic carriers of the hepatitis B (DOH). The
significance of this figure lies pn the very close association between hepatitis B and
hepatic carcinoma.

Three fatal and debilitating diseases--malaria, filariasis and dengue fever are broug about
by the vector mosquito. Malaria is endemic in most provinces in the country Filariasis, on
the other hand, is endemic in the Bicol Region and some provinces in Region 10 and
ARMM. In the past few years, there has been a significant increase in the incidence of
dengue fever (DOH).

Mental illness
Mental illness is the third most common form of disability, after visual and hearing
impairments, according to a disability survey by the National Statistics Office in 2000.
Almost 2 deaths (1.8) per 100,000 population resulted from suicide and self-inflicted
injuries. In another survey in 2004, 0.7% of the households included have a family
member with mental disability. The incidence of mental illness is reportedly highest
among older age groups. Other vulnerable groups are drug users and those who could not
cope with stresses of daily living (NOH 2005).

PRIMARY HEALTH CARE AND HEALTH PROMOTION

The practice of community health nursing is guided by the philosophy, goals and
strategies of primary health care and health promotion. In their search for more effective
strategies and interventions, community health nurses should also learn from the lessons
of Alma-Ata and the different charters of health promotion. A major lesson from all of
them is that meaningful improvements in the socioeconomic determinants of health are
required to have significant improvements in people's health.

Primary health care

In 1978, representatives from 134 countries who attended the International Conference on
Primary Health Care in Alma-Ata, USSR signed the Declaration on Primary Health Care
(PHC) because they believed that the global health situation was unjust. There was a
wide gap in the health of underdeveloped and developed countries and even within
countries.

Community health nurses subscribe to the beliefs articulated in the Declaration,

specifically: (1) The promotion and protection of the health of the people is essential to
sustained economic and social development and contributes to a better quality of life and
to world peace; (2) The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care; (3) PHC is premised
on the spirit of social justice; and, (4) PHC is an integral part of the country's health
system and of the overall social and economic development of the community
((WHO/UNICEF 1978:2-4).
PHC was viewed as the approach that could improve the health situation throughout the
world. It was defined as "essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community can afford to maintain at every stage of their development in the spirit of self
reliance and self determination" (WHO/UNICEF p. 16).

The essential elements of PHC include: education about prevailing health problems,
including methods of prevention and control; promotion of adequate food supply and
proper nutrition: Immunization against the major infectious diseases, provision of safe
water and basic sanitation; maternal and child health care, including family planning:
prevention and control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and, provision of essential drugs. Although these were identified
decades ago, these are still reflective of the needs of most people in the world,
particularly in developing countries.

Realizing that health and illness are multi-causal and could be addressed only by an
integrated effort, the CHN works with other health workers and those from other
government agencies and non-government organizations (NGOs). Multisectoral linkage
ensures that the different facets of health problems are addressed. (These concepts are
elaborated in other chapters of this book.)

Appropriate technology is used in addressing people's problems for many reasons. Herbal
medicines and acupressure which have been proven to be effective, have the advantage of
safety, acceptability and affordability.

Three decades after the International Conference on Primary Health Care, access to basic
health services has not significantly improved for certain segments of the country's
population. Why? The answer s on the political commitment to primary health care which
"implies more than formal support from the government and community leaders.... For
developing countries in particular, it implies the transfer of a greater share of health
resources to the under-served majority of the population. At the same time, there is a
need to increase the national health budget until the total population has access to
essential health care..." (WHO/UNICEF 1978, in Werner and Sanders, p. 18).

In addition, many people (health workers and communities) have not fully understood the
essence of community participation and have not developed the necessary competencies
to participate more effectively.

Nurses should do their share in making basic health services available and accessible
through advocacy and proper management of health programs and services. Community
participation should be ensured in all the phases of the nursing process and other
community health nursing processes. Nurses must be competent on the use of
participatory approach to engage clients/community partners to look, think and act in
order to address illness realities and barriers to quality health care, by enhancing the
competence of client-partners to understand, analyze and carry out options to address
hopelessness, apathy and helplessness, they can sustain their motivation to change. the
current reality in order to out health and health care in their hands (Maglaya, 2008). The
participatory approach is described in Chapter 5 and pursued with specific examples in
Chapter 18 as participatory action research on family empowerment for malaria
prevention and control in a barangay in Abra Province.

Health promotion

Almost ten years after the Declaration of Primary Health Care was signed, the Ottawa
Charter of Health Promotion came out of the First International Conference on Health
Promotion in November 1986. The Charter defines health promotion as "the process of
enabling people to increase control over, and to improve, their health". It identified five
priority action areas: building healthy public policy, creating supportive environment,
strengthening community action, developing personal skills and reorienting health
services

The Second International Conference on Health Promotion that was held in Adelaide,
South Australia in 1988 focused on healthy public policy. Four priority areas were
identified: supporting the health of women, improving food security, safety and nutrition,
reducing tobacco and alcohol use and creating supportive environments for health.

The Third International Conference on Health Promotion that was held in Sundsvall
Sweden centered on sustainable development and equity in creating supportive
environments for health.

The Jakarta Declaration on Leading Health Promotion into the 2 Century which is the
output of the Fourth International Conference on Health Promotion held in 1997
identified five priorities for action: promoting social responsibility for health, increasing
community capacity and empowering the individual, expanding and consolidating
partnerships for health, increasing investments for health development and securing an
infrastructure for health promotion.

The Fifth Global Conference on Health Promotion (2000) examined the contributions
made by health promotion in improving the health and quality of life of people living in
difficult circumstances. It called for the strengthening of the science and art of health
promotion and strengthening political skills and actions for health promotion.

Recognizing the changed global context for health promotion, the Bangkok Charter of
Health Promotion in a Globalized World which was adopted during the 6th Global
Conference on Health Promotion in 2005 focuses on the need to address the determinants
of health in a globalized world through health promotion. Consequently, it expands the
definition of health promotion to include the determinants of health: Health promotion is
the process of enabling people to increase control over their health and its determinants.
This is done by strengthening individual skills and capabilities and the capacity of groups
to change the social and economic conditions that affect health (Tang, Beaglehole and
O'Byrne, 2005:884).

The Charter recognizes that organized and empowered communities are highly effective
in determining their own health, and are making governments and the private sector
accountable for the health consequences of their policies and practices.

About thirty years after the Alma-Ata Declaration and twenty-two years after the Ottawa
Charter, there are many questions that still need to be asked. Is there enough political will
to institute meaningful and lasting structural changes that do not only aim to improve
health but to effectively address the socioeconomic and other determinants of health? Are
the communities competent, confident and committed enough to actively participate in
matters that affect them? And the questions to be answered by community health nurses
are: Do nurses engaged in practice do so in accordance.

with the beliefs of primary health care and health promotion? Are they committed to help
catalyze change in their communities? Are they willing to share power with the
community and treat them as partners and not just as recipients of health services? Are
they willing to learn how to work with the community as partners?

CHNs should take affirmative actions to help cornmunities attain the goal of PHC and
health promotion-improved health and quality of life.

NURSING PRACTICE IN THE COMMUNITY

Nursing practice in the community entails the utilization of a number of processes to
respond to the health needs and problems of clients, manage health programs and
resources, and influence decisions that affect the delivery of health and nursing services.
And to be effective, community health nurses should subscribe to the principles of equity,
participation, and involvement of their clients in making decisions about health care. As
Leonard pointed out, health cannot be improved just by mere provision of health services.
Nurses and clients should be partners in working for the achievement of the latter's health
goals (2000:95). Chapter 5 elaborates on the partnership approach and the participatory
action methodology from a nursing perspective.

Table 1.1 presents the different processes that are important in contributing to the
attainment of the goals of community health. There are three major targets or foci of
nursing actions or processes-clients, health care unit and political leaders/decision
makers. The processes engaged in by CHNs include: nursing process; program planning.
implementation and evaluation; health education; management and supervision; quality
assurance; research; and, advocacy and political action. Leadership cuts across these
processes.
 Focus/Target Processes
Clients  Nursing Process
 Program planning, implementation,
monitoring and evaluation

Health care unit (health center)  Management and supervision
 Quality assurance
 Nursing research/health systems
research
Political leaders/ decision-makers  Advocacy and political action
Table 1.1 Process in community health nursing
A common element in all of these processes is critical thinking because there are no hard
and fast rules to use with different clients and situations. Even so-called standards could
not capture all the possible situations or circumstances in the field or work place.

Critical thinking in community health nursing

Because of the complexity of problems, issues and concerns that they face in their day-to-
day professional practice, nurses need to think critically. Bandman and Bandman
(1995:7) defined critical thinking as the "rational examination of ideas, inference,
assumptions, principles, arguments, conclusions, issues, statements, belief and actions".
This means that nurses should not accept as true or correct something simply because
others say so or continue to do certain things because these have been done by their
seniors.

Critical thinking in nursing means that nurses should: (1) use the processes of critical
thinking in all of daily living; (2) discriminate among the uses and misuses of language in
nursing: (3) identify and formulate nursing problems; (4) analyze meanings of terms in
relation to their indication, their cause or purpose, and their significance, (5) analyze
arguments and issues into premises and conclusions; (6) examine nursing assumptions;
(7) report data and clues accurately; (8) make and check inferences based on data,
making sure that the inferences are, at least, plausible; (9) formulate and clarify beliefs;
(10) verify, corroborate, and justify claims, beliefs, conclusions, decisions and actions;
(11) give relevant reasons for beliefs and conclusions; (12) formulate and clarify value
judgments; (13) seek reasons, criteria, and principles that effectively justify value
judgments; and, (14) evaluate the soundness of conclusions.

Nursing process

Nursing process is the main framework or guide in nursing practice and the means by
which nurses work with client-partners to enhance wellness or address the health needs
and problems of their clients. It is a logical and systematic way of processing information
gathered from different sources and translating intentions into meaningful actions or
interventions. There are five phases: assessment, diagnosis, planning of outcomes and
interventions, implementation and evaluation. The nurse starts with the establishment of a
working relationship.
The nursing process by type of client-partner is well illustrated in specific chapters in the
book.

Establishing a working relationship

The relationship between CHNs and their clients lasts for months or years; it does not end
after the resolution of a health problem of the client. Particularly in rural communities,
PHNs are either personally related to their clients or the latter are friends or
acquaintances.

Establishing a working relationship based on respect, trust, shared goals and clarity of
expectations results in positive outcomes such as good quality of collected data,
partnership in addressing identified health needs and problems, and satisfaction of the
nurse and the client in working together.

Assessment
Assessment is the process of collecting, organizing and analyzing data/information about
the client. The CHN should collect not just quantitative but also qualitative data.
Qualitative data give a more in-depth understanding not just of the clients' health and
nursing problems but their lived experience. Qualitative data represent the clients'
perspective while the quantitative data are collected from the nurse's point of view.

Table 1.2 presents the basic data/information that need to be collected by type of client-
partner.

In assessing population groups, other data should be added, particularly on their context.
For example, assessment of workers should also focus on factors such as nature of their
work, immediate physical and social environment, exposure to occupational health
hazards and health resources.
Assessment
Individual Family Community
Health Status Family structure, Demographic, cultural and
Knowledge, attitudes and characteristics and dynamics socioeconomic variables
practices (KAP) Socioeconomic and cultural Environmental factors
Adaptation Process Pattern characteristics Health and illness patterns
Lifestyle Environmental factors Community resources
Help-seeking behavior Health status of each member Community competence
Utilization of health services Values and practices on health Examples:
promotion/maintenance and  Participation
disease prevention  Machinery for
Competencies on family facilitating
health care interaction and
decision-making
 Articulateness
 Conflict
management
Reasons for the failure of past
health programs
 Table 1.2 Assessment data for individuals, families and communities
Diagnosis
Diagnosis is the identification of the client's wellness status or needs and problems based
on an analysis of the data/information gathered. A CHN formulates a nursing diagnosis.
Nursing diagnosis was defined in the 12th North American Nursing Diagnosis
Association (NANDA) Conference in 1996 as "a clinical judgment about individual,
family or community responses to actual or potential health problems/life processes"
There were 165 NANDA nursing diagnoses in 2003-2004 (Daniels, 2005:221; 1513-
1514). NANDA's focus, however has been at the individual rather than community level
of diagnosis. Refer to the Typology of Nursing Problems in Family Nursing Practice
(Chapter 2) and the three categories of community health nursing problems health status
problems, health resources problems and health-related problems, in Chapter 7.

Planning of outcomes and interventions

Planning is a logical step-by-step process in designing a plan of action to accomplish
specific goals and objectives (Allender and Spradley, 378). Desired outcomes could be in
terms of a person's health, knowledge, attitudes and practices, and ability to cope with
problems. (Refer to Chapter 3 for developing family nursing care plan and Chapter 8 for
planning for community health nursing programs and services.)

Objectives of care which reflect the desired outcomes, should be specific, measurable,
attainable, realistic and have specific time frame (SMART). The presence of SMART
objectives will definitely facilitate evaluation.

Nursing interventions should: (1) be appropriate and responsive to the condition on

problems of the client and should contribute to the attainment of the objectives; (2) be
evidence-based and reflective of nursing standards; (3) be culturally sensitive and
appropriate to the client's personal circumstances; and, (4) enhance the capability and
empowering potential of clients.

Some of the most common nursing actions or interventions in a community setting are
provision of nursing care, counseling, health education, capacity-building, coordinating
and making referrals.

If the focus is a community or population group, systematic intervention usually takes the
form of a project or program. Community health programs involve the different levels of
prevention-primary, secondary and tertiary (refer to Chapter 7).

In the light of the nursing profession's efforts to standardize the language that nurses use,
there are other taxonomies in addition to the NANDA-- Nursing Interventions
Classification and Nursing Outcomes Classification (Daniels, 354-5). CHNs should be
familiar with these taxonomies and use their agency's recommended classification.

Implementation
In the nursing process, the implementation phase consists of doing or carrying out the
interventions specified in the care plan in partnership with client-partners and/or other
members of the team. It involves enhancing client-partners' ability to unleash their
empowering potential for wellness, prevention, management or control of health
problems. It includes the use of participatory action methodology to maximize client
partners' experiences on the "look-think-act" iterative experiential learning cycle. Client-
partner competence is achieved through adequate opportunities for parctice sessions and
feedback.

Evaluation
Evaluation phase of the nursing process is a planned, ongoing, purposeful activity in
which the nurse and the client-partner determine the client's progress toward achievement
of goals and outcomes. It also involves examining the other steps of acmevement the
nursing process. As Alfaro-Le Fevre (2002: 191) succinctly explains, evaluating nursing
care includes analyzing nursing inputs and client-partner realities in each step of the
nursing process (Fig. 1.1). Evaluation is an important aspect of the nursing s because
conclusions drawn from the evaluation determine whether the nursing process
interventions should be terminated, continued or changed/ modified. Evaluation is
continuous. Evaluation done while or immediately after implementing a nursing
intervention enables the nurse and client-partner to make on-the-spot modifications in an
intervention (Kozier and others, 2004: 318).

The focus of evaluation in the care of individuals are: quality of life, functional status,
patient satisfaction, compliance measures, and impact of educational interventions
(Alfaro-LeFevre, 2006:234). These are the broad areas contained in the objectives of
nursing care. In family health nursing, the nurse determines the extent to which the
family could perform its health tasks to maintain wellness or to address specific health
threats, health deficits, foreseeable crisis / stresspoints.

In evaluating programs, the evaluator looks into the inputs, processes and/or outcomes.
Inputs are the important resources the program cannot do without (e.g., Iron and Vitamin
A for a nutrition program and vaccines for an immunization program).

Processes are important activities of the program. The outcomes of a program are
outputs, effects and impact. Outputs are the specific products or services which an
activity is expected to produce from its inputs to achieve its objectives. Effects are the
results of the use of project outputs. Impact is the outcome of program effects and is an
expression of broader, long-range program objectives.
 EVALUATION
Assessment Diagnosis Planning Implementation
1. Determine 1. Determine if 1. Determine if the 1. Analyze how
whether there problem/s, interventions the plan was
are changes in requiring are appropriate implemented.
health status. nursing care are and adequate to 2. Determine what
2. Make sure that resolved, achieve client factors are
assessment data improved or outcomes. related with the
are accurate and controlled. 2. Specify the success in
complete. 2. Consider if client’s status implementing
there are new based on the plan.
problems. expected 3. Specify what
outcomes of factors created
care. problems or
barriers to care
Fig 1.1 Application of evaluation by Phase of the Nursing Process

Documentation
It is not enough to assess, diagnose, plan, implement and evaluate. CHNs should
document all the things that they did and the corresponding outcomes. Their
documentation should include the following: client assessment and health needs/
problems identified, interventions carried out, client response to interventions, outcome
of interventions and future plan of care (Clark, 1999:209).

In the health centers, it is also important for the PHNs to document what they do, whether
client-centered, program-related or unit-centered. They should document their
innovations, their participation in multidisciplinary endeavors and their efforts in shaping
policies or influencing policy makers.

Of the different responsibilities of the CHN, documentation is considered by many as the

least priority; it is an additional "burden". However, no matter how it is viewed by
practitioners, documentation is still an important component of the nursing process. It
serves a number of functions, among which are: (1) it serves as a "proof" of the thinking
and decision-making that nurses do; (2) it could protect the nurse from a lawsuit (it is
generally believed that what is not written was not done); (3) it gives decision makers an
idea of the workload of nurses; and, (4) it provides information that could be used in
research and quality assurance activities and for training purposes.

Program planning, implementation and evaluation

To address the needs and problems of the community or specific population groups
CHNs, together with other health workers participate in the planning, implementation
monitoring and evaluation of health programs. (Program planning implementation and
evaluation are discussed in Chapters 8 and 9)
Health education

Health education is one of the strategies of health promotion and a major function and
improve our snderstanding needed for program and poll intervention of a CHN. Green
and Kreuter define health education as "any combinanation of learning experiences
designed to facilitate voluntary actions conducive to health that people can take on their
own individually or collectively, as citizens looking after their own health or as decision
makers looking after the health of others and the common good of the community" (1991,
in Meade, 1997:156). The goals of health education include: (1) client participation in
health decision making; (2) increased potential to comply with health recommendations;
(3) development of self care skills; (4) improve client and family coping; (5) increased
participation in continuing care for specific, conditions; and, (6) adoption of healthier
lifestyles (JCAHO in Clark, 2008:263).

Management and supervision

CHNs in different levels perform different management and supervisory functions. A

general definition and description of management functions may be the same but the
scope and level of activities done may be different for each level of management.

Quality assurance in community health nursing

The provision of quality care is a professional responsibility. It is not enough to ensure
the delivery of basic health services and implementation of public health programs.
CHNs, together with other health workers should ensure the quality in health (and
nursing) care. Allender and Spradley, (2001) identified five reasons for doing quality
measurement and improvement in community health nursing: (1) professional self
regulation of clinical competence; (2) certification and accreditation; (3) legislation and
regulation; (4) reimbursement; and, (5) consumer demands.

For a more detailed discussion of management in public health, refer to Chapter 17.

Research and evidence-based nursing practice

To improve the quality of nursing services in the community, there is a need to adopt
evidence-based practice. Evidence-based practice is the "conscientious integration of best
research evidence with clinical expertise and patient values and needs for the delivery of
quality, cost-effective health care" (Sackett and Associates, 2000 in Burns and Grove,
2007:500). Evidence-based nursing, therefore, is " the process by which nurses make
clinical decisions using the best available research evidence, their clinical expertise and
patient preferences (University of Minnesota, in Simpson, 2004:10).

There is a need, therefore, for CHNs to engage or participate in research. To be able to

integrate the best research evidence into practice, they should have working knowledge
on research concepts and processes and skills to be able to critique published research
reports.
CHNs also conduct research with the community to generate knowledge that the latter
can use to influence policy and decision makers. They can serve as resource persons in
the community's research activities.

Research in community health serves a number of purposes, among which are: (1)
improve our understanding of clients and their specific contexts; (2) provide data needed
for program and policy development and evaluation; (3) support advocacy and lobbying
for specific policies; (4) improve the delivery of health services and implementation of
existing programs; (5) improve cost-effectiveness of programs; and, (6) project a good
image of nurses.

Advocacy and political action

Advocacy is an ethical and professional responsibility. The American Nurses Association
(2007, in Clark, 2008:6) defines advocacy as "the act of pleading or arguing in favor of a
cause, idea, or policy on someone else's behalf, with a focus on developing the
community, system, individual, or family's capacity to plead their own cause or act on
their own behalf". Policy advocacy is a very important modality for influencing the
health of people (Williams, 1991:619).

Community health nurses are in a very strategic position to speak on issues that directly
and indirectly impact on the health of the community. But in doing advocacy, they
uphold a client's autonomy, which means that they reserve for their clients the right to
make their own decisions. They just translate and articulate the problems, aspirations,
health and illness experiences, the perspectives and positions of their clients, particularly
those who are vulnerable, to health planners and policy makers, until such time that the
clients can do these for themselves.

Not too long ago, the prevalent view among nurses is that politics is outside the concern
of nurses and it is "unethical" to engage in political actions. Politics, then, was associated
with "activists" who were viewed negatively by many nurses. Today nurses getting
involved with politics are not frowned upon anymore.

Being political means speaking up and meeting with politicians. Nurses should always be
adequately prepared-with accurate and up-to-date data/information, researches and sound
assumptions and reasoning; better if they have well-written and engaging position papers.

Political action requires a good working knowledge on the workings of the political
system and the dynamics of policy-making both at the local and national levels.

COMMUNITY HEALTH NURSING IN THE PHILIPPINES

Most of the community health nurses in the Philippines work in health centers as public
health nurses, industries/companies as occupational health nurses (company nurses) and
school nurses. Few of them work with non-government organizations (NGOs).
The roles and functions of nurses are defined by the nursing law (RA 9173) and standards
that are developed by professional associations such as the Philippine Nurses Association
(PNA), Occupational Health Nurses Association of the Philippines (OHNAP) and the
National League of Philippine Government Nurses (NLPGN) and agencies such as the
Department of Education (DepEd).

Public health nursing

PHNs, together with the other members of the health team, are the implementers of the
local government units' mandate in promoting and protecting the health of their
constituents. They participate in the planning, implementation, monitoring and evaluation
of the LGU's health programs. They act as program coordinators of health programs such
as EPI, TB Control Program, Leprosy Control program, etc. They also deliver nursing
services to individuals in the health centers, schools and homes, including health
education. The functions and activities of PHNS contained in the resource manual
Training Course on Supervision for the Public Health Nurse (1994) are listed on the
following pages.

PHN FUNCTIONS AND ACTIVITIES

Management

1. Plans and organizes the nursing service of the health unit.

1.1 Identifies problems related to clients, resources, program implementation and
service delivery.
1.2 Prepares the nursing service plan. 2. Participates in the preparation of the
municipal health plan.

3. Participates in the implementation of the municipal health plan.

4. Implements the nursing service plan.
4.1 Coordinates with the different health units and related agencies and facilities.
4.2Delegates the task to the midwives, if necessary.

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).

Training
Participates in meeting the training needs of midwives, student affiliates and other
trainees.

1. Prioritizes the identified needs of rural health midwives (RHMS) that can be addressed
by training.

2. Organizes a staff development program for RHMs.

3. Conducts a staff education program or coaching session.

4. Evaluates effects of training on work performance.

Supervision
Supervises the RHMs:

1.Formulates a supervisory plan.

1.1 Identifies factors affecting the performance and job satisfaction of the
midwives

1.2 Identifies the needs of the midwives for supervision in relation to: congruence
between organizational and personal goals, work situation, motivation, moral
values, personal situation, knowledge, skills and attitudes, and performance.

1.3 Identifies priorities

1.4 Identifies objectives and strategies to meet the midwives' need for supervision.
1.5 Determines indicators and standards for evaluation of supervisory visits.

Health education

Conducts health education activities.

1. Identifies clients' need for health education.

2. Conducts health education activities.
3. Assesses the effects of health education activities on the capabilities of clients.

Coordination

1. Identifies persons, 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, family and community health care.
2. Refers patients to other health personnel, health facility or government agency.

Source: DOH. Training Course on Supervision for the Public Health Nurse. Resource
Manual. 1994
Occupational health nursing

Occupational health nursing is "aimed at assisting workers in all occupations to cope with
actual and potential stresses in relation to their work and work environment. It is
primarily geared at helping workers attain and maintain optimum level of physical and
psychological functioning" (PNA-ANSAP, 1982).

Book IV of the Labor Code contains provisions on health, safety and welfare benefits for
employees. Section 4(b, c, and d) of Rule 1 states that if a company has more than 50
workers, the services of a full-time nurse should be provided. A company nurse who is a
registered nurse, should preferably have training in occupational nursing conducted by
the DOH, University of the Philippines Manila College of Public Health, or any
organization accredited by the former.

The major considerations in occupational health nursing practice are laws (such as PD
856-Sanitation Code of the Philippines), policies and standards (e.g., Department of
Labor and Employment, Department of Health, Social Security System, Philippine
Health Insurance Corporation and Employees Compensation Commission) and
professional standards such as those developed by the OHNAP and the PNA. The
standard job description or statement of the duties and responsibilities of occupational
nurses has been formulated by the OHNAP. The duties and responsibilities are grouped
into four headings --curative/palliative, preventive, educative and administrative
functions. The major areas of concern of occupational health nurses include: emergency
and palliative care, family planning, counseling, immunization, environmental sanitation,
work safety, disaster prevention and control, orientation of new employees, and
dissemination of health information/ health education. In small companies, physicians are
either totally absent or are just working part-time. Because of this, nurses are also in
charge of a number of administrative functions (OHNAP 2002)

School nursing

School nursing aims to promote the health of school personnel and pupil/students. It aims
to prevent health problems that could hinder students' learning and performance of their
developmental tasks. Health, in this particular instance, is considered as an important
resource in education.

The major considerations in school nursing practice include laws such as the Child and
Youth Welfare Code (PD 603) and Letter of Instruction 764 (declaring the School Health
Program the priority program of the national government); policies and standards of the
Department of Education and the DOH, and standards of the nursing profession. And
probably more important influences are the socioeconomic realities in the schools,
homes, communities, and local government units (LGUS).

Just like workers in their workplaces, school children who are in school are generally
well. For this reason, most of the activities of school nurses are focused on health
advocacy, health promotion, disease prevention and early detection of disease. More
specifically, nurses perform: (1) health and nutrition assessment, screening, and case
finding; (2) treatment of common ailments and attending to emergency cases; (3)
counseling and health education; (4) nursing procedures; (5) supervision of the health and
safety of the school; and (6) referrals and follow-ups of pupils and personnel. On top of
these, the nurse manages the school clinic, monitors and evaluates health programs and
projects.

For a detailed presentation of the activities of school nurses, refer to Chapter 4 of the
NLPGN's book Public Health Nursing in the Philippines (2007).

COMMUNITY-BASED CASE MANAGEMENT

While there is no clear agreement about the definition and component activities of case
management, its use is based on the assumption that people with complex health
problems need assistance in using the healthcare system effectively (Rheaume and others,
1994). Case management is about choice and empowerment for people. To achieve these,
case managers need to be accessible and act as people's advocate (Thornicroft, 1991).
Bergen (1992) divides five distinct phases of case finding, assessment and need/ problem
identification, design and implementation care packages, monitoring or reassessment,
which lead to the last phase of case closure or repetition of the cycle. The responsibilities
of the case manager, are, therefore, to assess, monitor, mutually plan of care and activate
interventions and coordinate healthcare services to the individualized needs of patients
and their families (Ethridge and Lamb, 1989; Gibson and others, 1994). To achieve this,
Meisler and Midyette (1994) specify five roles of a nurse case manager: manager,
clinician, consultant, educator and researcher.

A manager's role involves financial accountability in terms of evaluating and monitoring

costs and resources. As a clinician, the nurse case manager develops and manages plan of
care for a specific patient type or population through coordinating with hospital staff for
the discharge plan and the rest of the team for the home-based care. As consultant, the
case manager collaborates with the multi-disciplinary team, serves as a patient liaison,
offers clinical support and expertise, coordinates consultations and encourages patient
and family participation. The educator's role includes explaining the use of a patient's
care plan, involving the entire team in the total process of care and updating the team of
practice changes. As a researcher, the case manager continuously monitors and evaluates
outcomes and costs.

Case management aims to achieve quality and access while managing cost in a seamless
health care system. It is a systematic process that hopes to achieve cost effective, high
quality, comprehensive health services for clients across a continuum of care.

ETHICOLEGAL ASPECTS OF COMMUNITY HEALTH NURSING

The practice of community health nursing is guided by a number of legal and ethical
principles that center on the welfare of clients and protection of their rights. CHNs are in
a position to influence others to respect and protect these rights. Nursing practice is legal
if the practitioner works within the bounds of law; it is ethical if the nurse upholds ethical
principles such as autonomy, beneficence/nonmaleficence, justice, fidelity and veracity.

Nurses should at all times respect their clients' rights such as the right to be informed
about their condition and treatment or any health intervention that needs to be done They
are entitled to accurate and adequate information so that they could make an informed
decision. Clients' refusal (e.g., specific FP methods) should not affect their access to other
health services.

Clients have the right to safe and quality care and nurses can ensure this only if they are
competent. CHNs, therefore, have a responsibility to update themselves on the latest
developments in health care and in community health nursing. They should read new
books, professional journals, manuals and other related materials; and, attend seminars
and conferences that could enrich their professional practice. They should be updated on
the latest Professional Regulation Commission (PRC) guidelines on continuing
professional education (CPE).

Clients should be treated respectfully at all times. Their right to privacy, particularly
during medical or nursing procedures should be respected. Their health records are
treated confidentially.

In prioritizing health services and activities, health workers in general should be guided
by the principle "the greatest good for the greatest number". Another principle that guides
the provision of health services, particularly in government-owned health facility is
distributive justice. In a "micro" setting, this could mean "fair, equitable and appropriate
distribution" (Beauchamp and Walters, p. 26) of services and resources such as medicines
and medical supplies. Primarily because resources are limited, PHNs should be guided by
the equity rule, that is, (assuming that the need is the same) the scarce resources should
be given to the one who is in greater need. "Need" is dictated not only by one's health
condition but also by his inability to pay. CHNs do not only deliver needed health
services, they also humanize the health care delivery system as well.