COLLEGE OF NURSING

MODULE 6: COMMUNITY AS A CLIENT

OVERVIEW OF THE MODULE:

This lesson is an introduction to community health nursing practice in providing
nursing intervention to a community. Specific discussions go around basic
concepts and definitions of community, community health, and community health
nursing. Skills in diagnosing a community is aimed to be develop through
introduction to basic approaches, tools and methodologies.

LEARNING OUTCOMES:
At the end of the lesson, student is expected to:
 Explain benefits of using theoretical models in CHN practice
 Apply a conceptual model to determine health of the community

OBJECTIVES:
 Describe roles of the nurse in providing community health nursing care to
the community as a client
 Profile a community using nursing tools
 Identify at least five health needs or health issues of a community
DISCUSSION:

Community or public health nursing is characterized by community-oriented,

population-focused care and is based on interpersonal relationships. In the event
that there is a dengue outbreak, as a community health nurse, the focus is not
limited to management of the dengue infected individuals, rather it includes wide
range of intervention to address the outbreak.

The nurse also: (1) uses disease-investigation skills to locate possible

sources of infection, (2) determines how the community’s knowledge, values,
beliefs, and prior experiences with infectious disease may influence its
interpretation of the disease, response to the outbreak, and treatment
preferences, (3) uses knowledge and suggestions gathered from the community
to develop, in collaboration with other health professionals, a community-specific
program to prevent future outbreaks (Allender J., Rector C., Warner K. 2014).

🔎 the situation explained above illustrates a community-oriented

intervention.
Community Orientation is a process that is actively shaped by the unique
experiences, knowledge, concerns, values, beliefs, and culture of a given
community.

Population Group. It refers to any group of people who share at least one
characteristic, such as age, gender, race, a particular risk factor, or disease.
🔎 Lesbian, Gay, Bisexual and Transgender (LGBT) community is a population
group. However, Lesbian can be taken out further as a separate population
group from the rest. (culture, characteristics and gender). Splitting them in
basis of age or sex, would also create a separate unique population group.

🔎 Prostate and liver cancer survivors are a cancer survivor population group;
however, prostate cancer survivors and liver cancer survivors can be split into
two separate population groups. (characteristics, disease, and risk factors)
 Community health nursing services can be effective if appropriate
measures are taken to address the emergence of population-focused health
issues. Paying attention to population groups enables the nurse to provide focus
on vulnerable populations such as: infants and young children, school age,
adolescents, mothers, males, and old people.

A population focus implies that a nurse uses population-based skills such

as epidemiology, research in community assessment, and community organizing
as the basis for interventions. Community-oriented, population-focused care
employs population-based skills and is shaped by the characteristics and needs
of a given community. Public health nurses provide community-oriented,
population-focused care when they count and interview homeless people
sleeping in a park and, based on these data, help develop a program to provide
food, clothing, shelter, health care, and job training for this population (Allender
J., Rector C., Warner K. 2014).

🔎 More examples:
A community health nurses pays attention to male population especially boys
at the age of 16-24 to find solutions to the alarming increase of sexually
transmitted infection among young males. Another example is a school nurse
developing nutrition and sanitation program for school children. These two
examples are applying nursing processes in a population-focused fashion by
focusing their attention to young males and school children respectively.

What are the dimensions of the community?

There are a number of ways on how to view a health community.

According to LeBan, one view is looking at the people, structure and process
(Allender J., Rector C., Warner K. 2014).

People. This refers to the state of health or status of the people in the
community. It includes health indicators such as mortality and morbidity data
which can define the physical, emotional, and other social determinants of health:
political, social, cultural, economic, environmental, and education.

Health Community Diagram

Social determinants of health can be identified by looking at the

peoples’ employment conditions, living conditions, level of social inclusion, public
health or primary health care programs, women and gender equity, early child
development, among others.

Structure. This refers to the resources and services which are available and
accessible in the community. This can be institutions which provides basic
services such as health, water, education, and social services. It also includes
community associations that provide opportunities for development and services
– such us community-based organizations, professional groups, and support
groups and services. Structure are measured through for example: number of
doctors, nurses, midwifes; number of available facilities; trained and skilled
health personnel; and, political support.

Process. This is the ability of the community to function effectively. In involves

functional systems within the community such as collaboration between peoples
and institutions, collaboration among subsystems, and linkages of the community
to local and national governments. The nurse can assess process by looking at
existing systems of collaboration, like the Service Delivery Network tackled on
the previous chapters – its strengths and weaknesses, opportunities and threats
(SWOT analysis).
Characteristics of a competent can:
 Collaborate effectively in identifying community needs
and problems
 Achieve a working consensus on goals and priorities
 Agree on ways and means to implement the agreed upon
goals
 Collaborate effectively to take the required actions.

Community Diagnosis
A process by which the nurse collects data about the community in order
to identify factors which may influence the deaths and illnesses of the population,
to formulate a community health nursing diagnosis and develop and implement
community health nursing interventions and strategies
Two Types of Community Diagnosis
Comprehensive Community Problem-oriented Community
Diagnosis Diagnosis

Aims to obtain general information Type of assessment responds to a

about the community particular need

Steps:

I. Preparatory Phase
1. Site selection – in site location, another perspective of social
determinants may apply: physical location, population and social systems.
 Physical Location
Boundary of the community.
The geographical makeup of
the community, its features,
resources and neighboring
community may be a basis in
measuring incidence of health
and wellness, strengths and
weakness and opportunities in
the community. Geographic
features and climate may
include swamp areas, volcanoes, coastal sites, incidence of typhoons and
floods etc. – areas that may either do potentially harm and injury, or
provide recreational and physical activities.

Social systems
Location of health services can be accounted for. Its accessibility and
level of the facility. Are these primary, secondary or tertiary health
facilities? Are there available mechanisms in making health services
available to the people? Political intervention also determines if health
and social services are a priority of local governments, and political will
of the people and its leader to engage in health investments in the
community level.

Population
Status of the people. What is the main source of income of the people in
the community? What is potential general need of the community? Is it a
young population, hence, health services for young people should be
strengthened? Or is the population are mostly elderly, hence, geriatric
services should be the focus?
2. Preparation of the community – In preparing the community, certain
courtesy protocols should be done. Again, we need to embrace the
community as an equal partner and make them feel valued as a co-
collaborator in the health initiatives.

Equally important is to find a focal person in the community. Who is the

community leader? Who are the influencers within the community? Who
is the community in general – its culture, beliefs, health practices?

3. Statement of the objectives – Prepare the basic purpose of the

community diagnosis.

Community diagnosis ultimate aim is to identify where the community is

now? where does it want to be? and how it will get there?

Where the community is now? In most situations, you can determine

that current status of the community through the utilization of secondary
data. Sources of data includes:
 Civil registration (Philippine Statistics Authority)
 Reports of field personnel (data in the rural health office)
 Other sources: such as reports conducted by private groups,
independent researchers, and researches by academic
communities that is located or serving the community

Where does it want to be? This is where the voices of the people in the
community comes in. They may want to know their current situation and
as a nurse, we can help facilitate processing of goal setting – therefore,
visualizing where the community wants to be in the next few months or
years.
 How will it get there? This question pertains to what are the resources in
the community, what are the strengths and capabilities of the people in
the community, what are opportunities that can be the focus of further
strengthening through training and education – and identifying these
elements should be realistic as possible.

4. Determine the data to be collected – Upon identifying the objectives,

you will be able to determine what exactly you want to know to be able to
understand the health situation of the community.

Being able to identify the data needed is helping you to develop what
questions to asks, know who are the people to look for, find the place
which needs to be investigated, and choose what methods to be used.

5. Identify and finalize methods, sample and instruments for data

collection – There are a number of methods and instruments for data
collection, like one on one interviews, conduct of surveys, and ocular
inspection.

Your method will depend on the data you need. It is your choice which
type of data will help you on your attempt to diagnose a community.

Qualitative vs. Quantitative

Qualitative
If you want to know about
experiences and meanings or
anything which cannot be
defined by numbers
Primary vs. Secondary
Primary
Quantitative
If you want to measure using
numerically and/or to develop a
more mechanistic understanding
of an issue
Secondary
 Direct from the source Available collected data

It’s important to know what is demography and how it can help you
understand the state of health of the community and its people.
Demography is the study of population size, composition and spatial
distribution as affected by major processes like births, deaths and
migration.

Sources of Demographic Data

1. Census – this is the complete enumeration of the population and
is available from credible sources such as the Philippine
Statistics Authority.
De jure De facto
People were assigned to the place People were assigned to the place
where they usually live regardless where they are physically present at the
of where they are at the time of time of census, regardless, of their usual
census. place of residence.
2. Continuing population registers – this is the daily records of
offices in charge of keeping records of births and deaths on a
daily basis. Most reliable source of such information are the civil
registrar offices in the local government units.
3. Other sources – there a number of government and private
agencies which also collect demographic data. Demographic
information such as education, employment and health can be
found in the National Demographic and Health Survey (NDSH),
while some information can be sourced out from Department of
Labor and Employment, Department of Health and Department
of Education.

Components of Demographic Data

1. Population size
 Natural increase = subtracting the number of deaths from
the number of births
(birth – death = natural increase)
  Rate of natural increase = subtracting the crude death rate
from the crude birth rate
(birth rate – death rate = rate of natural increase)

 Net migration = subtracting the number of persons leaving

(emigrants) from number of persons entering (immigrants) a
geographic area
(immigrants – emigrants = net migration)

2. Population Composition
 Sex ratio is the ratio of males to females in a population
Note: if the sex ration is 109, this means that the ratio of
males to females is 109:100 (109 males is to 100 females)
 Age-dependency ratio is the sum number of people below
15 years old and above 65 years old. This refers to the
number of people who are potentially or assumed dependent
population. This is computed by dividing the sum of the
dependents by number of people 16 to 64 years old.
(number of dependents or the sum of 15 years old and
below and 65 years old and above ÷ number of
population age of 16 to 64)

 Population Pyramid is used to present and study the age-

sex structure of the population of a country or a geographical
area.
 The overall shape of the pyramid indicates the potential for
future growth. The four representations of population age-
sex structure provide an overall example of what a pyramid
for different levels of population growth would look like —
rapid growth, slow growth, zero growth, and negative growth.
The horizontal bars show the percentage (or in some cases
the actual numbers) of males and females in each age group
(Population Reference Bureau 2009).

3. Population Distribution
 Urban-rural distribution is the ratio of population between
urban and rural areas. However, it is important to review the
operation definition of what is urban and what is rural. In the
Philippines, we consider a barangay as urban if it has a
population size of more than 5,000.
 Population density refers to the number of people that
occupies a unit area. For example, based on the 2015
census of population in the Philippines is 308-337 Pilipinos
per square kilometer.
(no. of people / land area = population density)
  Crowding index refers to the peoples sharing a house. It is
computed by getting the the total number of people or
residents in one household, excluding the newborn infant,
divided by the number of rooms (bathroom and kitchen are
excluded).
(no. of co-residents ÷ number of rooms = crowding
index)

It is impractical to interview the entire population – it costs a lot, needs a

lot of effort and is time consuming. To avoid unnecessary costs and
maximize the efforts, sampling is a method that allows the nurse to
collect information about a population from a part or portion of the total
population, without having to investigate every individual.

Random sampling vs. Non-random sampling

Probability of selection of each
individual is known and pre-
determined:
 Simple random sample
 Systematic random
sample
 Stratified random sample
 Multistage sample
 Multiphase sample
 Cluster sample
Probability of selection of each
individual is not known:
 Convenience sample
 Purposive sample
 Quota
 Snowball or network
sampling

6. Make a timetable – A timetable is a schedule set to specific activities and

events throughout the course (from preparatory phase to development of
your community diagnosis). Setting a timetable allows the nurse to tract
the progress and efficiently manage allocation of effort and resources.
II. Implementation Phase. This phase is practically the assess phase of the
entire process. The implementation phase of diagnosing a community
evolves around community assessment and processing, analyzing and
validating the collected information:
1. data collection 5. prioritization of health problems
2. data organization/collation 6. development of a health plan
3. data presentation and analysis 7. validation and feedback
4. identification of health problems

Community needs assessment is the process of determining the real

or perceived needs of a defined community. In some situations, an
extensive community study may be the first priority; in others, all that is
needed is a study of one system or even one organization (Allender J.
et.al 2014).

Windshield survey. One of the common ways to start in getting familiar

with the community is the windshield survey. Imagine going around the
neighborhood to get yourself familiarize with it at the same time examine
the community. Its practically doing an assessment by ocular inspection.
You drive around or walk around the community to validate already
existing data, or to acquire primary information through observations
such as peoples’ common interests, physical activities, source of water,
observable cultural traits and physical facilities such as schools,
occupational hazards, etc.
Physical. Condition of roads; lighting of streets; community waste
management; open spaces like parks and public gardens; natural
geographic features like rivers, mountains, lakes; man-made structure
like buildings, bridges; signs of population

Economic. Common industry; does it looks like a developing or

developed community; shopping and commercial centers; homeless
 people

Services. Places of worship; educational institutions like schools,

public libraries; health facilities like private clinics and diagnostic
centers; recreational facilities like basketball courts, gyms, spas;
political activities such as notices, posters, campaigns; is there
internet connection?

Social. Are there common areas for socialization such as tambayan

(hangout place); language or dialect; religion or cultural background;
ethnicities (diverse or homogenous?)
Adapted from Allender J (2014) Community and public health nursing: promoting the public's health

Upon completing the assessment – data collected are analyzed

and health needs are prioritized – the nurse can now develop a
community diagnosis. Community diagnosis is a report made by the
nurse that presents focus of nursing interventions to be developed and
planned for the community. This process involves making clinical
decisions based on the information collected.

Assessment is the key in understanding the community. It involves

two important activities which are data collection and analysis of the
information. We put special attention to community assessment to be able
to come up with a sound understanding of the community. Identified and
prioritized health issues in the community diagnosing process will help the
nurse in his/her population-focused health planning or client-focused
nursing care.
EVALUATION:
📝 Activity 1: Using sources from the internet, search for a local Philippine ethnic
group or population and describe their health practices, culture, social structure,
and economic activities. With the information you are able to collect, how can you
prepare yourself in ensuring that you and this community will develop a working
relationship as equal partners?

📝 Activity 2:
SET 1. Getting your data ready: Matching Type Activity: Match column A with the
correct answer on column B. Write only the answer on the space provide before
each number:

A B
(Data/information you need) (Source of data)
 _____ 1. Teenage pregnancy rate in A. Primary
our barangay
B. Secondary
_____ 2. Lived experiences of
teenage fathers
_____ 3. No. of women of
reproductive age
_____ 4. Perception of young males
on gender-based violence
_____ 5. Total population of the
community in 2019

SET 2. Using secondary source (using online reliable sources), do some

research on health challenges faced by teenagers amidst COVID-19 pandemic.
Identify at least five health needs or issues. Support your answer with data and
include your source (web link).
REFERENCES:

Allender J., Rector C., and Warner K. (2014), “Community and public health
nursing: promoting the public's health", Wolters Kluwer Health - Lippincott
Williams and Wilkins 2014, China

Population Reference Bureau (2009), “Human population: lesson plans” retrieved

from “https://www.prb.org/humanpopulation/”

Philippine Statistic Authority (2016), “Philippines – population pyramid”, retrieved

from “https://www/psa.gov.ph”