2F: Community Health Nursing What is a community?

Process
- Group of people (geopolitical):
Community Health Nursing Process - Common characteristics or
interests
- is a systematic, scientific,
- Interact with one another
dynamic, ongoing interpersonal
- Sense of unity or belonging
process in which the nurses and
- Function collectively within a
the clients are viewed as a
defined social structure to
system with each affecting one
address common concerns
and another and both being
affected by the factors within the Principles of CHN (ANA, 2007):
behavior.
- Focus on the community as the
- a systematic, rational method in
unit of care
providing nursing care for the
- Give priority to community health
prevention of disease and
needs
promotion of health of the
- Work with the community as an
community (Mona, 2005).
equal partner of health team
Stages and Process: - In selecting appropriate activities,
focus on primary prevention
1. Assessment - process that
- Promote a healthful physical and
uses quantitative and
psychosocial environment
qualitative methods to
- Reach out to all who may benefit
systematically collect &
from a specific service
analyze health status data
- Promote optimum use of
within a specific community
resources
2. Diagnosis – a quantitative &
- Collaborate with others working in
qualitative description of the
the community
health of the citizens and the
factors which influence their Conditions in the Community
health.
• People
3. Planning - logical decision-
➢ Population Variables
making process to design an
- Size, density, composition
orderly, detailed program of
- Growth & Decline of a population
action to accomplish specific
- Cultural Characteristics of
goals & objectives.
Community
4. Implementation - putting the
- Migration
plan into action and
- Social class & educational level
conducting all activities as
planned.
5. Evaluation - phase of • Location
determining whether the ➢ Natural variables
planned actions met the - Geographic features
client's needs. - Flora & Fauna
 ➢ Man-made Variables
- Presence of open spaces
- Quality of soil, air & water
- Location of health facilities
➢ Community Boundaries
Characteristics of a Healthy
- Urban – (5-175-5)
Community (Hunt ,1997; Duhl, 2002)
- Rural
• Social System
- patterned series of
interrelationships existing
between individuals, groups or
institutions and forming a
coherent whole which includes:
o Family
o Economic
o Educational
o Communication
o Political
o Legal
o Religious
o Recreational
o Health Systems
Factors Affecting Health
• Physical Factors
Ottawa Charter (1986)
- Industrial development
- Community size
- Environment
- Geography
• Social/Cultural Factors
- Beliefs, Traditions, and
Prejudices
- Economy, Politics, Religion
- Socioeconomic status
- Social Norms
• Community Organization
- Ways in which communities
organize their resources
- Tax vs Non-tax supported
services
• Individual Behaviors
- Takes the concerted efforts of
many, if not most, to make a
community voluntary program
work
- Shared sense of being a
community based on history &
values
- General feeling of empowerment
& control over matters affecting
the community as a whole
- Existing structures that allow
subgroups within the community
to participate in decision making
- Ability to cope with change, solve
problems, manage conflicts
through acceptable means
- Open channels of communication
and cooperation
- Equitable & efficient use of
community resources –
sustainable development of
natural resources
- Landmark document on health
promotion
- Paved the way for the Healthy
Settings Initiative (Healthy Cities
Movement)
- International Conference on
Health Promotion, Ottawa,
Canada
Types of Community Assessment
➢ 3 categories of community
health determinants (People,
Location, Social System)
1. Planned Approach to Community
Health (PATCH)
2. Comprehensive Needs
Assessment
3. Problem Oriented Assessment
• Planned Approach to
Community Health (PATCH)
Data collected for the PATCH Process
1. Community profile: demographic,
educational and economic data
2. Morbidity & mortality data,
including a unique health
3. Behavioral data focusing on risk
factors such as smoking,
drinking, and leading a sedentary
lifestyle and prevailing good
health practices in the community
such as breastfeeding and getting
regular exercise
4. Opinion data from the community
leaders, such as what they think
about the main health problems
of the community, their causes
and measures that may alleviate
or correct them
• Comprehensive Needs
Assessment
- Systematic process where data is
collected regarding all aspects of
the community to be able to
identify actual or potential health
problems (Maurer & Smith,
2009).
- Requires much time & effort;
most useful in determining
baseline community health
assessment
- Periodic assessment and
evaluation of health programs
• Problem Oriented Assessment
- Focused on a particular aspect of
health
- Nurse collects information with a
certain community problem in
mind, then proceeds to gather
information from the aggregate
vulnerable to the problem
- Useful when comprehensive
community assessment has been
done
Four Types of Community Needs
- "A community needs assessment
identifies the strengths and
resources available in the
community to meet the needs of
[community members). The
assessment focuses on the
capabilities of the community,
including its citizens, agencies,
and organizations. It provides a
framework for developing and
 identifying services and solutions
and building communities that
support and nurture children and
families.”
1. Perceived needs
- Based on what the individuals
feel their needs are
2. Expressed needs
- Defined by the number of
individuals who sought help
3. Absolute needs
- Needs deemed universal,
including those for survival
4. Relative needs
- Needs rendered necessary based
on equity
Tools for Community Assessment
• Primary Data - data that have
not been gathered before.
- ex. Observation, Survey,
Informant Interview, Community
Forum, Focus Group Discussion
• Secondary Data - existing data
sources
- ex. Vital Registries, Health
Records & Reports, Disease
Registries and Publications
Collecting Primary Data
1. Observation
• Ocular or windshield survey –
driving, riding or walking to
observe people, environmental
conditions, existing community
facilities.
• Participant observation -
purposeful observation of formal
and informal community
activities by sharing, if possible,
in the life of the community;
determines community values,
beliefs, norms, priorities,
concerns, powers or influence
structures.
2. Survey
• No available information
• Determines community attitudes,
knowledge, health behaviors,
perceptions & health services
• Opportunity for making members
of community more aware of
community problems and their
effects and capacity to influence
decision making about health
policies
3. Informant Interview
• Purposeful talks with either
key informants (formal or
informal community leaders or
persons of position and
influence) or ordinary
members of the community.
• Valuable information on
community perceptions about
health and health care
• Structured / Semi-
structured/ Unstructured
4. Community Forum
• Open meeting of the members
of the community
• Information on community
perceptions on needs, health
and health care
• Medium of community
member's expression of views
and developing their capacity
to influence decision makers
• Venue for information
dissemination, data validation
 of secondary data and getting
feedback from people
• Example: Pulong-pulong sa
Barangay
5. Focus Group Discussion (FGD)
• Smaller group: 6-12 members
• Homogenous composition –
similar sociocultural or health
conditions
• Assessment of health needs of
specific groups
• Example: FGD of primigravid
mothers
Secondary Data Sources
1. Registry of Vital Events
• RA 3753 – Civil Registration Law
– NSO - central repository of civil
registries
• RA 7160 – Local Government
Code – local civil registries
• RA 10625 – The Philippine
Statistical Act of 2013 - Philippine
Statistics Authority - merge of
National Statistical Coordination
Board (NSCB), National Statistics
Office (NSO), Bureau of Labor
and Employment Statistics
(BLES) of the DOLE and Bureau
of Agricultural Statistics (BAS) of
the DA.
• PD 856 - Sanitation Code of the
Philippines - death certificate
before burial
• Births, Marriages and Death –
vital events
• FB birth – administrator must
register
• Non-FB birth – physician,
midwife, nurse or any who
attended the delivery or either
parent (within 30 days at LCR)
• Physician who last attended the
deceased = makes death
certificate and submits to
Municipal Health Officer
(MHO)/Community Health Officer
(CHO) within 48 hours.
• If not attended by a physician,
nearest relative reports to
MHO/CHO within 48 hours.
• If no MHO/CHO, the mayor,
municipal secretary or
municipal/city councilors may
issue death certificate for purpose
of burial.
• Registration of deaths shall be
within 30 days
2. Health Records & Reports
• Field Health Service
Information System (FHSIS) -
official recording and reporting
system of the DOH & used by
PSA to generate health statistics
(EO 352, 1996).
• Essential tool in monitoring the
health status of the population &
provides facility-level database
for more in-depth studies
• Basis for (1) priority setting of
LGU, (2) planning & decision
making at different levels, (3)
monitoring & evaluating health
program implementation
• FHSIS Recording Tools:
- Individual Treatment Record
(ITR)
o building block of FHSIS
o contains date, name,
address of patient,
presenting signs and
symptoms or complaint,
diagnosis, treatment and
its date.
- Target Client List (TCL)
o second building block of
FHSIS
o Purpose:
(1) plan & carry out patient care and
service delivery
(2) facilitate monitoring & supervision
of service delivery
(3) report services delivered
(4) provide clinic-level database that
can be accessed for further
studies
- Summary Table (ST)
o accomplished by the
midwife & retained at BHS
o 12 column (12 months of
the year)
o 2 components: Health
Program Accomplishment
(ready source of reports) &
Morbidity Diseases
(disease trends & 10
leading cause of morbidity)
- Monthly Consolidation Table
o accomplished by the nurse
based on ST
o serves as source
document for the Quarterly
Form & Output Table of
RHU or Health Center
- Monthly Forms
o Regularly prepared by the
midwife and submitted to
the nurse
➢ Program report (M1) -
indicators categorized as
maternal care, child care,
family planning and disease
control (TB, Leprosy, Malaria,
Schistosomisis, Filariasis);
from ST
➢ Morbidity report (M2) – list of
all aces of diseases by age &
sex
- Quarterly Forms
o Regularly prepared by the
nurse; only 1 Quarterly
forms per municipality or
city (official report);
submitted to the PHO.
➢ Program report (Q1) - 3
month total of indicators
 categorized as maternal care,
child care, family planning,
dental health and disease
control
➢ Morbidity report (Q2) - 3
month consolidation of
Morbidity report (M2)
- Annual Forms
o A-BHS - report by the
midwife that contains
demographic,
environmental & natality
data.
➢ Annual Form 1 (A-1) -
prepared by the nurse and is
a report of the RHU or health
center; it contains
demographic, environmental,
natality & mortality for entire
year
➢ Annual Form 2 (A-2) –
prepared by the nurse and is
Presenting Community Data
the yearly morbidity report by
age & sex
➢ Annual Form 3 (A-3) –
prepared by the nurse and is
the yearly mortality report by
age & sex
- their lives
- Disease Registries
o Listing of persons
diagnosed with a specific
type of disease in a
defined population
o Basis for monitoring,
decision making and
program management
- Census
o PB 72 – national census of
population & other related
data in PH every 10 years
o Philippine Statistics
Authority (PSA) • De Jure
(legally established place
of residence) vs De Facto
(actual physical location)
o Demographic
characteristics, household
size, data on fertility &
mortality
• Purpose of Presenting
Community Data:
- Information dissemination
- Appreciation of significance /
relevance of health information to
- Solicit broader support and
participation in CHN process
- Validate findings
- Allow wider perspective in the
analysis of data
- Provide bases for better decision
making
Methods of Data Presentation:
• Bar Graph
- To compare values across
different categories of data
Community Diagnosis
- Display data as rectangular bars
with lengths proportional to the
values that they represent
- Can be vertical (column) or
horizontal
- Horizontal bars are used when
there are many categories of data
and each bar requires a long
label
• Line Graph
- To have visual image of trends in
data over time or age
- To present a time-series data that
shows changes in values from
one time to another
Shuster & Goeppinger (2004)
- Do not use line graph with
categorical data
• Pie Chart
- To show percentage distribution/
proportion or composition of a
variable such as population or
household
- Useful for showing the
proportions of a single variable's
frequency distribution
• Scatter Plot or Diagram
- To show correlation or
relationship between 2 variables
- To create a scatter diagram you
must have a pair of values (one
for each variable) for each
person, group, country, or other
entity in the data set, one value
for each variable. A point is
placed on the graph where the
two values intersect.
- Process of determining the health
status of the community and the
factors responsible for it (WHO,
2004).
- Health worker makes a
judgement about the health
status, resources, & health action
potential or likelihood that the
community will act to meet health
needs or resolve health
problems.
- NANDA International; Shuster &
Goeppinger & The Omaha
System
- Proposed a practical adaptation
of a format of nursing diagnoses
for population groups.
- Three-part statement:
1. The health risk or specific
problem to which the
community is exposed.
2. The specific aggregate or
community with whom the
nurse will be working to deal
with the risk or problem.
3. Related factors that influence
how the community will
respond to the health risk or
problem.
- Example: Risk for maternal
complications leading to maternal
mortality among pregnant women
r/t cost and inaccessibility of
skilled birth attendants and
community member's perception
 that skilled birth attendants are
not important.
The Omaha System
- Research-based, comprehensive
practice and documentation
standardized taxonomy designed
to describe client care.
- 3 components: Assessment
component (Problem
Classification Scheme), a care
plan/services component
(Intervention Scheme), and an
evaluation component (Problem
Rating Scale for Outcomes).
1. Problem Classification Scheme
- Provides a structure, terms, and
system of cues and clues for a
standardized assessment of
individuals, families, and
communities.
- It helps practitioners collect, sort,
document, classify, analyze,
retrieve, and communicate
health-related needs and
strengths.
- It is a comprehensive, orderly,
non-exhaustive, mutually
exclusive taxonomy or hierarchy.
- Four domains appear at the first
or most general level.
- Forty-two client problems or
areas of concern are at the
second level; by definition,
problems are neutral, not
negative
- The third level consists of two
sets of problem modifiers: health
promotion, potential, and actual
as well as individual, family, and
community
- Clusters of signs and symptoms
that describe actual problems are
at the fourth or most specific
level.
2. Intervention Scheme
- Designed to describe and
communicate multidisciplinary
practice, practice that is intended
to prevent illness, improve or
restore health, decrease
deterioration, and/or provide
comfort before death.
- Practitioners use the Intervention
Scheme to describe health
related care plans and services
for individuals, families, and
communities.
- The Scheme is a comprehensive,
orderly, non-exhaustive, mutually
exclusive taxonomy or hierarchy.
- It consists of three levels of
actions or activities:
1. Four broad categories appear
at the first or most general
level.
2. An alphabetical list of 75
targets or objects of action
and one "other" are at the
second level.
3. Client-specific information
generated by practitioners is
at the third, most specific
level.
3. Problem Rating Scale for
Outcomes
- A method to evaluate client
progress throughout the period of
service.
- It consists of three five-point,
Likert-type scales to measure the
 entire range of severity for the - The community should have
concepts of K-B-S. genuine representation in the
- Knowledge is defined as what planning group.
the client knows, Behavior as
what the client does, and Status
as the number and severity of the
client's signs and symptoms or
predicament.
- Each of the subscales is a
continuum providing an
evaluation framework for
examining problem-specific client
ratings at regular or predictable
times.
- Suggested times include
admission, specific interim points, Nominal Group Technique (Shuster &
and dismissal. Goeppinger, 2004)
- The group makes a list of
identified health problems or
conditions
- Each identified problem is treated
separately using a set of criteria
agreed upon by the group (e.g.
WHO criteria on priority setting)

Planning Community Health

Interventions
- A logical process of decision
making to determine which of the
identified health concerns
requires more immediate
consideration & what actions may
be undertaken to achieve goals
and objectives.
- Involves priority setting,
formulating goals & objectives
and deciding on community
interventions
 Formulating Goals & Objectives
Resources
• Goals - desired outcomes at the
end of the interventions
• Objectives – short-term changes
in the community that are
observed as the health team and
community work towards
attainment of goals.
Deciding on Community
Interventions:
- Analyze reasons for people's
health behavior and direct
strategies to respond to
underlying causes
- Consider the demographic,
Standards of Evaluation (CDC, 2011)
psychological, social, cultural,
and economical characteristics of
the target population and
available health resources.
Implementing the Community Health
Interventions
- Referred as Action Phase
- Intended to enhance the
community's capability in dealing
with common health conditions/
problems.
- The role of the nurse is to
facilitate the process.
- Entails stakeholder coordination
of the plan, common
understanding of the goals &
objectives & multi-sectoral
collaboration.
Evaluating Community Health
➢ Approaches:
• Structure evaluation -
manpower & physical
resources
• Process evaluation -
manner by which
ADPIE were
undertaken
• Outcome evaluation -
determining the degree
of attainment of goals
and objectives
• Utility – usefulness of results
(insights on strengths and
weakness, manner of
implementations, policy change,
identify barriers)
• Feasibility – answers the
question whether the plan for
evaluation is doable or not
considering the available
resources.
• Propriety – involves ethical and
legal matters, transparency and
accountability.
• Accuracy - validity and reliability
of the results of evaluation.