yas ehensive text on community and | pu lth nursing in the Philippines ®e . Zenaida U. Famorca / Mary A. Nies Melanie McEwen Scanned with CamScannerNursing Care of the Community Win ‘ wy a Zenaida U. Famorca, MPH, RN Associate Professor II College of Nursing, University of Santo Tomas Manila, The Philippines Mary A. Nies, PhD, RN, FAAN, FAAHB Carol Grotnes Belk Endowed Chair in Nursing and Professor Adjunct Professor Department of Public Health Sciences College of Health and Human Services University OF North Carolina at Charlotte Charlotte, North Carolina, USA. Melanie McEwen, PhD, RN Associate Professor University of Texas Health Science Center at Houston “om, School of Nursing Houston, Texas, USA eye sy Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto Scanned with CamScannerELSEVIER MOSBY Nursing Care of the Community Copyright © 2013 Elsevier (Singapore) Pte Ltd. All rights reserved AURing Care ofthe Community by Zenaida U. Famorca, Mary A. Nies, and Melanie McEwen includes some adapted content 1m Community/Public Health Nursing, 5th ed by Mary A. Nies, PhD, RN, FAAN, FAAHB, and Melanie McEwen, PhD, RN, and is Published by arrangement with Elsevier Inc All rights reserved. No part of this book may be produced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from the publishers. Permissions may be sought directly fram tlseviers Health Sciences Rights Department in Singapore phone: +65-6349 0200, fax: +65-6733 1817, Elsevier (Singapore) Pte Lid 3Killiney Road, #08-01 Winsland House | Singapore 239519, Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. 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To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, product, instructions, or ideas contained in the material herein. Publishing Manager: Hooi Ping Chee Developmental Editor: Peter Michael C, Sandico and Suthichana ‘Tharmapalan Publishing Services Manager: Vivian Tan ISBN 978-981-2729-99-6 Printed in Singapore your source for books, TRIE journats and rnukimedia Inthe health sconces www.elsevierhealth.com Working together to grow libraries in developing countries | pal, rinabeiacom | wrokidny | wnabcons | ping Scanned with CamScannerZenaida U. Famorca, MPH, RN Associate Professor I College of Nursing, University of Santo Tomas Manila, The Philippines Zenaida U. Famorca, MPH, RN is an Associate Professor II at the College of Nursing at the University of Santo Tomas in the Philippines. She received her BSN (Summa Cum Laude) from the University of Santo Tomas; and she graduated top of the class for her Master of Public Health from the College of Public Health at the University of the Philippines Manila. With 35 years of teaching experience in nursing education, Associate Professor Famorca also supervises the application of electronic technology and e-learning in the nursing faculty. Mary A. Nies, PhD, RN, FAN, FAAHB Carol Grotnes Belk Endowed Chair in Nursing and Professor Adjunct Professor Department of Public Health Sciences College of Health and Human Services University of North Carolina at Charlotte Charlotte, North Carolina, USA Mary A. Nies, PhD, RN, FAAN, FAAHB, is the Carol Grotnes Belk Endowed Chair in Nursing and Adjunct Professor for the Department of Public Health Sciences in the College of Health and Human Services at the University of North Carolina at Charlotte. Dr. Nies received her MSN from Loyola University, Chicago; and her PhD in Public Health Nursing, Health Services, and Health Promotion Research at the University of illinois, Chicago. She completed a postdoctoral research fellowship in health promotion and community health at the University of Michigan, Ann Arbor. She is a fellow of the American Academy of Nursing and a fellow of the American Academy of Health Behavior. Dr. Nies co-edited Community Health Nursing: Promoting the Health of Aggregates, which received the 1993 Book of the Year award from the American Journal of Nursing. Melanie McEwen, PhD, RN Associate Professor University of Texas Health Science Center at Houston School of Nursing Houston, Texas, USA Melanie McEwen, PhD, RN, is an Associate Professor at the University of Texas Health Science Center at Houston School of Nursing. Dr. McEwen received her BSN from the University of Texas School of Nursing in Austin; her Master's in Community and Public Health Nursing from Louisiana State University Medical Center in New Orleans; and her PhO in Nursing at Texas Woman's University. Dr. McEwen has been a nursing educator for more than 22 years and is also the co-author of Community-Based Nursing: An Introduction (Saunders, 2009) and co-author/ editor of Theoretical Basis for Nursing (Lippincott, 2011) Scanned with CamScannerContributors (The Philippines) Enrique M. Cruz Ill, MPH, RN Faculty College of Nursing University of Santo Tomas Jose S. Cruz Ill, RN Former Director, Office of Community Development Faculty, College of Nursing University of Santo Tomas Ritzmond Fainsan Loa, MAN, RN Faculty College of Nursing University of Santo Tomas Maridel P. Borja, PhD, MSc Med Stat, MSPH Professor College of Public Health University of the Philippines Manila Isidor F. Cardenas, RN Former eHealth Nurse Health Informatics Team National Telehealth Center University of the Philippines Manila Melissa J. Pedrena, RN Former eHealth Nurse and Coordinator for Telemedicine Certificate Course National Telehealth Center University of the Philippines Manila Contributors (USA) Beverly Cook Siegri Professor School of Nursing Western Kentucky University Bowling Green, Kentucky EdD, MS, RN, CNE Bonnie Rogers, PhD, COHN-S, FAAN Director, Occupational Health Program School of Public Health University of North Carolina ~ Chapel Hill Chapel Hill, North Carolina Bridgette Crotwell Pullis, PhD, RN Assistant Professor of Nursing The University of Texas Health Science Center Houston, Texas Carrie L. Abele, PhD, RN Assistant Professor School of Nursing Oakland University Rochester, Michigan Catherine A. Pourciau, RN, MSN, FNP-C Louisiana State University Health Sciences Center Baton Rouge, Louisiana Diane C. Martins, PhD, RN Assistant Professor College of Nursing The University of Rhode Island Kingston, Rhode Island Edith B. Summerlin, PhD, RN Instructor School of Nursing University of Texas Health Science Center Houston, Texas Elaine C. Vallette, DrPH, RN Dean, Nursing and Allied Health Baton Rouge Community College Baton Rouge, Louisiana Scanned with CamScannerReviewers (The Philippines) Bernadette C. Apita, MPH, MAN, RN Assistant Professor Il College of Nursing San Juan De Dios Educational Foundation Incorporated Bevan Balbuena, MN, RN CHN Clinical instructor Nursing Department San Pedro College Marilen Pacis, MAN, RM, RN Professor College of Nursing Lyceum of the Philippines University Marina Magnolia Gallardo-Ninobla, MAN, RM, RN Associate Professor Il Far Eastern University-Institute of Nursing Segundo Francis Z. Barte III, MAWD, BSCD, RN Head Integrated Community Health Nursing Department Trinity University of Asia-St. Luke's College of Nursing Wilhelmina Z. Atos, PhD, RN College Secretary and Curriculum Chair College of Nursing University of the East Ramon Magsaysay Memorial Medical Center Reviewers (USA) Alice Susan Bidwell, BSN, MSN, EdD, RN-BC, CS Professor and Chair, MSN Program ‘School of Health Professions Marymount University Arlington, Virginia Brenda Talley, PhD, RN, NEA-BC Associate Professor School of Nursing Georgia Southern University Statesboro, Georgia Fatma Youssef, RN, MPH, DNSc Professor ‘School of Health Professions Marymount University Arlington, Virginia Lynn M. Leon, MSN, RN Associate Professor School of Nursing Malone University Canton, Ohio Mary Lashley, PhD, APRN, RN, BC Professor College of Health Professions Towson University Towson, Maryland Scanned with CamScannerForeword I welcome this opportunity to be among the first to congratulate the authors for their significant contributions to the field of Community Health Nursing in the Philippines. Community Health Nursing is one field of nursing that is very much context-based. While books and literature from other countries can help nursing students and nurses to learn the theories and principles of community health nursing, the health needs of the community and the approaches and programs to address these needs must consider the people, the culture and the resources available indigenously. This is the unique contribution of this book. Students in nursing, both undergraduate and graduate, will find this book very helpful in understanding the various health needs and problems of our people; the rationale behind the various strategies and programs of the Department of Health; how to interpret and use epidemiological data and understand the framework of the Philippine Health System. While the health statistics of the country change over time, the basic knowledge of how to interpret these various data and apply these concepts to community health nursing which are provided in this book will help guide the students, clinical instructors and nurse practitioners in their community health nursing practice. Community Health Nursing as a specialization in nursing does seem to attract many nurse practitioners to venture into this field. 1 hope this book, with its rich discussions and relevant local examples of the various health needs of our communities and the programs of the Department of Health including control of communicable and non-communicable diseases; maternal and child health and nutrition; integration of information technology in public health, will arouse the interest of young nursing scholars to venture into this less popular field of nursing. This Philippine edition of Community Health Nursing is an important addition to the much needed books that are written by reputable local authors. The publishing of this book is a step in the right direction and | hope that more Filipino authors will write about the many facets of nursing in the Philippines so our nurses can. better serve the Filipino people even as they also provide care to the peoples of the world Prof, Teresita R. Itigo-Barcelo, PhD, RN Dean, College of Nursing Centro Escolar University , Philippines Scanned with CamScannerUNIT 1 INTRODUCTION TO COMMUNITY HEALTH NURSING Chapter 1 Fundamental Concepts of Community Health Nursing Definitions of Health and Community, 5 Health, 5 Community, 6 Determinants of Health and Disease, 7 Indicators of Health and Illness, 8 Definition and Focus of Public Health and Community Health, 9 Preventive Approach to Health, 11 Health promotion and levels of prevention, 11 Thinking upstream: Examining the root causes of poor health, 13 Definition and Focus of Community Health Nursing, Public Health Nursing, and Community-Based Nursing, 14 Community and public health nursing, 15 Distinguishing features of community health nursing practice, 17 Population-Focused Approach and Community Health Nursing Interventions, 17 Levels of Clientele of the Community Health Nurse, 19 The Intervention Wheel, 19 The prepayment mechanism in community health nursing practice, 24 Emerging Fields of Community Health Nursing in the Philippines, 22 Competency Standards in Community Health Nursing, 24 History of Public Health and Public Health ‘Nursing in the Philippines, 25 Summary, 27 UNIT 2 COMMUNITY HEALTH AND DEVELOPMENT CONCEPTS, THEORIES, AND STRATEGIES Chapter 2 Theoretical Foundations of Community Health Nursing Practice Historical Perspectives on Nursing Theory, 34 How Theory Provides Direction to Nursing, 35 Review of Theoretical Approaches, 36 General Systems Theory, 36 Social Learning Theory, 37 The Health Belief Model, 37 Milio’s Framework for Prevention, 39 Pender’s Health Promotion Model, 42 The Transtheoretical Model, 43 PRECEDE-PROCEED Model, 44 Summary, 44 xi Scanned with CamScannerChapter 3 Primary Health Care Introduction, 49 Brief History of Primary Health Care , 50 Definition of Primary Health Care, 51 Key Principles of Primary Health Care , 51 The 4 As of PHC: Accessibility, affordability acceptability, and availability, 52 Support mechanisms, 52 Multisectoral approach, 52 Community participation, 53 Equitable distribution of health resources, 54 Appropriate technology, 54 Primary Health Care versus Primary Care, 57 Summary, 58 Chapter 4 Community Organizing: Ensuring Health in the Hands of the People Definition of Community Organizing, 62 Core Principles in Community Organizing, 63 Community organizing is people-centered, 63 Community organizing is participative, 64 Community organizing is democratic, 64 Community organizing is developmental, 64 Community organizing is process-oriented, 64 Phases of Community Organizing, 65 Pre-entry, 65 Entry into the community, 65 Community integration, 66 Social analysis, 67 Identifying potential leaders, 68 Core group formation, 68 Community organization, 69 Action phase, 69 Evaluation, 70 Exit and expansion phase, 70 Goals of Community Organizing, 71 Community Organizing Participatory Action Research, 71 Summary, 75 w Chapter 5 Health Promotion, Risk Reduction, and Capacity-Building Strategies Health Promotion and Community Health Nursing, 77 Risk and Health, 78 {he Relationship of Risk to Health and Health Promotion Activities, 79 Diet and health, 80 Physical activity and health, 84 Sleep,85 Tobacco and health risk, 86 Alcohol consumption and health, 88 The Ottawa Charter for Health Promotion, 90 Health Education, 92 The effective nurse educator, 92 Effectiveness of health education, 93 Competency-Based Training of Community Barangay Health Workers, 93 Summary, 94 UNIT 3 THE ART AND SCIENCE OF FAMILY AND COMMUNITY HEALTH NURSING Chapter 6 Family Health Nursing The Family, 100 Functions of the family, 101 ‘The family as a client, 102 The family as a system, 103 Developmental stages of the family, 103 Family health tasks, 104 Characteristics of a healthy family, 105 Family Nursing and the Nursing Process, 105 Family health assessment, 106 Family data analysis, 107 Family nursing diagnosis, 112 Formulating the plan of care, 113 Implementing the plan of care, 114 Evaluation, 116 Scanned with CamScannerFamily-Nurse Contacts, 116 Home visit, 117 Application of the Nursing Process, 121 Assessment, 121 Individual level, 122 Family level, 123 summary, 123 Chapter 7 The Nursing Process in the Care of the Community Principles of Community Health Nursing, 128 Conditions in the Community Affecting Health, 129 People, 129 Location, 130 Social system, 132 Characteristics of a Healthy Community, 133 Community Assessment, 134 Tools for community assessment, 135 Methods to present community data, 140 Community Diagnosis, 142 The Omaha System, 143 Planning Community Health Interventions, 145 Priority setting, 145 Formulating goals and objectives, 148 Deciding on community interventions, 148 Implementing the community health interventions, 149 Evaluation of Community Health Interventions, 149 Standards of evaluation, 149 Summary, 150 Chapter 8 Applications of Epidemiology in Community Health What Is Epidemiology?, 155 Practical applications of epidemiology, 156 Assessment of the Health Status of the Community (Community Diagnosis), 158 Morbidity indicators, 158 Mortality indicators, 161 Population indicators, 164 Sources of data for calculation of health indicators, 166 Considerations in the analysis and interpretation of health indicators, 169 Elucidation of the Natural History of Disease, 169 Determination Of Disease Causation, 170 Models of disease causation, 171 Prevention and Control of Diseases, 172 Outbreak investigation, 172 Monitoring and Evaluation of Health Interventions , 174 Monitoring, 174 Evaluation, 174 Provision of Evidence for Health Policy Formulation , 175 Summary, 175 UNIT 4 PUBLIC HEALTH NURSING a Chapter 9 The Health Care Delivery System ‘The World Health Organization, 182 The Millennium Development Goals, 184 ‘The Philippine Health Care Delivery System, 184 The Department of Health, 185 Levels of health care delivery, 186 The Rural Health Unit, 188 Local health boards, 190 The health referral system, 190 Health sector reform: Universal Health Care, 191 Public health programs, 194 Summary, 195 xiii Scanned with CamScanner1 Integrated Management of Childhood Ilinesg an Overview, 247 IMCI Case Management, 247 Chapter 10 Maternal, Newborn, and Child Health and Nutrition The Current Maternal and Child Health and Nutrition Situation, 200 The Maternal, Newborn, and Child Health Summary, 250 and Nutrition Strategy, 203 The MNCHN core package of services, 204 — MNCHN service delivery network, 209 (Te Reproductive Health Program, 211 The Philippine Family Planning Program (PEPP), 213 Four pillars of the PFPP, 213 Client counseling and assessment, 214 Benefits of family planning , 214 Family planning methods, 214 Newbom Screening, 223 ‘Newborn Screening in the Philippines, 223 Newborn screening procedure, 224 Newborn hearing screening, 225 Expanded Program on Immunization, 226 Goals of the expanded program on immunization and supporting legislation, 227 Immunization schedule for infants and young children, 228 EPI vaccines, 229 Target setting and vaccine requirements, 229 ‘Maintaining the potency of EPI vaccines, 229 Side effects and adverse reactions of immunization, 232 Contraindications to immunization, 232 EPI recording and reporting, 234 Infant and Young Child Feeding, 234 Infant and young child feeding: The Philippine situation, 235 ‘Nutritional assessment of the infant and young child, 236 Recommended infant and young child feeding practices, 237 ‘Micronutrient supplementation, 242 Food fortification, 243 Deworming, 243 Malnutrition in children, 244 Chapter 11 Control of Noncommunicable Diseases Introduction, 258 Noncommunicable Diseases, 258 Cardiovascular and cerebrovascular disease, 255 Cancer, 260 Chronic obstructive pulmonary disease, 260 Diabetes, 262 Risk Factors for Noncommunicable Diseases, 262 Prevention of Noncommunicable Diseases, 264 Promote physical activity and exercise, 264 Promote healthy diet and nutrition, 266 Promote a smoke-free environment, 269 Stress management, 268 Mental Health, 269 Disability, 272 Visual Impairment, 273 Laws Affecting Control of Noncommunicable Diseases, 275 Summary, 276 Chapter 12 Control of Communicable Diseases Introduction, 282 Communicable Diseases, 283 Epidemiologic Triangle Model, 283 Chain of Infection, 283 Diseases Targeted for Eradication, 284 Functions of the Public Health Nurse in the Control of Communicable Diseases, 286 Specific Communicable Diseases, 286 Tuberculosis (Phtisis, Consumption disease, Koch's disease), 286 Mosquito-bone diseases, 291 Scanned with CamScannerSexually transmitted infections, 295 Schistosomiasis (Snail fever, Bitharziasis), 298 Rabies (Hydrophobia, Lyssa), 298 Leptospirosis (Canicola, Weils disease), 299 Leprosy (Hansenosis, Hansen's disease, Leontiasis), 299 Laws for the Control Of Communicable Diseases, 301 Summary, 303 Chapter 13 Environmental Health Introduction, 306 Environmental Health Records Management, 307 Solid Waste Management, 309 Water Sanitation, 311 Emergency water treatment, 312 Air Purity, 313, Toxic And Hazardous Waste Control, 318. Food Safety, 318 Sanitation, 319 Vermin and Vector Control, 322 Built Environments, 322 Summary, 323 Chapter 14 Disaster Management Disaster Definitions, 328 ‘Types of disasters, 328 Characteristics of disasters, 332 Frequency, 332 Predictability, 333 Preventability, 333 Imminence, 334 Scope and number of casualties, 336 Intensity, 336 Disaster management, 336 Disaster management stages, 337 Governmental responsibilities, 344 iblic health system, 345 Philippine Red Cross, 345 ‘The National Disaster Risk Reduction and Management Plan, 346 Incident Command System, 348 Responses to a Disaster, 351 Jommunity responses to a disaster, 351 Common individual reactions to a disaster, 351 Summary, 352 UNIT 5 INFORMATION TECHNOLOGY AND COMMUNITY HEALTH Chapter 15 eHealth in the Community Setting Introduction, 357 What is eFfealth?, 358 The power of data and information, 359 Good data qualities, 361 eHealth Situation in the Philippines, 361 Factors affecting eHealth in the country, 362 Using eHealth in the Community, 364 Universal Health Care and ICT, 364 Electronic medical records, 365 Telemedicine, 366 eLearning, 366 Examples of eHealth projects in the community, 367 Roles of Community Health Nurses in eHealth, 367 Data and records manager, 367 Change agent, 367 Educator, 370 Telepresenter, 370 Client advocate, 370 Researcher, 370 Summary, 370 Scanned with CamScannerUNIT 6 OTHER COMMUNITY HEALTH SETTINGS _ Chapter 16 School Health Historical Development of School Health Programs, 377 School Health Services, 378 Health education, 378 Physical education, 380 Health services, 380 Nutrition, 382 Counseling, psychological, and social services, 383 Healthy school environment, 385 Health promotion for school staff, 385 Family and community involvement, 386 School Nursing Practice, 388 Future Issues Affecting the School Nurse, 388 Summary, 390 Chapter 17 Occupational Safety and Health Introduction, 394 Evolution of Occupational Health Nursing in the Philippines, 395 Occupational Health Strategies: Assessment and Control of Hazards in the Workplace, 396 Framework and Scope of Occupational Health ‘Nursing Practice, 397 xvi Levels of Preventive Care and Occupational Health Nursing, 400 Primary prevention, 400 Secondary prevention, 402 Tertiary prevention, 403 Skills and Competencies of the Occupational Health Nurse, 404 Competent, 405 Proficient, 405 Expert, 405 Examples of skills and competencies for occupational health nursing, 405 non Occupational Impact of Legis! Health, 407 Working conditions and rest periods, 408, Medical, dental, and occupational safety, 408 Compensation, 409 Working conditions for special groups of employees, 410 ‘Trends and Issues Concerning Occupational Health, 410 Ethical insights: Confidentiality of employee health information, 413 Case study: Application of the nursing process, 414 Summary, 416 Appendices, 419 Index, 435 Scanned with CamScannerUnit Bill Introduction to Community Health Nursing Chapter 1: Fundamental Concepts of Community Health Nursing Scanned with CamScannerOr lelcae 1 Fundamental Concepts of Community Health Nursing Melanie McEwen, Mary A. Nies, Zenaida U. Famorca Re adiie eu LL Le Definitions of Health and Community Health ‘Community Determinants of Health and Disease Indicators of Health and Illness Definition and Focus of Public Health and Community Health Preventive Approach to Health Health promotion and levels of prevention Thinking upstream: Examining the root causes of poor health Definition and Focus of Community Health Nursing, Public Health Nursing, and Community-Based Nursing ‘Community and public health nursing Community-based nursing Distinguishing features of community health nursing Population-Focused Approach and Community Health Nursing Interventions Levels of Clientele of the Community Health Nurse The Intervention Wheel The prepayment mechanism in community health nursing practice Emerging Fields of Community Health Nursing in the Philippines Competency Standards in Community Health Nursing History of Public Health and Public Health Nursing in the Philippines Summary OBJECTIVES Upon completion of this chapter, the reader should be able to: 1. Define health and community. 2. Discuss the focus of public health 3. List the three levels of prevention, and give one example of each. 4. Explain the differencesamong community health nursing, public health nursing and community-based nursing. 5. Cite the distinguishing features of community health nursing, 6. Discuss public health nursing practice in terms of public health’s core functions and essential public health functions. 7. Compare the different fields of community health nursing practice. 8. Apply the competency standards of nursing practice in the Philippines in community health nursing practice. Scanned with CamScanner9. Discuss community health nursing interventions based on the Intervention Wheel 10. Outline the historical development of public health and public health nursing in the Philippines aggregates community health community health nursi developmental service disease prevention EntrepreNurse faith community nursing health health promotion home health care hospice care population population-focused nursing prepayment mechanism. primary prevention public health public health nursing secondary prevention tertiary prevention Community health nurses are in a position to assist in the transition of the Philippine health care system from a disease-oriented system to a health-oriented system, The budgetary allocation for health care is relatively small. In 2011, for example, the budget of the Department of Health accounted for only about 2% of the total national budget. Because of the devolution of basic government services, local government units augment the national budget to an undetermined extent. Nevertheless, this scenario requires strategies that will allow maximization of limited resources Community health activities focusing on health promotion and disease prevention are therefore of the essence. 4 Yt Considering the high cost of the cate of th sick, to which a considerably large Portion Of the health budget goes, Philippin, health indicators have remained marked}, below the health indicators of many othe, countries, From 1960 to 2005, the leading causes of morbidity in the Philippines hays mostly been infectious, preventable disease, Within the same period, the leading cause, of mortality have remained a mixture of nfectious diseases and noncommunicable lifestyle diseases, such as heart and vascular conditions and malignant neoplasms. These data reflect the general living conditions in the country as well as the severe disproportion of funding for preventive services and social and economic opportunities. Furthermore the health status of the population within the Philippines varies markedly across areas of the country and among groups. For example the economically disadvantaged and. many cultural and ethnic groups have poorer overall health status compared with Filipinos who belong to the upper socioeconomic classes Nurses constitute a large group of health care workers; therefore, they are in a position to create a health care delivery system that will meet the health-oriented needs of the people. Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal o! community health nursing is to preserve the health of the community and surrounding populations by focusing on health promotio® and health maintenance of _ individu! families, and groups within the commun Thus, community/public health nursing * associated with health and the identificatio® of populations at risk rather than with 2 episodic response to patient demand. The mission of public health is soci that entitles all people to basic necessit® such as adequate income and he! protection, and accepts collective burdet to make this possible, Public health, witt egalitarian tradition and vision, conflicts al justice Scanned with CamScannerthe predominant model of market justice that only entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. The tendency of the economically able private health sector to focus on high-level technology and curative medical services within the market justice system has stifled the evolution of a health system designed to protect and preserve the health of the population, There is a need for an ethic of social justice, for it is society's responsibility, rather than the individual's, to meet the basic needs of all people. Thus, there is a need for public funding of prevention efforts to enhance the health of our population Because of the rising prevalence of chronic lifestyle diseases, the Philippine health policy advocates changes in personal behaviors that might predispose individuals to chronic disease or accident. This policy promotes exercise, healthy eating, tobacco cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens the focus on collective behaviors necessary to change the determinants of health stemming from such factors as air and water pollution, workplace hazards, and unequal access to health care. Because living arrangements, work/school _ environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, that will positively influence the health of the entire population Community and public health therefore, must align themselves with public health programs that promote and preserve the health of populations by influencing sociocultural issues such as human rights, homelessness, violence, and stigma of illness. This allows nurses to be positioned to Promote the health, welfare, and safety of all individuals. nurs DEFINITIONS OF HEALTH AND COMMUNITY Health The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms, rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and is used in the context of units of people in communities who interact with each other. “Social health” connotes community vitality and is a result of positive interaction among groups within the community with an emphasis on health promotion and illness prevention. For example, community groups may sponsor feeding programs in churches and civic organizations to help alleviate problems with hunger and nutrition, Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health. In the mid 1980s, the WHO (1986, p. 73) expanded the definition of health to include a Scanned with CamScanneration of the following socialized conceptual health: The extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, and physical capacities. Saylor (2004) pointed out that the WHO definition considers several dimensions of health. These include physical (structure/ function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macro perspective, as a resource to be used rather than a goal in and of itself. Nursing literature contains many varied definitions of health. For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray et al., 2009, p. 53); “actualization of inherent and acquired human potential through goal- directed behavior, competent self-care, and satisfying relationships with others” (Pender et al., 2006, p. 22); and “a state of a person that is characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 2001) ‘The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, respons or behaviors possessing “soundness,” “wholeness,” and/or ‘well-being’. Problems may arise when the definition involves a unit of analysis. For example, some authors use the individual or “person” as the unit of analysis and exclude the community, Others may include additional concepts such as adaptation nent in health definitions ang and environ nt as static and ronme! then present the environt requiring human adaptation, rather than as changing and enabling human modification For many years, community and public health nurses have favored Dunn's (1961) asic concept of wellness, in which family jety, and environment are interrelated and have an impact on health from his viewpoint, illness, health, and peak wellness are on a continuum health is fluid wnd changing. Consequently, within a social environment, the state of health depends ‘on the goals, potentials, and performance of individuals, families, communities, and societies Community The definitions of community are numerous and variable. Baldwin et al. (1998) outlined the evolution of the definition of community by examining definitions that appeared in community health nursing texts. They determined that, before 1996, definitions of community focused on geographical boundaries, combined with social attributes of people. Through citing several sources from the later part of the decade, the authors observed that geographical location became a secondary characteristic in the discussion of what defines a community. In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging’ (Allender et al., 2009, p. 6); “a group of people who share something in common and interact with one another, who may exhibit ¢ commitment with one another and may share @ geographic boundary” (Lundy and Janes 2009, p. 16); “a group of people who share common interests, who interact with each other, and who function collectively within defined social structure to address common concerns” (Clark, 2008, p. 27); and “a locality- cl commu y, soc also Scanned with CamScannerbased entity, composed of systems of formal organizations reflecting society's institutions, informal groups and aggregates” (Shuster and Goeppinger, 2008, p. 344). Maurer and Smith (2009) further addressed the concept of community and identified four defining attributes: (1) people, (2) place, (3) interaction, and (4) common characte- ristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of locality-based individuals, interacting in social units and sharing common characteristics, values, and/or goals. Maurer and Smith (2009) noted that there are two main types of communities: geo- political communities and phenomenological communities. Geopolitical communities interests, are most waditionally recognized or imagined when considering the term community. Geopolitical communities are defined or formed by both natural and man- made boundaries and include barangays, municipalities, cities, provinces, regions, and nations. Other commonly recognized geopolitical communities are congressional districts and neighborhoods. Geopolitical communities may also be called territorial communities. Phenomenological communities, on the other hand, refer to relational, interactive groups, in which the place or setting is more abstract, and people share a group perspective or identity based on culture, values, history, interests, and goals. Examples of phenomenological communities include schools, colleges, and universities; churches, and mosques; and various groups or organizations. These communities may also be described as functional communities. A community of solution is a type of phenomenological community, and is a collection of people who form a group specifically to address a common need or concern. The Gawad Kalinga, whose members aim to alleviate poverty by community development, and a group of indigenous people who lobby against environmental degradation of their ancestral land are examples. These groups or social units work together to realize a level of potential “health” and to address identified actual and potential health threats and health needs. Population and aggregate are related terms that are often used in public health and community health nursing. Population is typically used to denote a group of people having common personal or environmental characteristics. It can also refer to all of the people in a defined community (Maurer and Smith, 2009). Aggregates are subgroups or subpopulations that have some common characteristics. or concerns (Clark, 2008). These common characteristics or concerns may make the members of an aggregate vulnerable to similar health problems. Examples of aggregates are age groups or groups undergoing similar __ physiologic processes like pregnancy and menopause. Depending on the situation, needs, and practice parameters, community health nursing interventions may be directed toward a community (eg., residents of a small town), a population (eg., all elders in a rural region), or an aggregate (e.g, pregnant teens within a school district). DETERMINANTS OF HEALTH SS ; Ai AND DISEASE in The health status of a community is associated with a number of factors such as health care access, economic conditions, social and environmental issues, and cultural practices. It is essential for the community health nurse to understand the determinants of health and recognize the interaction of. the factors that lead to disease, death, and disability, The World Health Organization states that the health or lack of health of individuals depends on the context of their lives. WHO cites the social and economic environment, the physical environment, 7 Scanned with CamScannerand the person's individual characteristics and behaviors as determinants of health. The following determinants are specifically mentioned, with a corresponding short explanation on how they affect health: + Income and social status ~ higher income and social status are linked to better health. ‘The greater the gap between the richest and poorest people, the greater the differences in health + Education - low education levels are linked with poor health, more stress and lower self-confidence. * Physical environment - safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. © Employment and working conditions = people in employment are healthier, particularly those who have control over their working conditions. * Social support networks - greater support from families, friends and communities is linked to better health. * Culture — customs and traditions, and the beliefs of the family and community all affect health. * Genetics - inheritance plays a part in determining lifespan, healthiness and the ‘likelihood of developing illnesses * Personal behavior and coping skills — balanced eating, keeping active, smoking, drinking, and how we deal with life's stresses and challenges all affect health * Health services ~ access and use of services that prevent and treat disease influences health. * Gender - men and women suffer from different types of diseases at different ages In the Philippines, this is evident in the leading causes of death during the past six decades. Indeed, the individual's biology and behaviors influence health through their interaction with each other and with the individual's social and physical environments, In addition, policies and interventions ¢, improve health by targeting detrimenty, or harmful factors related 0 individual, and their environment. In a seminal wor, McGinnis and Foege (1993) described wha, ctual causes of death” in the United States. Leading the list were smoking diet and activity patterns, and alcoho} Although all of these causes of mortality are related to individual lifestyle choices, they can, also be strongly influenced by population, focused policy efforts and education. For example, concerns about the prevalence of micronutrient deficiencies in vulnerable groups have led to population-based measures to address the issue such as food fortification Community and public health nurses should understand these concepts and appreciate that health and_ illness are influenced by a web of factors, some that can be changed (eg,, individual behaviors such as tobacco use, diet, activity) and some that cannot (eg. genetics, age, gender). Other factors (¢.g., physical and social environment) will require changes that may need to be accomplished from a policy perspective Community health nurses must work with policy makers and community leaders to identify patterns of disease and death and to advocate for activities and policies that Promote health at the individual, family, and community levels. they termed “a INDICATORS OF HEALTH AND ILLNESS SS pet eae A variety of health indicators are used by health providers, policy makers, and yommunity health nurses to measure the health of the community. The National Epidemiology Center of the Department of Health, the National Statistics Office, and local health centers/offices/departments provide morbidity, mortality, and other health status- related data. Local health centers/offices/ Scanned with CamScannerdepartments are responsible for collecting morbidity and mortality data and forwarding the information to the higher level health facility, such as the Provincial Health Office. Some of the more commonly reported indicators are life expectancy, infant mortality, maternal mortality, age-adjusted death rates, and disease incidence rates. Indicators of mortality illustrate the health status of a community and/or population because changes in mortality reflect a number of social, economic, health service, and related trends (Torrens, 2008). These data may be useful in analyzing health patterns over time, comparing communities from different geographical regions, or comparing different aggregates within a community. Community health nurses should be aware of health patterns and health indicators within their practice. Nurses should ask many questions, including the following: What are the leading causes of death and disease among various groups served? How do infant mortality rates and maternal mortality rates in this community compare with national and regional rates? What are the most serious communicable disease threats? What are the most common environmental risks? The community health nurse may identify areas for further investigation and_ inter- vention through an understanding of health, disease, and mortality patterns. For example, the school nurse learns that the incidence rate of severe acute diarrhea in the community higher than national average. Working with school officials, parents and students, the nurse addresses this problem.,. Likewise, if occupational health nurses discover an apparent high rate of chronic lung disease in an industrial facility, they should work with company management, employees, and health officials to identify potential harmful sources. The nurses should then participate in investigative efforts to determine what is precipitating the increased disease rate and work to remedy the identified threats or risks, DEFINITION AND FOCUS OF PUBLIC HEALTH AND COMMUNITY HEALTH C. E. Winslow is known for the following classic definition of public health “Public health is the science and art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for 1, sanitation of the environment, 2. control of communicable infections, 3. education of the individual in personal hygiene, 4. organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and 5. 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, 1960, p. 23), ‘A key phrase in this definition of public health is “through organized community effort”. The term public health connotes organized, legislated, and tax-supported efforts that serve all people through health departments or related governmental agencies. Its purpose is to improve the health of the public by promoting healthy lifestyles, preventing disease and injury, and protecting the health of communities In a key action, the Institute of Medicine of the United States (1988) identified the following three primary functions of public health: assessment, assurance, and _ policy development, Box 1.1 depicts each of the three primary functions and describes them briefly. All nurses working in community settings should develop knowledge and skills related to each of these primary functions. Public health efforts focus on prevention and promotion of population health at the Scanned with CamScannerAssessment: Regular collection, analysis, and information sharing about health conditions, risks, and resources in a community Policy development: Use of information gathered during assessment to develop local and state health policies and to direct resources toward those policies. Assurance: Focuses on the availability of necessary health services throughout the community. It includes maintaining the ability of both public health agencies and private providers to manage day-to-day operations and having the capacity to respond to critical situations and emergencies. From Institute of Medicine. The future of public health, Washington, DC, 198, National Academy Press. national and local levels. These efforts at the national level concentrate on providing support and advisory services to public health structures at the local level. The local level structures provide direct services to communities through two avenues: * Environmental health services, which Protect the public from hazards such as Polluted water and air and tainted food * Personal health care services such” ag immunization and family planning services, well-infant and mateme care, and teatment-prevalent health conditions, both communicable and noncommunicable. Personal health services Public health effort and often target. the Populations most at risk and in need of services. Public health efforts are multi- disciplinary because they require people with many different skills, Community health nurses work with a diverse team of Public health professionals, including health May be part of the 10 officers, midwives, and sanitation inspecto,, Public health science methods that Sse 55 biostatistics, epidemiology, and population needs provide a method of “measuri, characteristics and health indicators ang disease patterns within a community. In 2995 based on a three-country study, the Worig Health Organization Regional Office for ti, Western Pacific drafted a list of nine esse public health functions (Box 1.2) The term community health extends the realm of public health to include organize health efforts at the community Jey through both government and private effons Participants include privately funded agencies such as the Philippine Cancer Society or the Philippine Red Cross. A variety of private Public structures serve communi efforts. ‘tial and health Health situation monitoring and analysis Epidemiological surveillance/disease Prevention and control Development of policies and planning in Public health Strategic management of health systems and services for population health gain Regulation and enforcement to protect public health Human resources in public health Health promotion, empowerment Ensuring the Population-base Research, devel Of innovative p development and planning social participation, and Quality of personal and cd health service lopment, and implementation Uublic health solutions from Regional Office fora Pacific Region, World Health Grae eos li lealth Organization, 2003. Essential ring ealth functions 9 three-country study re Western Pacit : bic health functions SH Region: 9 essential pu Scanned with CamScannerPREVENTIVE APPROACH TO HEALTH Health promotion and levels of prevention Contrasting with “medical care,” which focuses on disease management and “cure,” public health efforts focus on health promotion and disease prevention. Health promotion activities. enhance resources directed at improving well-being, whereas disease prevention activities protect people from disease and the effects of disease. Leavell and Clark (1958) identified three levels of prevention commonly described in nursing. practice: primary prevention, secondary prevention, and tertiary prevention (Figure 1.1 and Table 1.1). Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Examples of _ primary prevention include promotion of good nutrition, provision of adequate shelter, and encouraging regular exercise. Specific protection efforts reduce or eliminate risk factors and include such measures as mmunization and water purification (Keller et al., 2004a; McEwen and Pullis, 2008). Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Secondary prevention is implemented after a problem has begun but before signs and symptoms appear and targets those populations who have risk factors (Keller et al, 2004a). Mammography, blood pressure screening, newborn screening, and mass sputum examination for pulmonary tuberculosis are examples of secondary Prevention Activities Prevention of problems before they occur Example: Immunization level 2 Secondary Prevention Activities Early detection and intervention ‘Example: Screening for sexually transmitted disease Level 3 Tertiary Prevention Activities Correction and prevention of deterioration of a disease state Example: Teaching insulin administration in the home Figure 1.1 The three levels of prevention. " Scanned with CamScannerTable 1.1 Examples of Levels of Prevention and Clients Served in The Community LEVEL OF PREVENTION DEFINITION OF CLIENT SERVED* Individual Family (two or more individuals bound by kinship, law, or living arrangement and with common emotional ties and obligations) Group or aggregate (interacting people with a common purpose or purposes) Community and Population (aggregate of People sharing space over time within @ social system; population groups or aggregates with power relations and common needs or purposes) for example, families may be referr within a community, 12 _ Scanned with CamScanner Primary (health promotion and specific prevention) Dietary teaching during pregnancy Immunizations Education or counseling regarding smoking, dental care, or nutrition Adequate housing Mothers’ class on breastfeeding Education for drug abuse Prevention for high school students Fluoride water supplementation Environmental sanitation Removal of environmental hazards Secondary (early diagnosis and treatment) HIV testing Screening for cervical cancer Dental examinations Diabetes screening for family at risk Vision screening of first-grade class Mass sputum examination in a low-income neighborhood Hearing tests at a center for the elderly Organized screening programs for communities (e.g, health fairs) VORL screening for marriage license applicants in a city Tertiary (limitation of disability and rehabilitation) Teaching new clients with diabetes how to administer insulin Exercise therapy after stroke Skin care for incontinent patients Mental health counseling or referral for family in crisis (e.g., grieving or experiencing a marital conflict) Dietary instructions and monitoring for family with overweight members Group counseling for grade school children with asthma Exercise program for diabetics at a center for the elderly Alcoholics Anonymous and other self-help groups Mental health services for military veterans Shelter and relocation centers for fire, typhoon, or earthquake victims Emergency medical services Community mental health services for chronically mentally ill Home care services for lear-cut definitions; ‘ed to a5 an aggregate, and a population and subpopulations may existprevention. Secondary prevention is also directed toward prompt intervention to prevent worsening conditions of the affected population. This includes measures during the early stage of disease to prevent complicati Teaching a mother how to give Oresol (a salt and sugar solution) to her child suffering from diarrhea to prevent dehydration and administering vitamin A capsules to children with measles are examples. Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation: Aims of tertiary prevention are to reduce the effects of disease and injury and to estore individuals to their optimal level of functioning (Keller et al., 2004b; McEwen and Pullis, 2008). Examples include teaching how to perform insulin injection techniques and disease management to a patient with diabetes, referring a patient with spinal cord injury for occupational and physical therapy, and leading a support group for cancer patients who have undergone cancer treatment, such as surgery, chemotherapy, and/or radiation therapy. Much of community health nursing practice is directed toward preventing the progression of disease at the earliest period or phase feasible using the appropriate level(s) of prevention. For example, when applying “levels of prevention” concerning malnutrition among young children in a community, a nurse might perform the following interventions: * Educate pregnant women on the benefits of breastfeeding (primary prevention), * Conduct periodic Operation Timbang (secondary prevention) * Provide nutrition education to mothers of children with severe malnutrition (tertiary prevention) ‘The concepts of prevention and population- focused care figure prominently in a con- ceptual orientation to nursing practice referred to as “thinking upstream’. Thinking upstream: Examining the root causes of poor health I am standing by the shore of a swiftly flowing river and hear the cry of a drowning ‘man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. 1 jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. [lift her out onto the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with ‘great effort I eventually pull him to shore. 1 lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in... (Adapted from a story told by Irving Zola as cited in McKinlay JB, 2008. A case for refocusing upstream: the political economy of illness. In: P. Conrad, Ed. ‘The sociology of health and illness: critical perspectives, pp. 578-591, Macmillan: New York, NY.) In his description of the frustrations in medical practice, McKinlay (1979) used the image of a swiftly flowing river to represent illness. In this analogy, doctors are so busy rescuing victims from the river that they fail to look upstream to see who is pushing patients into the perilous waters, There are many things that could cause a patient to fall (get pushed) into the waters of illness, such as 8 Scanned with CamScannertobacco company products, companies that profit from selling products high in saturated fats, the alcoholic beverage industry, the beauty industry, exposure to environmental toxins, or occupationally induced illnesses. Manufacturers of illness are what push clients into the river. Further, McKinlay instructed health providers to refocus their efforts toward preventive and “upstream” activiti In a description of the daily challenges of providers to address health from a preventive versus curative focus, McKinlay differentiates the consequences of (downstream endeavors) from its precursors (upstream endeavors). The author then charges health providers to critically examine the relative weight of their activities illness response versus the prevention of illness. By examining the origins of disease, nurses identify social, political, environmental, and economic factors that often lead to poor health options for both individuals and populations. The call to refocus the efforts of nurses “upstream, where the real problems lie” (McKinlay, 1979) has been welcomed by community health nurses in a variety of practice settings. For these nurses, this theme provides affirmation of their daily efforts to prevent disease in populations at risk in schools, work sites, and clinics throughout their local communities and in the larger world. illness toward Inequities: Distribution of Resources In the United States, inequities in the distribution of resources pose a threat to the common good and a challenge for community and public health nurses. Factors that contribute to wide variations in health disparities include education, income, and occupation. Lack of health insurance is a key factor in this issue, as about 20% of nonelderly adults and 25% of children in the United States are uninsured, Lack of insurance is damaging to population health, as low- income, uninsured individuals are much less 4 oF likely than nonpoor, insured individuals , receive timely physical examinations 4,4 preventive dental care. Public health nurses are regularly confronty with the consequences of the fragmentey health care delivery system. They diligeny, work to. improve the circumstances f., populations who have not had adequay Fecess to resources largely because of who they are and where they live Ethical questions commonly encountered in community and public health nursing practice clude the following: Should resources (eg free or low-cost immunizations) be offered to all, even those who have insurance that will pay for the care? Should public health nurses serve anyone who meets financial need guidelines, regardless of medical need? Should the health department provide flu shots to persons of all ages or just those most likely to be severely affected by the disease? Should illegal aliens or persons working on “green cards” receive the same level of health care services that are available to citizens? Social justice in health care is a goal for al. To this end, community and public health nurses must face the challenges and dilemmas related to these and other questions as they assist individuals, families, and communities to deal with the uneven distribution of health resources (Ervin, 2004). [Note: The conditions cited in this article are US-based. But similar circumstances and ethical questions may well be asked by community health workers in the Philippines! DEFINITION AND FOCUS OF COMMUNITY HEALTH NURSING, PUBLIC HEALTH NURSING, AND Seeeescae gene The terms community health nursing public health nursing are often. synonyme™ or interchangeable. Like the practice ° community/public health nursing terms are evolving, In the past debates Scanned with CamScannerdiscussions, definitions of “community health nursing” and “public health nursing” indicate similar yet distinctive ideologies, visions, or philosophies of nursing, For purposes of clarity and in the context of the Philippine situation, this book will use these terms as some nursing authors do: referring to community health nursing as a global or umbrella term and public health nursing as a component or subset These concepts and a third related term— community-based nursing— section. are discussed in this Community and public health nursing In 1980, the American Nurses Association (ANA) defined community health nursing as “the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations” (p. 2) This viewpoint noted that a community health nurse directs care to individuals, families, ‘or groups; this care, in tur, contributes to the health of the total population. Community health nursing is considered to be a broader and more general specialty area that encompasses subspecialties that include public health nursing, school nursing, occupational health nursing, and other developing fields of practice, such as home health, hospice care, and independent nurse practice. Public health nursing has frequently been described as the synthesis of public health and nursing practice. Freeman (1963, p, 34) provided a classic definition of public health nursing: Public health nursing may be defined as 4 field of professional practice in nursing and in public health in which technical nursing, interpersonal, analytical, and organizational skills are applied to problems of health as they affect the community, These skills are applied in concert with those of other persons engaged in health care, through comprehensive nursing care of families and other groups and through measures for evaluation or control of threats to health, for health education of the public, and for mobilization of the public for health action. In the Philippines, to this day, “public health nursing” is seen as a subspecialty nursing practice generally delivered within “official” or governmental agencies. Recently, the ANA has revised the standards of practice for this specialty area (ANA, 2007). In the updated standards, the ANA used the definition presented by the American Public Health Association’s Committee on Public Health Nursing (1996). Thus, public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (ANA; American Public Health Association, 1996, p. 5). The ANA (2007) elaborated by explaining that public health nursing practice “is population- focused, with the goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy” (p. 5). Community and public health nurses practice disease prevention and_ health promotion. It is important to note that community health nursing practice is collaborative and is based in research and theory. It applies the nursing process to the care of individuals, families, aggregates, and community. Table 1.2 presents the Standards for Public Health Nursing as formulated by the ANA (2007). Community-based nursing ‘The term community-based nursing has been identified and defined in recent years to differentiate it from what has traditionally been seen as community and public health nursing practice. Community-based nursing practice refers to “application of the nursing process in caring for individuals, families and groups where they live, work or go to Scanned with CamScannerTable 1.2 Standards of pul Standards of care health nursing practice Standard 1. Assessment The public health nurse collects comprehensive data pertinent to the health status of populations. Standard 2. Population diagnosis and priorities The public health nurse analyzes the assessment data to determine the population diagnoses and priorities. Standard 3. Outcomes identification The public health nurse identifies expected outcomes for a plan that is based on population diagnoses and priorities. Standard 4. Planning The public health nurse develops a plan that reflects best practices by identifying strategies, action plans, and alternatives to attain expected outcomes, Standard 5. Implementation The public health nurse implements the identified plan by partnering with others. a. Coordination Coordinates programs, services, and other activities to implement the identified plan. . Health education and health promotion Employs multiple strategies to promote health, prevent disease, and ensure a safe environment for populations. c. Consultation Provides consultation to various community groups and officials to facilitate the implementation of programs and services d. Regulatory activities Identifies, interprets, and implements public health laws, regulations, and policies Standard 6. Evaluation The public health nurse evaluates the health status of the population Standards of professional performance Standard 7. Quality of practice The public health nurse systematically enhances the quality and effectiveness of nursing practice Standard 8. Education The public health nurse attains knowledge and competency that reflects current nursing and public health practice Standard 9. Professional practice evaluation The public health nurse evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations. Standard 10. Collegiality and professional relationships The public health nurse establishes collegial partnerships while interacting with representatives of the population, organizations, and health and human services professionals, and contributes to the professional development of peers, students, colleagues, and othe Standard 11. Collaboration The public health nurse collaborates with the representatives of the population, organizations, and health and human services professionals in providing for and promoting the health of the population. Standard 12. Ethics The public health nurse integrates ethical provisions in all areas of practice. Standard 13. Research The public health nurse integrates research findings in practice 16 Conined —_ Scanned with CamScannerTable 1.2 Standards of public health nursing practice — cont'd Standard 14. Resource utilization population The public health nurse considers factors related to safety, effectiveness, cost, and impact on practice and in the planning and delivery of nursing and public health programs, policies, and services. Standard 15. Leadership health, The public health nurse provides leadership in nursing and public Source: ANA, 2007. © 2007 by American Nurses Association. Reprinted with permission. All rights reserved school or as they move through the health care system” (McEwen and Pullis, 2008, p. 6). Community-based nursing is setting-specific, and the emphasis is on acute and chronic care and includes practice areas such as home health nursing and nursing in outpatient or ambulatory settings. Zotti et al. (1996) compared community- based nursing and community health nursing and explained that the goals of the two are different. Community health nursing emphasizes preservation and _ protection of health, and community-based nursing emphasizes managing acute or chronic conditions. In community health nursing, the primary client is the community; in community-based nursing, the primary clients are the individual and the family. Finally, services in community-based nursing are largely direct, whereas in community health nursing, services are both direct and indirect. Distinguishing Features of Community Health Nursing Practice In addition to its preventive approach to health, community health nursing is characterized by its being population or aggregate-focused, its developmental nature, and the existence of a prepayment mechanism for consumers of community health nursing services. Also, unlike nurses who work in hospital settings, community health nurses care for different levels of clientele. POPULATION-FOCUSED APPROACH AND COMMUNITY HEALTH NURSING INTERVENTIONS Ee ee eee eee Community health nurses must use a population-focused approach to move beyond providing direct care to individuals and families. Population-focused nursing concentrates on specific groups of people and focuses on health promotion and disease prevention, regardless of geographical location (Baldwin et al., 1998). In short, population focused practice (Minnesota Department of Health, 2003): ‘Focuses on the entire population, * Is based on assessment of the populations’ health status, © Considers the broad determinants of health, © Emphasizes all levels of prevention, and © Intervenes with communities, systems, individuals, and families Whereas community health nurses may be responsible for a specific subpopulation in the community (eg. a school nurse may be responsible for students enrolled in an elementary school), population-focused practice is concerned with many distinct and overlapping community — subpopulations. The goal of population-focused nursing is to promote healthy communities. Population-focused community _ health nurses would not have exclusive interest in one or two subpopulations but would focus on the many subpopulations that make up the 0 Scanned with CamScannerentire community. A population focus involves concern for those who do, and for those who, do not, receive health services. Nonusers of Preventive services often develop conditions that require high-cost care, It is therefore necessary that health workers develop strategies to reach out to them. A population focus also involves a scientific approach to community health nursing: community assessment and diagnosis are necessary and basic to planning, intervention, and evaluation for the individual, family, aggregate, and population levels. Community health nursing practice requires the following types of data for scientific approach and population focus: (1) the epidemiology, or body of knowledge, of a particular problem and its solution and (2) information about the community. Each type of knowledge and its source appear in Table 1.3. To determine the overall patterns of health in a population, data collection for assessment and management decisions within a community should be ongoing, not episodic, In addition to interviewing clients and assessing individual and family health, community health nurses must be able to assess an aggregate’s health needs and resources and identify its values. Community health nurses must also work with the community to identify and implement OY programs that meet health needs ang evaluate the effectiveness of programs after implementation. For example, school nurses were once only responsible for dealing with emergency health conditions. Now they are actively involved in assessing the needs of their population and defining programs to meet those needs through activities such as health screening and group health education and promotion. The activities of school nurses, may be as varied as designing health curricula with a school and community advisory group, leading support groups for elementary school children with chronic illness, and monitoring the health status of vulnerable school children. Similarly, occupational health nurses are no longer required to simply maintain an office or dispensary. They are involved in many different types of activities. These activities might include maintaining records of workers exposed to physical or chemical risks, moni- toring compliance with occupational health safety standards, teaching classes on health issues, and leading support group discussions for workers with health-related problems. Private associations and nongovernmental organizations (NGOs) employ community health nurses for organizational ability and health-related skill. Table 1.3. Information useful for population focus Type of information Examples Sources Demographic data Age, gender, race/ethnicity, socio- economic status, education level Vital statistic data (national, regional, local); census Groups at high risk those with disabilities) Health status and health indicators of various subpopulations in the community (e.g., children, elders, Health statistics (morbidity, Mortality, natality); disease Statistics (incidence and prevalence) Services/providers available Official (public) health departments, health care providers for low-income individuals and families, community service agencies and organizations (e.g., Red Cross) City directories, phone books, local or regional social workers, lists of low-income providers, local community health nurses (e.9., schoo! nurses) Scanned with CamScannerLEVELS OF CLIENTELE OF THE (COMMUNITY HEALTH NURSE Community health nurses focus on the care of several levels of clientele: the individual, the family, the group/aggregate, and the community as a whole in many settings, including homes, dlinics, and schools. Because most people belong to a family and their health is strongly influenced by the home situation, the family is considered the basic unit of care in community health nursing. The nurse in the clinic or health center focuses on the individual client. Still, the nurse has to interview the client on family health, considering the health status of the other members of the family, the values and behavior of the family members in relation to health, and the psychosocial and physical environment in the home. While teaching a group or aggregate of first- time pregnant women about infant care, the nurse must bear in mind the family situation of the women in the group. Likewise, the nurse conducting a class for diabetic clients is responding to the needs of a group or aggregate. When the nurse uses community organizing as a strategy for health promotion and disease prevention, the focus of care is the entire community. For community analysis, however, the nurse conducts interviews with families as the units of data collection. The Intervention Wheel The Public Health Intervention Model was initially proposed in the late 1990s by nurses from the Minnesota Department of Health to describe the breadth and scope of public health nursing practice (Keller et al., 1998) This model was later revised and termed the Intervention Wheel (Figure 1.2) (Keller et al., 2004a, 2004p), and it has become increasingly recognized as a framework for community and public health nursing practice. The Intervention Wheel contains important elements: (1) it is population- based; (2) it contains 3 levels of practice (community, systems, and individual/family); and (3) it identifies and defines 17 public health interventions. ‘The levels of practice and interventions are directed at improving population health (Keller et al., 2004a). Within the Intervention Wheel, the 17 health interventions are grouped into 5 “wedges” ‘These interventions are actions taken on behalf of communities, systems, individuals, and families to improve or protect health status. Table 1.4 provides definitions for these interventions. ‘The Intervention Wheel is further dissected into levels of practice in which the interventions may be directed at an entire population within a community, a system that would affect the health of a population, and/or the individuals and families within the population. Thus, each intervention can and should be applied at each level. For example, within the intervention “disease investigation”, a systems-level intervention might be the school nurse working with the local health department to coordinate a response to cases of measles in an elementary school. A population- or community-level intervention for “screening” would be when a public health nurse works with elementary schools in a School District to give each student a health profile to promote nutritional and physical activity lifestyle changes to improve health. Finally, an individual-level implementation of the intervention “referral and follow-up” would be a nurse who receives a referral to care for an individual with a positive result of sputum examination for tuberculosis who would require regular monitoring of his medication compliance to keep the patient from developing a drug-resistant form of the infection. The prepayment mechanism in community health nursing practice Although the developing fields of nursing practice, such as home health and hospice 19 Scanned with CamScanner