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COMMUNITY HEALTH

PREPARED BY Dr. TIBINYANE

(2020)
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Unit 1 POPULATION FOCUSED PRACTICE

Learning Objectives

By the end of this unit, students will be able to:

 Define community and health

 Define community health, and community health nursing
 List the roles of a community health nurse
 Identify the characteristics of community health nurses
 Describe the factors affecting health of the community
 Define population and population health
 Describe population focused practice
 Define aggregates
 Mention the core functions and related essential services of population focused
practice

Concepts

 A community is a collection of people who interact with one another, and whose
common interests or characteristics give them a sense of unity or belonging.
 A community can also be defined as geographic boundaries which includes
neighbourhood, city, county or state.
 Can be defined by race, location, occupation, age, common bonds, people that
share the same ideas.

Health:

• Is a dynamic state or condition that is multidimensional in nature;

• Results from a person’s adaptations to his or her environment;

• It is a resource for living and exists in varying degrees” (J. Mckenzi et al.,).

• Is a state of complete physical, mental, and social well-being and not merely the
absence of disease and infirmity (WHO).

Community health

The health status of a defined group of people and the actions and conditions,

Both private and public, to promote, protect, and preserve their health
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A medical specialty that focuses on the physical and mental well-being of the
people in a specific geographic region.

Is an important subsection of public health which includes initiatives to:

 help community members maintain and improve their health,

 prevent the spread of infectious diseases and
 prepare for natural disasters.

Community health nursing:

• Is the integration of nursing practice and public health practice,

• As applied to promoting and preserving the health of populations.

• Its philosophical orientation and the nature of its practice makes it unique.

• Is a systematic process of:

- assessing the population to identify groups in need of health promotion or

at risk for disease,
- planning for community intervention,
- implementing the plan,
- evaluating outcomes,
- using the resulting data to influence health care delivery

Community health nursing:

• Focuses on the prevention of illness, injury, or disability;

• Promotes and maintains the health of the populations.

• Engages in community involvement,

• Acquires knowledge about the entire population with personal, clinical

understandings of the health and illness experiences of individuals and families.

• Translates and articulates the health and illness experiences of diverse,

• Often vulnerable individuals and families in the population to health planners and
policy makers.

• Assists community members to voice their problems and aspirations.

• Are knowledgeable about multiple strategies for intervention,

• From those applicable to the entire population, to those for the family, and the
individual.

• Translates knowledge from the health and social sciences

• To individuals and population groups

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• Through targeted interventions, programs, and advocacy.

• In community health nursing, the client or “unit of care” is the population.

• The primary obligation is to achieve the greatest good for the greatest number of
people or the population as a whole.

• The processes used by community health nurses include working with the client(s) as
an equal partner.

• Selects appropriate activities in the course of Primary prevention.

• Focuses on strategies that create healthy environmental, social, and economic

conditions in which populations may thrive.

• Actively reaches out to all who might benefit from a specific activity or service.

• Uses available resources to assure the best overall improvement in the health of the
population

• Works in collaboration with a variety of other professions, organizations, and entities

is the most effective way to promote and protect the health of people.

Factors that affects the health of the community

1. Physical factors:

Geography (geographical location):

• Climate can be community health problem.

• Tropical countries are warm, humid temperatures and rain prevailing throughout the
year,

• Parasitic and infectious diseases are a leading community health problem e.g.
malaria, diarrhoea.

Environment:

• The quality of our environment is directly related to the quality of health of the
community.

• Proper sanitation and hygiene of the environment minimize the occurrence and
transmission of diseases.

• Dirty environment can easily lead to disease outbreak.

• Approximately 24% of the global burden of disease and 23% of mortality worldwide
are related to environmental conditions (WHO).

• Microorganisms such as bacteria, viruses, and fungi cause communicable diseases,

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• Animals contribute to the spread of these diseases.

Community size:

• Can have both positive and negative impact on the community’s health.

• Smaller population can effectively plan, organize, and utilize its resources

• Over populated community can easily be attacked by communicable diseases.

Industrial development:

• Many communities (especially urban area) are industrially developed

• Are more likely to be infected/affected by various diseases.

• The generated wastes from the industries are being released into water and the air.

• Water pollution and air pollution.

• Industrial development also provides the community with various resources.

2. Social and Cultural factors

Social factors:

• People living in the villages do not have easy access to certain amenities/ resources

• But they are stress free most of the time

• People living in urban area are often stressed due to their fast-paced life.

Cultural factors:

• Individuals inherit from being part of a particular society.

• These include respect, beliefs, traditions, norms etc.

• Tradition of certain ethnic group eat their own type of food,

• Have certain practices e.g. female genital mutilation

Economy:

• A community that is economically stable has low chances of suffering from disease
outbreak

• They have proper health care system in place and

• Their living conditions are more favourable.

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• In some cases, unemployed and employed people face poverty and deteriorating
health.

• Thus, the cumulative effect of an economic downturn significantly affects the health
of the community

Government:

• Government is involved in planning, implementing and

• Provision of community supplies such as water supplies, sanitation, medical supplies

etc.

• Therefore, the decision made by the government can have either positive or
negative impact on the community health.

Religion:

• Can affect health either positively or negatively.

• Limiting the type of medical treatment their members may receive.

• Some do not permit blood transfusion; to eat fish without scale.

• Actively address moral and ethical issues such as abortion, premarital intercourse,
and homosexuality.

3. Community organizing

• Is a process through which communities are helped to identify common problems or

goals, mobilize resources, and in other ways;

• Develop and implement strategies for reaching their goals they have collectively
set.

• This is an art of building a consensus among the community members.

4. Individual behaviour

• Community health is highly influenced by individuals, and

• It takes a team work for a community to function effectively.

• For example, proper disposal of waste products by individuals, can reduce the
spread of communicable diseases;

• Abstinence from sexual activities and for sexually active individuals to use protection
will prevent the spread of HIV/AIDS and STDs etc.

5. Population:

• All of the people occupying an area, or

• All of those who share one or more characteristics.

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• Is made up of people who do not necessarily interact with one another and

• Do not necessarily share a sense of belonging to that group (belong to a

community).

• May be defined geographically: Namibian population or

• A city’s population such as Windhoek.

5.1 Population-focused care:

• A process that uses the population-based approach.

• It focuses on the entire population,

• Is grounded in community assessment,

• Considers all health determinants,

• Emphasizes prevention, and

• Intervenes at multiple levels

• Population consists of community members such as the elderly, children, pregnant

women, vulnerable population etc.

5.2 Population health:

• Is the attainment of the greatest possible biologic, psychological, and

• Social well-being of the population

• As an entity and of its individual members.

• Healthy populations provide their members with knowledge and

• Opportunities to make choices that improve health.

• In large part, the health of a population is defined and determined by perceptions,

norms, and values of its members.

5.3 Aggregates:

• Are subpopulations within the larger population

• Possess some common characteristics,

• Often related to high risk for specific health problems.

• School-aged children, persons with (HIV) infection, children, pregnant

women, and the elderly are all examples of aggregates (Clark, 2008).

6. Population focused practice:

• Is “defined as interventions aimed at disease prevention and

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• Health promotion that shape a community’s overall profile” (DHHS, 1994a).

• Community health nursing’s specialty practice serves populations and aggregates

of people.

7. Community health nursing:

• Is regarded as a population focused practice because

• Community health nurses continually look for problems in the environment

• That influence community health and seek ways to increase environmental quality.

• They work to prevent health problems, such as promoting school health programs,
giving of health education to individuals and general public,

• Doing home visits for the elderly in the community, etc.

8. Core functions AND Related essential services

• Assessment: -Monitor health status to identify health problems in the

community

-Diagnose and investigate health problems and in the

community

-Evaluate the effectiveness, accessibility and quality of

personal and population based health services

 Policy development: -Inform, educate and empower people with

respect to health issues

-Develop policies and plans that support

individual and community health efforts

-Enforce laws and regulations that protect health

and ensure safety

• Assurance: -Assure the community about the availability of

competent health care workers (personal & public health

care workforce)

-Mobilize community partnerships to identify and solve

health problems

-Conduct research on innovative solutions/ideas that will

solve health problems

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UNIT 2 HEALTH CARE SYSTEMS

Learning objectives

By the end of this session students will be able to:

• Define health systems

• List the main goals of health systems

• Describe the building blocks in health systems

• Describe the components of health systems

• List the functions of health systems

A health system (healthcare system):

 The method by which healthcare is financed, organized, and delivered to a

population.
 It includes access, expenditures, and resources (healthcare workers and
facilities).
 “All the activities whose primary purpose is to promote, restore, of maintain
health” (WHO, 2000, p.5).
 “The health system delivers preventive, promotive, curative and rehabilitative
interventions through a combination of public health actions
 And the pyramid of health care facilities that deliver personal health care — by
both State and private health sector” (WHO, 2010).

Main goals of health system (WHO)

 Improving the health of populations

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 Improving the responsiveness of the health system to the population it serves.

 Fairness in financial contribution i.e. the extent to which the burden of paying for
health system is fairly distributed across households.

Building blocks/components (6) in health system (WHO)

• Service delivery

• Health workforce

• Health information systems

• Access to essential medicines

• Financing

• Leadership and governance

1. Service delivery

• Comprehensiveness:

Appropriate to the needs of the target population, including

Preventative, curative, palliative and rehabilitative services and

health promotion activities.

• Accessibility:

No undue barriers of cost, language, culture, or geography.

Health services are close to the people, with a routine point of entry to the service
network at primary care level (PHC).

Services may be provided in the home, the community, the workplace, or health
facilities as appropriate.

• Coverage:

All people in a defined target population are covered, i.e. the sick and the healthy,
all income groups and all social groups.

• Continuity:

It provides an individual with continuity of care across the network of services, and
over the life-cycle.

• Quality:

It is effective, safe, centred on the patient’s needs and given in a timely fashion.

• Person-centeredness:

Organized around the person, not the disease or the financing.

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People are partners in their own health care.

• Coordinations:

 The patient’s primary care provider works in collaboration with other levels and
types of provider.
 Local area health service networks are actively coordinated.
 Coordination also takes place with other sectors and partners (community
organizations).
 Accountability and efficiency: Health services
 Are well managed so as to achieve the core elements described above with a
minimum wastage of resources.
 Managers are allocated the necessary authority to achieve planned objectives,
 Managers are held accountable for overall performance and results.
 Appropriate mechanisms for the participation of the target population and civil
society are assessed (WHO, 2010).

3. Health Information Systems (HIS):

• This is a system that is designed to capture, store and transmit health data.

• It is used to collect, process, use and report health information.

HIS can be used for:

decision making,
facilitating the delivery of care as well as
handling of administrative tasks.

3.1 Resources:

 Involves the legislative, regulatory, and planning frameworks

 Required for system functionality.
 This includes personnel, financing, logistics support, information and communications
technology (ICT), and
 Mechanisms for coordinating both within and between the six components.

3.2 Indicators:

• “Health indicator is a measure designed to summarize information about a given

priority topic in population health or health system performance” (CIHI, 2020).

• This involves a complete set of indicators and relevant targets,

• Including inputs, outputs, and outcomes, determinants of health, and health status
indicators.

3.3 Data sources:

• It includes both population-based data sources:

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- (health survey, census, birth and death registration) and

• Institution-based data sources:

- (health facility, reporting, health resource tracking such as database).

3.4 Data management:

• Collection and storage, processing and flow, and compilation and analysis of data.

Information products:

• Data which has been analysed and presented as actionable information.

3.5 Dissemination and use:

• The process of making data available to decision-makers and facilitating the use of
that information.

4. Access essential medicine:

• The following are needed to achieve the objectives as put forth by the WHO in
describing a well-functioning health system:

National policies, standards, guidelines and regulations that support policy

 Information on prices, the status of international trade agreements and the

capacity to set and negotiate prices.
 Reliable manufacturing practices when they exist in-country and quality assessment
of priority products.
 Procurement, supply and storage, and distribution systems that minimize leakage
and other waste.
 Support for rational use of medicines, commodities and equipment, through
guidelines and strategies to assure adherence, reduce resistance, maximize patient
safety and training.

5. Health system financing:

 The purpose of health financing is to make funding available,

 To set the right financial incentives to providers,
 To ensure that all individuals have access to effective public health and personal
health care” (WHO, 2000).
 Health system financing is fundamental to the ability of health systems to maintain
and improve human welfare.
 Financial risk protection is determined by how funds are raised, and whether and
how they are pooled to spread across the population groups.

6. Leadership and governance:

 Ensures that strategic policy frameworks exist and;

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 Are combined with effective oversight, coalition-building, regulation, attention to

system design and accountability.
 Accountability is an important aspect of governance that
 Concerns the management of relationships between various stakeholders in health.
 These are individuals, households, communities, firms, governments,
nongovernmental organizations, private firms and;
 Other entities that have the responsibility to finance, monitor, deliver and use health
services.

HEALTH SYSTEM IN NAMIBIA

 Namibia has a dual health system (public 85%; private 15% of the population).
 Namibia has 249 clinics, 44 health centres, 1150 outreach points, 3 intermediate
hospitals, 1 national referral hospital and 30 district hospitals.
 There are 14 MoHSS regional directorates and 34 districts.
 Some of the health challenges in Namibia are HIV/AIDS, Tuberculosis, mother and
child mortality, gender-based violence etc.
 Creates an enabling environment for the provision of quality health care and social
services.
 Develops the capacity for health planning and social services in order to optimally
and efficiently use the available resources dedicated to the sector.
 Designs and implements projects and programmes that are responsive to the needs
of the citizens in terms of healthy leaving, etc.

Such projects and programmes include health extension services, community-based

disability prevention, rehabilitation services, etc.

 Develops strategies to prevent and manage disease (communicable and non-

communicable diseases),
 Injuries (environmental & occupational health) and
 Other health conditions such as maternal and child health, through the promotion
of healthy behaviours.
 Provides curative services for the provision of treatment and therapies to patients
and clients in line with set standards, policies, guideline and manuals.
 Develops capacity and systems to provide specialised health care services which
will allow the use of facilities and
 Expertise through bilateral cooperation with other countries.
 Hospitals shall provide a broad range of programmes to deliver inpatient and
outpatient health care services.
 Health centres shall provide healthcare services at the clinics throughout the
country to reduce the pressure on district and intermediate hospitals.
 Provides outreach services at various localities that are without clinics to reach the
majority of the people.
 Establishes capacity and systems for disease surveillance, analysis, database and
control measures, by identifying risk factors for disease and targets for preventive
medicine and public policies.
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 Develops policies, measures, programmes and standards to determine the

prevention of health hazards and diseases emanating from the environmental
management.
 Develops efficient emergency response services in times of need and
 Capacity for the detection, prevention and management of the introduction of or
utilization of hazardous or toxic material with the potential to harm the health of
Namibians.
 Develop the capability for diagnostic services (medical laboratories).

Mandate:

“To promote and protect the health of the Namibian people and, provide quality social
services to all, especially the vulnerable members of society.

This means that the Ministry has an overall function to develop essential health care
programmes based on a primary health care approach which is scientifically sound and
socially acceptable” (MOHSS, 2014).

Vision: “Our vision is to be the leading public provider of quality health and social services”
(MOHSS, 2014).

Mission: “Our mission is to provide integrated, affordable, accessible, quality health and
social services that are responsive to the needs of the population” (MOHSS,2014).

UNIT 3: PRIMARY HEALTH CARE

Learning objectives
At the end of this session, students should be able to
 Define primary healthcare
 List the core components of PHC
 Describe the foundation and pillars of PHC
 Describe the levels of prevention
 Strategies for the implementation of PHC
 Identify the principles of multidisciplinary approach
 Identify the actions and interventions of political commitments
 Define comprehensive PHC and selective PHC
 Describe GOBI-FFF
 Tabulate the differences between CPHC and SPHC

Introduction
In the past decades, the equity in access to healthcare was neglected during the colonial
period which made hospital- based care to become unsustainable. There was political
instability in many countries which prevent the population from having access to
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appropriate health care. Due to this situation, World Health Organization (WHO) under the
leadership of Halfdan Mahler, introduced a Comprehensive community-based healthcare
approach called Primary Health Care (PHC). This international conference took place in
Alma-Ata in 1976.

Definition
According to WHO, Primary health care (PHC) is “defined as the essential health care based
on methods and technology made universally accessible to individuals, families and
communities through their active participation and at an affordable cost. PHC is an integral
part of a country’s health system and, ideally, its main focus. It is the first level of contact for
individuals, families and communities and enables health care to be delivered as close as
possible to where people live and work and constitute the first element of a continuing
healthcare service” (WHO,2020).
PHC services are the point of entry into healthcare system, medical conditions can be
managed at PHC level or clients can be referred to secondary level if the medical condition
cannot be handled at PHC level.
PHC is a people-centred and community empowerment approach and is based on
selective and comprehensive health care delivery. It requires participation of other sectors
and stakeholders for it to succeed.
PHC requires intersectoral and multi-disciplinary team approach which coordinates all
sectors involved in health and community development.
Core Components of Primary Health Care
According to Alma-Ata declaration, PHC programme should have the following 8
components:
1. Health education about prevailing health problems as well as methods of preventing
and controlling them
2. Adequate supply of safe water and basic sanitation
3. Promotion of adequate food supply and proper nutrition
4. Maternal and child healthcare, including family planning and care of high-risk groups
5. Immunization against major infectious diseases
6. Prevention and control of locally endemic diseases
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs
9. Mental/dental/eye health care
10. Improved management

Characteristics of an ideal health care service

 Affordable
Should not only be affordable to the patient but also to the country as such.
Should be rendered as economically as possible; cost containment should be an
ongoing process,
 Accessible

Should not be situated more than five kilometres from where the patient stays.
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Patients should not be refused health services because they are unable to pay for such.

Communication in services should be in the language of the patient’s preference,

especially with the very young and the elderly who can be very insecure when
communicated to in a foreign language.
Religious perceptions should be kept in mind.
 Available
Should not only be comprehensive but should be open at all time that there is a need for
the service.
Must be rendered after hours and over weekends so that the working patients and clients
can attend.
 Acceptable
A health service that is not accessible, affordable, available, equal, effective, efficient,
continuous, caring, comprehensive and comfortable, will not be acceptable to the
patient,
 Appropriate
Should respond to the health needs of the community in terms of the most prevailing
health conditions.
Community diagnosis must be done so as to plan the service accordingly.

The house of Comprehensive health care built through PHC (Alma Ata)

ROOF
IMPROVED HEALTH
STATUS

SUPPORT
P P C R PILLARS
R R E
U
E H
V
O R A
E M A L
T I
N O
B
T T I
I
I V
I T
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FOU FOUNDATION
COMMUNITY PARTICIPATION

INTERSECTORAL COLLABORATION

INFORMATION, EDUCATION AND COMMUNICATION

EQUITABLE DISTRIBUTION OF RESOURCES

The foundation represents the principles of Primary Health Care

 Equitable distribution of resources

 Information, education and communication
 Intersectoral collaboration
 Community participation

The house of Comprehensive health care built through PHC

Namibian PHC house

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Foundation of PHC
Foundation of PHC is regarded as principles of primary health care. In Namibia PHC is based
on five foundations and they are as follows:
 Equity: It is essential that everyone in the community regardless of colour, tribe,
race or educational background, have equal access to health care and
social services without any discrepancies in the care given.
 Affordability: The amount that needs to be paid for health care services given
at PHC facilities should be at the range that community members can afford.
However, no one should be denied treatment because of money as
everyone have the right to receive quality healthcare services.
 Accessibility: PHC services/ facilities must be within reach (at a reasonable
distance) of the people in the community and special attention must be
given to people living in rural areas as well as the disadvantaged people.
 Acceptability: healthcare services rendered to the community must be
acceptable by the community. Health facilities must be conducive and
environmentally friendly. Health workers need to be accommodating and
friendly for quality services to be rendered.
 Community involvement: community members need to be involved in the
healthcare. It is essential to encourage community members to take
responsibility of their health and to be part of decision making, planning,
implementing as well as evaluating the care they receive. Community
members need to work together with the healthcare workers for quality
services to be rendered.

Pillars of PHC
In Namibia, primary healthcare is based on 4 pillars and they are as follows:
1. Health promotion: According to WHO (2020), it is “the process of enabling people to
increase control over and improve their health. It covers a wide range of social and
environmental interventions that are designed to benefit and protect individual
people’s health and quality of life by addressing and preventing the root causes of ill
health, not just focusing on treatment and cure.” There are 3 key elements in health
promotion:
 Good governance for health: policy makers need to make health the central
line of government policy by prioritizing the policies that prevent people from
becoming ill but rather promote the health of the community. For example,
placing restriction/ increasing the tax rate and/or banning of alcohol and
tobacco consumption etc.
 Health literacy: People need to acquire the knowledge, skills and information
to make healthy choices, for example about the food they eat and healthcare
services that they need. They need to have opportunities to make those
choices. And they need to be assured of an environment in which people can
demand further policy actions to further improve their health.
 Healthy cities: Strong leadership and commitment at the municipal level is
essential to healthy urban planning and to build up preventive measures in
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communities and primary health care facilities. From healthy cities evolve
healthy countries and, ultimately, a healthier world.
2. Disease prevention: It focuses on specific efforts aimed at reducing the development
and severity of chronic diseases and other morbidities. This involves creating
awareness about health conditions/ diseases that is affecting or can affect the
community.

Levels of prevention
 Primary prevention: These are actions aimed at avoiding the manifestation of
a disease. This include
 Changing the impact of social and economic determinants on
health
 Provision of information on behavioural and medical health risks as
well as consultation and measures to decrease them at the personal
and community level
 Provision of nutritional and food supplementation
 Giving of health education regarding oral and dental hygiene
education
 Clinical preventive services such as immunization of children etc
 Secondary prevention: This involves early detection of diseases/ infection
which in turn increases the chances of positive health outcomes. This include
activities such as
 Evidence-based screening programs for early detection of diseases
or for prevention of congenital malformations
 Preventive drug therapies of proven effectiveness when
administered at an early stage of the disease. Examples are cancer,
TB, STI, etc.

 Tertiary prevention: It deals with managing disease post diagnosis to slow down
or stop disease progression through measures such as chemotherapy,
rehabilitation, and screening for complications.

3. Curative services: Curative care refers to treatment and therapies provided to a

patient/client with the main intent of fully resolving an illness and the goal of bringing the
patient to their status of health before the illness presented itself. Complete physical and
mental wellbeing can be achieved through treatment ailments and diseases. The focus is to
restore the individual to a full functional healthy state through the treatment of diseases.
4. Rehabilitation: “Rehabilitation consists of a wide range of activities which includes
rehabilitative medical care, physical, psychological, speech, and occupational therapy
and support services. People with disabilities should have access to both general medical
care and appropriate rehabilitation services.” (WHO, 2020) Integration of rehabilitative
healthcare into PHC helps in providing holistic care to the affected and sick individuals.
Strategies for the implementation of Primary Healthcare
1. Multidisciplinary approach: Is an integrated team approach to healthcare which
involves treating patient holistically. “The evaluation of treatment options and
treatment planning are collaborative processes involving medical and allied
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healthcare professionals in concertation with the patient and the patient's family.
Individual patient-specific treatment plans are developed, and delivery of care
becomes a shared responsibility.”
The principles of Multidisciplinary approach
 A team approach, involving specialists, the general practitioner and allied
healthcare professionals including a supportive care provider, who deals with
the psychosocial aspects of care
 Regular communication among team members
 Access to a full range of therapeutic options, irrespective of geographical
remoteness, rural or urban healthcare service
 Provision of care in line with national standards, and treatment decisions based
on adequate information
 The patients should be involved in their care discussions and management and
should receive timely and appropriate information from the healthcare
professionals.
2. Multi- sectoral collaboration: It is a collective action that involves various sectors/
stakeholders, performing different roles for a common purpose. Different sectors have
the different resources, technology and skills that are necessary for the attainment of
health by individuals, family and community at large. For a health care system to
function effectively, various stakeholders need to be involved.
These involve government, businesses, various profit and non- profit
organizations and any other sectors that can help in the promotion of health
which allows equitable health services to rendered in the community [Vaishnavi
& Priyadarshini, 2018]. For multi-sectoral collaboration to be successful; the roles
and responsibilities of stakeholders must be clearly defined and there must be
proper orientation of policies and programmes [Vaishnavi & Priyadarshini, 2018].
Example of sectors is the municipality.

3. Community participation and involvement: this involves allowing community

members to be active participant in their own health care. A community participation
approach is a cost-effective way to extend a health care system to the geographical
and social periphery of a country. For example, studies shows that Direct Observed
Treatment increased the prognosis of tuberculosis (TB) due to active community
participation. In order to address the determinants of health in the community,
community participation principles need to be applied.
4. Political commitment: According to Alma-Alta declaration in 1978, “all governments
should formulate national policies, strategies and plans of action to launch and
sustain primary healthcare as part of a comprehensive national health system and in
coordination with other sectors. Therefore, it will be necessary to exercise political will
to mobilize the country’s resources and to use available external resources rationally.”
According to Astana declaration, for political commitment to be efficient, there are
various actions and intervention that need to be in place.

Political commitment: actions and interventions

 Policy level: government need to
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 Integrate a comprehensive vision of PHC as a core component of

national strategies, including integrated health services, multisectoral
policy and action, and empowered people and communities
 Convene and broker health sector decision-making amongst a wide
range of stakeholders, including the lay population, for policies and
action that can address the social, economic, environmental and
commercial determinants of health
 Create an enabling environment for participation by proactively
identifying barriers and opportunities for empowering people and
communities, by building community capacities for meaningful
dialogue, and by providing and regularly evaluating policy dialogue
mechanisms
 Assess the health services to determine if public health functions and
primary care have been appropriately resourced, and reallocate as
necessary
 Operational/implementation level
 Collaborate with higher administrative levels to ensure that community
needs and views are given appropriate attention in decision making
 If appropriate, given the level of decentralization, carry out the same
efforts at the sub national level as at the national level:
 bring together stakeholders for multi-sectoral policy and action.
 Include community members in decision making
 ensure that appropriate levels of resources are dedicated to
public health and primary care
 People and communities
 Participate in efforts to establish inclusive processes
 Demonstrate leadership as a champion for the comprehensive vision of
PHC
 Global / regional partnership
 Support national political commitment and leadership by committing to
base financial and technical support on nationally defined priorities
rather than donor or partner priorities
 Support efforts to share lessons learned around political commitment
and leadership
 Support efforts to build the evidence base about how PHC approaches
contribute to the SDGs

Approaches to implementing Primary Health care

1. Comprehensive PHC: “Comprehensive” in Comprehensive Primary Health Care refers to a
broad approach that tackles the health problems that the population is facing by providing
preventative, curative, rehabilitative and promotive health services to the community and
population at large. It brings healthcare services as close as possible to where people have
their everyday living and activities. It is an approach that promotes equity in the health
system, and involves multisectoral collaboration, community involvement, and the use of
appropriate technology [WHO, 1978].
 23

This includes health promotion and prevention in addition to rehabilitation and curative
healthcare services. It deals with the holistic provision of healthcare services and
management of diseases in the community.
Health promotion and disease prevention help the community to strengthen the socio-
economic conditions that contribute to the quality of health such vaccinations and
provision of health education to the at-risk populations in the community [Vaishnavi &
Priyadarshini, 2018].
The Ottawa Charter (1986) identifies five components of health promotion action pg. 153:
 Build public policies that support health
 Create supportive environments
 Strengthen community actions
 Develop personal skills in the community and workplace
 Re-orientate health services

In addition, there are prerequisites for health and include peace, shelter, education, food,
income, a stable ecosystem, sustainable resources, social justice and equity. These are
necessities of life that contribute to health of the individual and community at large.
2.Selective PHC: Julia Walsh et al (1979), “presented selective primary health care as an
"interim" strategy to begin the process of primary health care implementation. They argued
that the best way to improve health was to fight disease based on cost-effective medical
interventions.” Selective approach is palliative in nature and it deals with management of
identified health problems. Selective Primary Health Care identified four factors to guide the
selection of target diseases for prevention and treatment: prevalence, morbidity, mortality,
and feasibility of control.
GOBI-FFF is a type of selective approach which was announced three years after Alma-Ata
declaration and it is called child survival revolution. Its main objective is to reduce the high
morbidity and mortality in infants and children in the developing countries.
GOBI-FFF
G- Growth monitoring: The nutritional status of the under five children should be accessed
on regular basis through growth monitoring. This is done by measuring the weight, muac,
length and head circumference of the under 5 children. Early detection of abnormality will
be treated accordingly.
O- Oral dehydration therapy: Diarrhoea is one of the leading causes of death among the
under 5s in developing countries. Loss of electrolyte usually lead to dehydration which is why
is it highly essential to teach mothers how to prepare ORS at home. ORS is prepared by
adding half teaspoon of salt and eight teaspoons of sugar to 1 litre of boiling water. ORS is
also readily available at the clinics and can be purchased over the counter at the
pharmacy.
B-Breastfeeding: Breast milk is the best food for babies. Breast milk is highly nutritious and also
protects babies against infection. It also helps with the uterine contraction which allows the
uterus expel blood and allow the uterus to go back to its normal shape.
 24

I-Immunization: “Immunization is the process whereby a person is made immune or resistant

to an infectious disease, typically by the administration of a vaccine. Vaccines stimulate the
body’s own immune system to protect the person against subsequent infection or disease.”
(WHO, 2020)

“Immunization is a proven tool for controlling and eliminating life-threatening infectious

diseases and is estimated to avert between 2 and 3 million deaths each year. It is one of the
most cost-effective health investments, with proven strategies that make it accessible to
even the most hard-to-reach and vulnerable populations. It has clearly defined target
groups; it can be delivered effectively through outreach activities; and vaccination does
not require any major lifestyle change.” (WHO, 2020)

F- Food supplementation: this refers to feeding schemes used to supplement the diets of the
community members that are affected by famine, poverty, drought and/ or natural disaster.
For example, Harambe prosperity plan, school feeding scheme, soup kitchen as well as
teaching community members on how to practice subsistence farming
F- Female literacy: one of the contributing factors of infant and maternal mortality rates is
female literacy. Education allows a woman to make right and better choices regarding her
health and that of her child. Therefore, it is very important for women to be educated.
F- Family planning: it is very essential for women to be educated in order for them to able to
make right decision about their life, they need to be well informed on child spacing. Family
planning prevent unwanted pregnancy as well as abortion.

Differences between comprehensive PHC AND selective PHC
CPHC
It is an expensive approach, though; it
encompasses every aspect of the
healthcare services an individual requires
in his/her lifetime. It promotes holistic
approach.
Focus on providing preventative,
curative, rehabilitative and promotive
health services [Schaay & Sanders, 2008].
Traditional PHC system in Namibia
incorporates all the aspects of CPHC, with
services provided in systematic fashion at
different levels of the health system.
Focus on equity and community
development. The primary goal of the
PHC approach is to ensure every
individual has access to the type of
healthcare service that they require,
Namibian healthcare delivery system is
designed in such a way that no patient is
turned away at a facility that is
designated for such services. This is
different from the way the referral system
is fashioned.
Focus on positive wellbeing of the Focus on absence of disease only in the
population [Magnusse, Ehiri & Jolly, 2004]. population [Magnusse, Ehiri & Jolly, 2004].
Make use of multidisciplinary health team
and community-based health care
workers as healthcare providers [SOPH,
2019]
Make use of communities and individuals
to have locus of control over health
[SOPH, 2019]
25
SPHC
It seems like a cost- effective approach,
however, the downside of the approach
makes it more costly to maintain the
health of an individual and the
population in general.
Focus on rehabilitation and treatment of
disease such as prevalence, morbidity
and mortality [Magnusse, Ehiri & Jolly,
2004]. For example, prevalence of
malaria in a population and maternal
mortality. These two are linked, in that
pregnant women are prone to morbidity
in a malaria endemic environment such
as the northern part of the country.
The focus is on vertical programs such as
growth monitoring, oral rehydration
therapy, breastfeeding, immunization,
family planning, female education and
food supplementation [Magnusse, Ehiri &
Jolly, 2004]. These may benefit some
individuals; however, many people will be
left out of the services since they do not
qualify.
Make use of medical doctors as
healthcare providers [SOPH, 2019].
Make use of health professionals to have
locus of control over health [SOPH, 2019].
 26

Unit 4 Economics of Healthcare Delivery

Learning Objectives

By the end of this unit, students will be able to:

 Define health economics and health care economics

 Explain the role of nurses in health care economics
 Differentiate the two basic theories underlying the science of economics
 Explain the supply and demand in health care economics
 Discuss trends and Issues Influencing health care economics
 Explain the effects of health economics on community health practice

Introduction
With the increasing emphasis on providing efficient and equitable services from primary care
and against a background of increasing demands on limited resources, economic theory
seeks to facilitate both the direction of primary care and the decisions that are made within
it (Kernick, 2000). There is a need for a closer relationship between health economists and
those who commission and deliver primary care, including the end users. Pragmatic
decision-making frameworks which draw upon economic concepts and principles and
which reflect the realities of the environment in which they are applied are needed.

Concepts
 Health economics is a branch of economics concerned with efficiency,
effectiveness, value and behaviour in the delivery and consumption of health
and healthcare.

 Health spending is the final consumption of health goods and services. It includes
spending by both public and private sources (AAP, 2020).

 Health care economics is a specialized field of economics that describes and

analyzes the production, distribution, and consumption of goods and services,
as well as a variety of related problems such as finance, labour, and taxation
(Aday, 2005). The structure and economics of community health care are
intertwined.

The role of nurses in health care economics

 Nurses preparing for population-based practice need to be familiar with how
the health care delivery system is organized and operates.
 It is through this system that they are able to offer community health services.
 27

 This system forms an organizing framework for the design and implementation of
programs aimed at improving the health of communities and vulnerable groups.
 It is within this system or framework that community health nurses labour, realize
the opportunity to shape future health services, and develop innovative and
more effective means of improving community health.
 Nurses concerned with the delivery of needed community health services also
must understand how those services are financed.
 Nurses must be well-informed about the issues related to health care financing
and about ways to obtain funding to address identified health needs in the
community.
 In an era when health care costs are rising while resources are limited and
providers are competing for scarce dollars, nurses are needed advocates to
overcome scarcity by making good choices and providing essential services,
which is the goal of health care economics.
 Service delivery systems directed at restoring or promoting the public’s health,
have evolved over centuries, and nurses were part of such systems;
 The structure, function, and financing of health care systems have changed
dramatically during that time in response to evolving societal needs and
demands, scientific advancements, more effective methods of service delivery,
new technologies, and varying approaches to resource acquisitio n and
allocation (Barton, 2003), of which nurses played a major role.

The economics of health care

Economics is defined as the science of making decisions regarding scarce resources.
Economics permeates our social structure—it affects and is affected by policies.
Consequently, health is closely tied to economic growth and development, in that a healthy
population is necessary for adequate national productivity. Ample evidence exists for a
“health–income gradient,” as personal income (specifically poverty) is linked to health status
(Aday, 2005, p. 191). Health economics can be better understood by examining the two
basic theories underlying the science of economics: microeconomics and
macroeconomics. In addition, concepts of health care payment must be understood

Microeconomics

Microeconomic theory is concerned with supply and demand. Supply is the quantity of
goods or services that providers (healthcare) are willing to sell at a particular price. Demand
denotes the consumer’s (patients) willingness to purchase goods or services at a specified
price (Chang, Price, & Pfoutz, 2001). In our free market–driven economy, supply-and-
demand is a key concept.

Economists using microeconomic theory study the supply of goods and services as these
relate to how we, as consumers, allocate and distribute our resources—as well as how
markets compete. They further study how allocation and distribution affect consumer
demand for these goods and services.
 28

In health care, demand-side policies are enacted to reduce demand for health care (e.g.,
raising insurance deductibles, and co-payments), and supply-side policies restrict the supply
of resources (e.g., preadmission screening to reduce the likelihood of insuring someone with
a serious health condition, denial of coverage for specific services, utilization of preferred
providers who practice within boundaries set by insurance companies) (Nyman, 2003).
Microeconomic theory comes into play when health care competition increases, because
the success of the supply-and-demand concept depends upon a competitive market.

Macroeconomics

Economists using macroeconomics study factors influencing “aggregate consumption,

production, investment and international trade, as well as inflation and unemployment”
(Aday, 2005, p. 186). The focus is on the larger view of economic stability and growth.
Macroeconomic theory is useful for providing a global or aggregate perspective of the
variables affecting the total economic picture (Aday, 2005).

Macroeconomic theory has been useful in providing a large-scale perspective on health

care financing, ultimately resulting in various proposals for national health plans, health care
rationing, competition, and managed care. The economics of health care encompasses
both microeconomics and macroeconomics, and an intricate and complex set of
interacting variables. Health care economics is concerned with supply and demand: Are
available resources sufficient to meet the demand for use by consumers? Are the resources
expended achieving the desired outcomes? When health care resources are scarce or
insufficient to address all needs (for example for programs and services for at-risk
populations), how should they be applied?

Supply and Demand in Health Care Economics

Some concerns about health care consumer and providers:

 As a health care consumer, however, can you truly be an efficient and effective
purchaser of health care goods and services?
 How does a patient determine what services are needed, where to buy them, and
how to evaluate the quality of the goods and services?
 Much less how does a patient know how to coordinate all necessary services?
 Does health care truly represent a competitive free market, then?
 Even with the growth of health information (and sometimes misinformation) available
on the Internet, physicians are still the system’s main gatekeepers,
 Patients must trust that these care providers have the competence to appropriately
diagnose and treat them, and coordinate necessary resources to provide quality
health care.
 Further, they trust that physicians will put the patients’ interests before their own (e.g.,
give them accurate information about risks and benefits and not induce them to
have expensive procedures to enrich the provider) (Dranove, 2000; Newhouse, 2002).
 29

A fundamental problem of the health care economy is that it is difficult for any person or
organization (e.g., patient, physician, health plan, government) to be “an efficient and
effective purchaser of health care goods and services” (Dranove, 2000, p. 9). Health care is
typically unpredictable and difficult to research.
Trends and Issues Influencing Health Care Economics

1. The high cost of health

According to Allender, Rector and Warner (2010) the high cost of health in America and
elsewhere were:

 Medical malpractice costs and the need to practice defensive medicine by ordering
excessive tests and x-rays (Sage & Kersch, 2006; RAND Institute for Civil Justice, 2004).
 Malpractice litigation results in higher malpractice insurance costs and defensive
medicine practices to protect physicians from lawsuits.
 An aging population (Cutler, 2004)
 Rapidly rising prescription drug and hospital costs (Goldman & McGlynn, 2005; Rice &
Rhodes, 2006)
 The failure of market forces, in that health care doesn’t respond to supply and
demand as in other areas of the economy (Nyman, 2003; Rice & Rhodes, 2006;
Sharma, 2006)
 High costs of insurance administration—in some cases, three times that of the cost in
other nations (Commonwealth Fund Commission on a High-Performance Health
System, 2006; Nyman, 2003)
 Ineffective, inappropriate, and inadequate health care leading to increased
morbidity and mortality and costs (Institute of Medicine, 2001)
 High proportion of uninsured—it has been estimated that a country’s economy would
benefit by billions of dollars a year if all citizens were provided health insurance
(Commonwealth Fund Commission on a High-Performance Health System, 2006)
 Restriction of the supply of health care in many countries leads to decreased
spending but also long waiting lists

2. Controlling Costs

Despite various public and private cost-control strategies, health care costs continue to rise
(Cutler, 2004). Many factors influenced this increase.
In the early 2000s costs rose and continue to rise. The price per day of hospitalization rose
tenfold (Kaiser Family Foundation, 2007c).

As medical care became more complex, insurance costs rose dramatically, as did costs of
public health care financing through Medicare and Medicaid (Cutler, 2004).

More than half of the health care dollar goes to hospital and physician costs (31% and 22%,
respectively) (Goldman & McGlynn, 2005).

The explosion of medical technology has been characterized as a “medical arms race” by
some (Dranove, 2000, p. 46), and a youth-oriented culture and unwillingness to accept illness
and death has helped fuel this and the growth of elective procedures, such as plastic
surgery.
 30

3. Access to Health Services:

The Uninsured and Underinsured

The state of Uninsured and Underinsured contributes to great inconsistencies in health care
quality and access (Collins, 2007). They often must choose between paying insurance and
health related expenses or foregoing needed care. They are more likely to “go without care
because of costs” (Forbes, 2007),
While 46% of underinsured were contacted by debt collectors, 35% reported changing their
usual way of life to pay medical expenses (Himmelstein, Warren, Thorne, & Woolhandler,
2005, p. 6). In addition, many underinsured have no dental or vision coverage, and have
higher deductibles.

A study indicates that adults in the 50- to 64-year age range have unstable health insurance
coverage (Collins et al., 2006). People in this age group have higher rates of chronic illness
(62% had at least one chronic condition, such as diabetes or hypertension) and higher
medical expenses. One-third of those in the study reported that they had problems paying
medical bills or that they were paying off medical debt. Two-thirds were concerned that
they would be unable to afford medical care in the future.

4. Medical Bankruptcies

In a 2001 study conducted by Harvard and Ohio University researchers, almost half of
participants cited illness—sometimes with loss of work—and medical expenses as the chief
cause for their bankruptcy (Himmelstein, Warren, Thorne & Woolhandler, 2005). The
consequences of not getting needed medical care are not trivial and can result in
unnecessary hospitalization and serious health problems—along with increased costs.
Because there is a lack of care coordination, duplicative and wasteful services are often the
case (Collins, 2007). And without a reliable care provider, the uninsured tend to use ERs for
nonemergency care. Recent research noted that 33% of ER visits could have been handled
in a primary physician’s office (Davis, 2003). Other consumers utilize public clinics and other
charity care services. Interruptions in care, duplication in medical records, and verification
of eligibility all lead to higher costs for everyone (Davis, 2003).

5. Managed Care

It refers to systems that coordinate medical care for specific groups to promote provider
efficiency and control costs. Managed care is a cost-control strategy used in both public
and private sectors of health care. Care is managed by regulating the use of services and
levels of provider payment. Managed care plans operate on a prospective payment basis
and control costs by managing utilization and provider payments. The managed care model
encourages the provision of services within fixed budgets, thus avoiding cost escalation.
Because costs are tight, preventive services are generally encouraged, so that more
expensive tertiary care costs can be avoided, if possible.
 31

Effects of health economics on community health practice

Health economics has significantly affected community health and community health
practice by advancing disincentives for efficient use of resources, incentives for illness care,
and conflicts with public health values.

Disincentives for efficient use of resources

 Abuse of resources in some parts of the system leads to depletion in other areas.
 This has had profound effects on community and public health programs,
 Severe budget cuts have affected even basic community health services, such as
health education programs (Institute of Medicine, 2002).
 Costs indirectly affect even appropriate use of nursing personnel in community health.
 Finally, the advent of prospective payment and limits on lengths of stay have
encouraged early hospital discharge, resulting in more acutely ill people needing
home care services.
 The immediate effect was an increase in the demand for highly skilled and more
expensive home care services, which required changes in provision patterns of
community health care.
 As acute care nursing shortages have intensified and salaries have increased, the
number of open, unfilled PHN positions has mounted (Chiha & Link, 2003).
 The long-range effects of this phenomenon:
- on family stress and caregiver health,
- on community health care reimbursement, and
- on the nature and structure of community health services,
- including the role of the community health nurse, are to be expected.

Incentives for Illness Care

 The traditional health care system tends to promote illness, because health care
providers have primarily been rewarded for treating problems, not for preventing
them.
 Hospitals derive more income when their beds are full of sick or injured people. Health
insurance plans compete, not by lowering costs or increasing quality, but by
“avoiding the sick”—leaving many without access to necessary health care
(Woolhandler et al., 2003, p. 798).
 Our disease-focused system of health care is thought by many to be the basic
problem (Adams, 2006).
 It rewards disease by paying doctors who diagnose, treat, and refer ill patients.
 It does not pay them for keeping their patients healthy. Most preventive care is
woefully inadequate and largely overlooked by both practitioners and patients alike
(Schoen et al., 2006).
 32

 Health promotion nursing activities, such as comprehensive maternal/infant care;

health education; and home services to enable the elderly to live independently
have not always been consistently covered by most insurers.
 The number and severity of health problems in a community increase when
individuals postpone care because they cannot afford visits to the doctor or clinic.
 It has been more difficult to encourage community clients to assume responsibility for
their own health and to engage in self-care, prevention, and active health
promotion.
 Furthermore, such illness-oriented incentives create a basic societal valuing of illness
care that, conversely, devalues wellness care.

Managed Care and Public Health Values

Initially, Managed Care Organizations (MCOs) focused on event-driven cost avoidance.

Strategies included
- decreasing inpatient days,
- decreasing specialty physician use,
- using physician extenders, and
- implementing provider discounting.
This evolved into a second stage, in which the principal objective was to control resource
intensity and improve the delivery process. Strategies used to meet this objective included
capitation of specialist costs, controls on units of service, patient focused redesign, clinical
pathways, and total quality management.
The emphasis, however, is now shifting to a focus on community-based health status
improvement that goes beyond just measuring utilization of care or mortality outcomes. This
focus calls for new strategies, such as community health assessments, identification of high-
risk individuals, targeted interventions, case management, and management of illness
episodes across the continuum. (Weiss, 1997, p. 28)

Summary

A focus on primary prevention demands a paradigm shift in thinking about the practice and
delivery of health care. It is one that fits more closely with the mission of public health. It
expects that citizens are involved in their health care, are knowledgeable about their health
status, can manage self-care practices, and can modify lifestyle behaviours to promote
wellness. This creates a rich environment for community health nurses to collaborate with
primary care practitioners and other health care professionals to control health care costs
while providing quality care focusing on primary prevention. Understanding this background
gives the community health nurse a stronger base for planning for the health of the
population under her care.
 33

UNIT 5. WEIGHT/GROWTH MONITORING AND NUTRITIONAL STATUS ASSESSMENT

Learning objectives
At the end of this session, students should be able to:
 Define the concepts

 Discuss aspects to remember during baby weighing

 Engage in dialogue with the parents

 Identify the medical legal hazards/ risks
 Discuss factors affecting the child’s body mass
 Observe possible faulty readings and rectify such
 Conduct physical observations during weighing
 Interpret the anthropometric measurements
 Discuss the pre-requisites for the ‘success’ of Road to Health Chart
 Elaborate on the benefits of the Road to Health Chart
 Discuss factors affecting child growth and nutrition
 Mention the guidelines for action

INTRODUCTION
Health workers at all levels should know the patterns of normal growth and the factors that
influence these. The child is a creature constantly changing in size,
shape, emotions, and abilities. Nowhere is this more obvious than in the field of physical
growth.

The normal growth, development and maturation of the healthy child proceed continuously
as dynamic processes till maturity. These are closely related, and take place in tissues,
organs, regions and systems, and in different physiological and chemical functions of the
body at different rate and velocity.
The direction of advancement in growth and the sequences in the evolution of function and
behaviour are genetically determined and remain constant for all human beings. But the
rate and the distance travelled along that direction will vary from person to person.

Environment cannot advance growth, development and maturation beyond the bounds of
genetically predetermined potentials, but it can retard them.
Environment can and do influence, modify and, to some extent, even determine
developmental patterns (especially behavior and emotion).

CONCEPTS:

Growth implies an increase in the size, composition, and distribution of tissues.

It is associated with changes in their proportions, shape and functions.

Development is the increase in the complexity of structures and of their functions. It takes
place in the same age period and often occurs in a parallel fashion.
 34

It is the product of the interaction between processes of maturation and learning.

Developmental milestones are sequential developmental achievements and performances.

These are indications, in terms of behaviour of the child’s progress towards maturity
(Nzimande). It is the “age” at which a specific measurement is achieved and varies
considerable between children.

Maturation is a process of achieving full growth and development; it also refers to changes
in developmental status that occur without practice. It is the process effecting the
genetically programmed biological inheritance, and by implication, an inherent regulating
and control mechanism). External factors, e.g. brain damage, poor nutrition may retard this
process.

Learning refers to enduring changes in behaviour resulting from contact with the
environment.

Growth monitoring refers to regular measuring of growth through weighing and plotting on
the growth chart, allowing early recognition of growth failure due to, among others, poor
nutrition, and appropriate action before there is overt malnutrition. Premature babies are
also monitored to ascertain their growth.

Monitoring growth means, “watching over children’s growth”. The speed or rate at which
children grow tells whether they are well nourished or undernourished. A good way to
monitor a child’s growth is to plot her weight on a growth chart so we can compare her
weight gain to the weight gain of healthy children.

Growth depends on:

 Good family care and love;
 The absence of diseases;
 Breastfeeding exclusively
 Complementary feeding at 6 months of age;
 Availability of the right food in adequate quantities;
 Good environmental care;
 Good medical care includes prevention of infectious diseases through immunization,
early treatment of diarrhoea, ARI, malaria and other diseases.

Growth promotion is the purpose of growth monitoring. It is done through maintaining weight
increase by preventing diseases and promoting good child care and proper eating.

Promoting growth means helping healthy children to keep growing well and children with
growth failure to grow better. A growing child is a healthy child;

Aspects to remember during baby weighing

Remember!! Child Growth is promoted by:

 Accurate weighing and plotting,
 Proper analysis of the probable problem,
 Taking appropriate action and,
 35

 Giving nutrition education.

Important aspects to remember

 Weigh regularly, i.e. monthly from birth to 59months;
 Use same accurate standardized scale;
 Undress baby, leave with minimum clothes on;
 Birth weight doubles 4 -5 months, and triples at one year;
 Low mass baby if born weighing below 2.5 kg grows fast, but is below 10kg at one
year.
 Big baby grows slower and is above 10 kg at 1 year.

Medical legal hazards/ risks

 Cross infection (not washing hands, not disinfecting scale),
 Injuries (falling, nappy pin, scissors, long nails etc.),
 Cough (cold room, open windows, open door, scale not covered etc.),
 Incorrect recording (wrong reading, ignorance),
 Neglecting reporting (abnormal weight, any abnormalities),
 Wrong interpretation (ignorance about the growth curves),
 Poor or inappropriate health education.

Factors affecting body mass

 Prematurity,
 Malnutrition (mother, child),
 Physical abnormality e.g. oesophagus constriction,
 Diseases (chronicity, others),
 Poor weaning practices,
 Emotional deprivation,
 Endocrine dysfunction.

Faulty readings because of:

 The two pointers not at zero/the reading not at zero
 Scale not well balanced,
 Scale not on a firm, flat surface,
 Too much clothes on the baby,
 Wet or soiled nappy
 Faulty previous readings,
 Different scales.

Physical observation
 Skin
 Head/ face
 Chest
 Lymphnodes
 Eyes, ears, nose, throat
 Genitalia, rectum
 Musculo-skeletal
 36

Dialogue with the parents (Watch mother/child relationship)

If the child’s progress is good:
 Praise the mother;
 Encourage her about breastfeeding and/or proper weaning practices;
 Give guidance for next step.

If not, explain this to the mother:

Encourage the mother to think of all events which can explain this such as:
 Any change in the feeding?
 Is the child eating well?
 Has the child enough balanced food to eat?
 Has the child been left in something else’s care?
 Has the child been sick?
 Has the child been hospitalized?
 Are any brothers and sisters underweight?
 Is the income/source of food adequate?
 Are decisions made on what to eat and how much?

ASSESSING NUTRITIONAL STATUS

 Monitoring the rate of growth is a key factor in health surveillance and promotion,
 When measured and results compared to norms, the degree of stunting (low length-
for age) or wasting (low weight-for-height) is appreciated (anthropometry).

ANTROPOMETRIC MEASUREMENTS
The following are the growth indicators based on the age, sex and measurements of weight-
for-age, length/height-for-age, weight-for- length/height, BMI-for-age

Weight-for-age:
 Reflects body weight relative to the child’s age on a given day.
 Used to assess whether the child is underweight or severely underweight
 Should a child fall below the -2 z-score – underweight,
 If below -3 z-score – severely underweight.

Advantage:
 Is relatively easily measured, cheap, simple and quick to use,
 Most frequently used – availability of scales in clinics,
 Measures either recent (acute) or long term (chronic) under- nutrition,
 Sensitive to small changes in nutritional status of child.

Disadvantage:
 Does not take height into account,
 A “healthy” child, genetically shorter may fall below the normal reference range of
weight-for-age,
 Need to know age of the child to the nearest month,
 Oedema and ascites may blur the picture (malnourished children).
 37

Length/height-for-age:
 This measurement of growth faltering reflects chronicity (due to prolonged undernutrition
or repeated illness) – stunting (short).
 A national stunting rate is usually indicative of poor overall socio-economic conditions of
a country (seen among less developed countries).
 Excessive tallness may reflect uncommon endocrine disorders.
 Should a child fall below the -2 z-score – stunted,
 If below -3 z-score – severely stunted.

Weight-for-length/height:
 Recommended measurements to diagnose severe malnutrition(wasting),
 Indicates whether or not the body is proportional,
 May confirm that the child is thin or overweight,
 Wasting can occur rapidly (seasonal changes in food availability, Dx prevalence),
 May be the result of a chronic unfavourable condition,
 Should a child fall below the -2 z-score – wasted,
 If below -3 z-score – severely wasted.

BMI-for-age:
 BMI-for-age is useful for screening for overweight and obesity

 See the MUAC cut-offs for Ages on the Handout: How to Measure MUAC in this unit:

o 6-59 months, Children 5–9 years, Children 10–14 years, Adolescents and adults
15 years and above (non-pregnant/post-partum) and Pregnant/post-partum
women.

 The classifications are: Severe Acute Malnutrition (SAM), Moderate Acute

Malnutrition (MAM) and Normal Nutritional Status

 A child with one obese parent has a 40% probability of being overweight

 With both parents, the probability goes up to 70%

Skull Circumference:
 Commonly used in paediatric practices,
 In the newborn infant, disproportionate sparing suggests recent weight loss,
 In reduction thereof in keeping with reduction in weight and length centiles suggests
prolonged intra-uterine malnutrition.

Mid-upper arm circumference:

 This measure detects loss of subcutaneous fat and muscle,
 Occurs in wasting (marasmus),
 Does not detect mild to moderate malnutrition,
 A cut-off of 13,5cm is used (12,5cm indicates severe marasmus),
 Can be done very quickly,
 Often used in emergency situations e.g. in targeting food aid during natural disasters and
conflicts.
 38

INTERPRETING TRENDS ON GROWTH CURVE

Trends may indicate that a child is growing consistently and well, or they may show that a
child has a growth problem, or that a child is “at risk’’ of a problem and should be assessed.
“Normally” growing children follow trends that are, in general, parallel to the median and z-
score lines. Most children will grow in a “track,” that is, on or between z-scores and roughly
parallel to the median; the track may be below or above the median.

Be aware for the following situations, which may indicate a problem or suggest risk:
 A child’s growth line crosses a z-score lines.
 There is a sharp incline or decline in the child’s growth line.
 The child’s growth line remains flat (stagnant); i.e. there is no gain gain in weight or
length/height.

A sharp incline on the child’s growth graph, after an illness and weight loss can be good and
indicate “catch-up growth.” For an overweight child a slightly declining or flat weight growth
trend towards the median may indicate desirable “catch-down.”

Upward direction of growth – GOOD

Catch-up – GOOD

Flat growth curve – WARNING

 39

Faltering of growth curve – WARNING

 40

Handout: How to Measure MUAC

1. Bend the client’s s left arm at a 90o angle.

2. Find the top of the shoulder and the tip of the elbow.
3. Keep the tape at eye level and place it at the top of the shoulder. Put your
right thumb on the tape where it meets the tip of the elbow.
4. Find the middle of the upper arm by carefully folding the endpoint to the top
edge of the tape. Place your left thumb on the point where the tape folds
(midpoint). Mark the midpoint on the client’s arm with chalk or a pen. Make
sure the tape is not twisted and is parallel to where the marking was placed.
5. Straighten the client’s arm so it is hanging loosely and comfortably at the side.
6. Wrap the tape around the midpoint.
7. Place the end of the tape through the window and correct the tension (not
too tight or too loose).
8. Read the measurement in cm in the window where the two lines meet.
9. Record the measurement to the nearest 0.5 mm.
41
 42

WHO has established MUAC cutoffs for children under 5 years old and is working to establish
cutoffs for older children and adults. Meanwhile, the cutoffs in the table below are based on
MOHSS guidelines.

MUAC CUT-OFFS

Severe Acute
Group Malnutrition Moderate Acute Normal nutritional
(SAM) Malnutrition (MAM) status

Children 6–59 months < 11.5 cm ≥ 11.5 and < 12.5 cm ≥ 12.5 cm

Children 5–9 years < 13.5 cm ≥ 13.5 and < 14.5 cm ≥ 14.5 cm

Children 10–14 years < 16.0 cm ≥ 16.0 and < 18.5 cm ≥ 18.5 cm

Adolescents and adults 15

years and above (non- < 19.0 cm ≥ 19.0 and < 22.0 cm ≥ 22.0 cm
pregnant/post-partum)

Pregnant/post-partum
< 19.0 cm ≥ 19.0 and < 22.0 cm ≥ 22.0 cm
women
 43

ROAD TO HEALTH CHART (RtHC)

The common purpose is to promote comprehensive child health through the

complementing actions of mother or caregiver and all health care personnel.
The format of the chart is meant to be uniform throughout the country to accommodate
children moving from one area to the other.
Pre-requisites for ‘success’ of RtHC
 Technical issues- sufficient, properly functioning equipment;
 Health worker must be able to weigh and plot correctly;
 Necessary knowledge and understanding for the health worker to assess and interpret
the findings;
 Ability to identify the probable cause of any growth faltering, whether this be related
to infection, due to insufficient food intake, or other emotional and social factors;
 Access to resources both human and, where necessary, material to react
appropriately and effectively. Action may range from complimenting and reinforcing
‘good progress’ to instituting or arranging for essential health care;
 Emergency food supplements or access to further clinical care have to be available
or accessible when needed.

Benefits of the RtHC

 Shows phenomenal growth and development which are the hallmarks of healthy
infancy and early childhood;
 Allows sharing of information concerning the child progress;
 Enables mothers as well as health workers to envisage progress and to react
accordingly;
 Promote good relationship between health worker and parents or caretaker and
family;
 Children at risk or needing extra care can be identified;
 Is a valuable diagnostic, intervention, evaluation and educational tool;
 Has wider applications for community studies e.g. the number of malnourished
children or on vaccination coverage;
 These studies may influence health and nutrition policies and planning;
 Provides the opportunity for early and therefore less costly action when growth
faltering is recognized before there is overt ill health.

FACTORS AFFECTING CHILD GROWTH AND NUTRITION

Drought:
Drought is a perennial event in Namibia, and can have a direct and dramatic impact on
food security and nutritional status of the vulnerable groups of the population.

 Crop producing farmers: low or no harvest,

 Live stock farmers: loss of animals – little or no milk and meat,
 Commercial farm labourers: loss of job, no income, their family’s place of residence is
lost.
 44

Water supply:
 Safe reliable supply of safe water is necessary for drinking, cooking, personal and
domestic hygiene,
 Is used for animal husbandry and agriculture and industrial development,
 Hence essential for economic development of any community especially the
vulnerable groups, and health of its members at large.

Sanitation (Environmental hygiene):

 Household refuse (left-over food, peels, leaves, plastics, etc) attracts flies and rodents,
decomposes and gives rise to odour and is unsightly, i.e. it becomes a nuisance,
 Domestic water waste for bathing, cooking, laundry and other domestic purposes.
Disposal areas are premises of the householder’s property in rural areas attracting flies
by accumulated water in offensive puddles on the surface thus causing diseases,
 Human excreta contain large amount/numbers of pathogenic microbes and the ova
of parasites:
o Attract flies and encourage their breeding,
o Pollute the land/soil,
o Contaminate water and food.

Cultural practices
Good nutrition starts in the womb and should be followed after birth by optimal
breastfeeding and appropriate weaning practices.
Food taboos cause small children and pregnant women not to be fed with appropriate
foods at the right frequencies to assist growth.
 Food – disease relationship
 Cultural “super-food”
 Special occasion food
 Breastfeeding restriction
 Superstitions

Socio-economic Structure
 High fertility rates
 Short birth intervals
 Women’s workload
 Poor household income
 Poverty
 Poor education
 Absent fathers
 Unequal distribution of food
 Demography of an area
 Urbanization
 Unemployment
 Inflation

Physical problems
 Illnesses/infections
 Malnutrition
 Prematurity
 45

 Inheritance
 Mass at birth
 Disability or handicap
 Congenital defects
 Metabolic abnormalities
 Endocrine abnormalities
 Emotional illness

Household Knowledge, Attitudes, Practice (KAP)

 Food resources
 Lack of information – food preparation and combination
 Health and sanitation practices
 Weaning and feeding practices
 Alien food practices
 Poor food storage and preservation
 Unsafe water usage

Healthcare Services
 Maternity Services: ANC and PNC, Family Planning
 Under-five’s clinics
 STD clinic, HIV and AIDS clinic

Guidelines for action

Illness
 Asses
 Diagnose
 Treat
 Refer
 Advice
Inadequate feeding
 Increase feeding – breast or otherwise
 Provide nutrition education to the mother
 Advice on family planning
Lack of food
Suggest practical solutions based on their actual local situations
 Seek assistance at family or friends
 Involve/educate the father through home visits
 At community level (headman, church, governor, social workers)
Social and Economic Problems
 Community support for action
 Social workers
Very poor health
 Refer to health facility.

NB!! Make use of GOBI-FFF principles in all your encounters with your clients!!
See Unit 2
 46

Unit 6 HISTORY TAKING

Introduction - A process of data collection and interpretation

The acquisition and interpretation of data, is the first stage in the process of assessing
the patient. Thorough planning of effective patient care depends on accurate and
complete collection of data for analysis and decision-making to plan care. Successful
data gathering depends, to a large extent, on the health care practitioner’s ability to
communicate effectively with the patient.
The interview is the technique used to get a history from the patient. Assessment
begins from the moment you make initial contact with the patient, and continues
throughout the interview. During the interview you will get information about the
patient’s health and feelings – verbally and in writing – while also observing gestures,
facial expression, body posture and changes in voice intonation.
The history is the most important component of the database and is a reflection of the
patient’s personal experience of his problems. It is generally accepted that at least
80% of all diagnoses can be accurately made by obtaining a complete history. A
diagnosis is the interpretation of the patient’s complaints and is based on the history
and physical examination.
The data provided by the patient when describing his illness is referred to as
‘symptoms’, whereas a ‘sign’ is something observed by the examiner that is a
deviation from the normal.
Approaches
Health oriented approach
The health oriented approach is concerned more with the maintenance of healthy
eating, and daily habits and routines which will improve health and promote a healthy
way of living. Data gathering will therefore be concerned with the current health
status and lifestyle of the health care user.
Disease / problem oriented approach
The information gathered relates to the present condition of ill health and hgow it
compares with the patient’s previous health status. It also looks at the patient’s
experience (symptoms) of the illness, what this means and what coping mechanisms
are being used. In this way the patient’s experience and the process of the illness are
revealed.
A database
A database is the data obtained during history taking and a physical examination,
together with the results of relevant special investigations and tests. It is not possible
to gather all data regarding the patient. The aim is to gather the information that will
have the most value with regard to the patient’s current circumstances.
3 phases
Phase 1 Introduction
The following should be considered during the introductory phase of the interview.
1. Interview scheduling – conduct the interview at a time that is suited to the
patient’s individual circumstances and be prepared to be flexible
2. Help patients feel at ease – try to make the patient feel at ease by
o Creating a pleasant and relaxed atmosphere,
 47

o Using a comfortable chair or examination bed,

o Arranging seating in a non-confrontational way, and
o Ensuring privacy
3. Identify roles and objectives – identify your role and discuss the objective of the
interview. Also, tell the patient how long the interview will take. With this
introduction, the patient knows what is expected of her, and she knows what to
expect from you. You can remove a lot of her possible anxieties, false
expectations and uncertainty just by introducing yourself properly and
explaining what you are abut to do.
4. Be sensitive to culture issues – be sensitive to the use of names in different cultures
and racial groups. Always check with the patient whether she prefers you to call
her by her first name or her surname. Simple communication to find out which
name is appropriate is respectful and helps to identify patients as unique people
at a time when they may be feeling quite anxious. This recognition also helps
lower your patient’s anxiety and increases her comfort level.
5. The reason for the visit – begin with the subject most important to the patient,
which is the reason for her visit to the health service
6. Ask open questions – ask open questions at the beginning of the interview and
do not try to assert your authority too much
7. Focus on your non-verbal behaviour – pay attention to non-verbal behaviour
such as a facial expressions or gestures and help the patient relax.

Phase 2 Active data collection

During this phase, use various interviewing techniques to encourage the patient to
talk. This will help you collect complete and accurate data within the specified time
period.
1. Directive interviewing techniques – these focus specifically on the subject under
discussion. These techniques are useful when you need to find out specific
information. Use directive techniques in an interview to;
 Get specific information
 Clarify what the patient has said
 Establish whether you have understood the patient correctly
 Draw the patient’s attention back to the subject if, for example, she has started
talking about something unrelated,
 When time is limited, and
 When the patient is not answering the questions accurately.
The following are directive interviewing techniques you can use.
Closed questions
Ask closed questions when you want specific information. Eg do you have pain in your
arm? You can also get a patient’s opinion by using this method eg do you think there
is a connection between the food you eat and your rash? These type of questions
often have only a ‘yes’ or ‘no’ answer.
Statements
Make statements to draw up the patient’s attention to your observations to find out
what her perception is, e.g. i notice you walk with difficulty. Is our foot sore?
 48

Repetition
Repeat* the patient’s explanation of her condition in more precise terms. This gives
you the chance to check the accuracy of the information the patient gives you, e.g.
do you man you fist felt the pain in your chest, and then you fell down? Or am i right
in thinking that you did not feel tired at the beginning?
Comparison
Use examples and draw comparisons to concrete events or objects. In this way a
vague or abstract concept can be more easily explained e.g. does the pain feel like
a sharp object that his you or a blunt object?
Transition
Use a transition to guide the conversation to another subject, without losing the
continuity of the interview, e. g. it seems to me that you have solved the problem of
your poor appetite yourself, but I would like to hear more about your diabetes. How
long have you been aware of this illness?
Sequencing
To effectively assess the patient’s needs, you often need to know the time frame within
which symptoms and/or problems developed or occurred. Ask the patient to place
a symptom, problem or an event in its proper sequence in time. This helps you to
become aware of any patterns in the patient’s behaviour that might indicate
recurring themes, e.g. did you experience this sharp pain before or after eating?
* indicates techniques that are also validatory in nature.

2. Non-directive interviewing techniques

Unlike directive techniques, which can limit a patient to one-word answers, non-
directie interviewing techniques give the patient a chance to talk more about their
problems. Non-directive techniques are useful for:
 Stimulating discussion,
 Encouraging the patient to convey her view of the problem,
 Validating or confirming information, and
 Reassuring the patient
The advantage of using non-directive techniques is that they give you the opportunity
to listen to the patient’s interpretation and experience of her problem. They also
create the opportunity for a relationship of trust to develop. Non–directive techniques
are effective for collecting data because you do not draw information out of the
patient, she gives the information freely. The following are non-directive interviewing
techniques that can be used:
Open questions
Ask open questions. Only suggest the direction of the answer, the patient is expected
to supply the structure in her reply. This type of question allows the patient to talk
about her view of the subject. In this way, what the patient sees as important, what
her intellectual capacity is and how well orientated she is, becomes clear. Open
questions also allow you to see how much the patient knows about the subject before
you ask her directly.
 49

Silence
Use silence to give the patient the chance to think, organise her thoughts, and use
her initiative or to show that she should continue talking about the subject. It also
gives you and opportunity to observe the patient. Avoid silences that last too long
because they can make the patient anxious.
Supportive remarks
Make supportive remarks to encourage the patient to continue with her account.
Show her you are listening by nodding your head
Reflection
Reflect* by repeating a patient’s word, sentence or phrase in exactly the same way
as it was said. This shows you are involved in what she is saying, and that she should
talk more about a specific point, or explain it further.
Summarise
Summarise* by organising and checking what the patient has said, especially after a
detailed discussion. Use this technique to indicate that a specific part of the discussion
is coming to an end and that if the patient wishes to say any more, she should do so.
Confrontation
Confront* a patient with an observation you have made and assess her reaction to it.
This technique is very useful when verbal and non-verbal communication do not
match
Interpretation
Interpret* or draw a conclusion from the information you have gathered and discuss
it with your patient to see whether it is true. The patient can then disagree with it, or
confirm that your conclusions are true, or she can give you her own interpretation.
You can also express your interpretation as interest or confrontation, e.g. you must
have been tired after such a long period in hospital
* indicate techniques that are also validatory.

Phase 3 Conclusion
Once you have actively collected data using directive and non-directive techniques,
you should now have enough information to take the next step in the interview
process. At this point, summarise the information briefly and allow yourself and the
patient to check whether the data is accurate and complete. Then, propose a plan
of action to the patient before finishing the interview.
During this phase, patients often express their fears, ask questions and tell you about
their expectations of themselves and those who will be treating them. You can
determine whether these expectations are realistic or not.
You won’t be able to finalise the discussion of the plan of action until you complete
the physical examination and collect any other relevant data.
 50

Subjective data: what the patient says

A database consists of objective and subjective data. Subjective data consists of the
history obtained from the patient. During this process, interviewing skills are used to
help the patient describe their experience of their health status or their health
problem. This includes his chief complaint or reason for the visit, history of the present
illness, previous history, history of family illness, psychosocial history and an overview of
the systems of the body.
Objective data: what the nurse observes or sees
During physical examination, objective data of the patient’s health status or of the
pathology related to the illness is obtained. Apart from the fact that additional
information is obtained during the course of the examination, the health care
practitioner also gets the opportunity to verify and validate the data taken during
history taking.
Requirements for a successful interview
Be sensitive to the patient’s needs
Show your sensitivity by asking a question about the subject that is most important to
the patient at the beginning of the interview, eg what made you come here today?
First allow the patient to discuss what is worry8ing him the most. This assures him you
care about his problem, and that he is, to a certain extent, in control of the interview.
This feeling of control will encourage him to take a more active part in the discussion.
Getting this information will also help you later in determining a priority list for the
patient’s care.
Maintain a low-authority profile
Maintain a low-authority profile at the beginning of the interview. As the interview
progresses and you use more directive techniques, you can gradually show more
authority. With this approach, the patient should report his problem easily and
spontaneously. Spontaneous reporting gives the broadest spectrum of relevant data.
Be clear und understandable
Determine the patient’s level of understanding and change your use of language,
comments and questions accordingly. Be clear in the nature and sequence of your
questions so that they are not confusing. Using terminology which the patient does
not understand can also frighten him and make him think he has a more serious
problem than he originally wanted help for. At the same time, the patient could give
incorrect information because, in his confusion, he gives affirmative answers to
questions about symptoms that he has not actually experienced.
However, note that patients often have knowledge of medical terminology and use
it in their everyday language. In such instances, give recognition to the patient by
using the terminology he knows after you have clarified the patient’s understanding
of it.
Listen attentively, not prejudice
Although the patient does most of the talking while you listen, make the listening
process active. Lead the patient by eye contact and appropriate gestures and
silences to give a reliable account of her story.
 51

When the patient is discussing his chief complaints and current illness at the beginning
of the interview, listen without interrupting. If the patient lapses into silence every now
and again, try to help him organize high thoughts. If the silence lasts too long, indicate
that you are still interested by saying ‘ yes’ ‘go on’ or ‘I see’, or nodding your head.
Silences that are too long can make the patient anxious, so intervene to give direction
to the discussion again.
Keep personal distance
When they are tense, most patients need physical contact with a person who shows
understanding and is helpful. Comfort such patients by touch on their shoulder or
hand. However, some patients become anxious if there is contact during the first visit.
They show their dislike by mov8ing away from you or sometimes even being reluctant
to give information.
Provide information to client - withhold advice and opinion for a later stage
During history taking, you will often have to answer questions about the examination.
But do not give information about the management of the problem. A patient whose
mind has been put to rest is more cooperative during the physical examination than
a patient who has doubts. By offering advice to the patient at this stage of
assessment, you may encourage him to be unhealthily dependent on you. By doing
this, you may prevent one of the objectives of care, which is to make the patient as
independent as possible in making decisions about his own health.
Be frank / honest
Although the interview is not an informal discussion, it must take place in an
atmosphere of openness and honesty. This is to ensure that there is trust between you
and the patient and that information is not withheld.
Be formal / professional
The interview must have a certain formality. This does not mean that it has to be ‘stiff’
or ‘cold’. However, it is a professional discussion, not a social chat.
There are usually differences in age, sex, occupation, cultural background and moral
and religious convictions between you and the patient. These differences make it
impossible for you to fully understand the patient’s behaviour and reactions.
You could hamper communication between you and the patient if you express your
opinion about certain behaviour or habits of the patient that you do not agree with
during the interview.
Culture
Be aware of trans-cultural issues. Be sensitive when dealing with someone from a
different culture. What is acceptable for one patient may not be acceptable for
another. Given the complexity of culture, no one can possibly know the health
believes and practices of very culture.
The use of eye contact, touching and personal space is different in various cultures
and rules about eye contact are usually complex, varying according to issues such as
race social status and gender.
 52

Avoid the following:

To complete the interviewing process as effectively as possible, you must guard
against a one-sided use of techniques, such as asking inappropriate questions, or
using a style that will damage communication between you and the patient.
Leading questions e.g. do you have a cough
Leading questions are questions that suggest and answer. In other words, a question
that shows you have a specific expectation, e, g.’ Do you feel tired when you get up
in the morning? Instead of :’How do you feel when you get up in the morning?’
This type of questions can reduce the value of the data being collected, as you are
already suggesting the answer to the patient, who then replies affirmatively and will
not disagree with you so they do not disappoint you, or to satisfy you.
Multiple questions in one
When you ask two or more questions in a single sentence, the patient may decide to
answer only one part of the questions and then you will have to repeat the other part
of the question. This confuses the patient and wastes valuable time.
Excessive use of open questions
When you ask too many open questions, you pass control of the interview to the
patient and you may lose time by collecting inappropriate, long-winded information.
Excessive use of closed question
When you ask too many closed questions, the interview may become one-sided. This
usually limits the quality and the quantity of information provided and can cause the
patient embarrassment
Questions which may antagonize the patient
Guard against asking questions that can antagonise the patient or make him
negative towards you and the interview. The patient may feel that you are being
critical. Words like ‘why’ ‘why not’ are often interpreted incorrectly, e. g. ‘Your blood
pressure is still high, why didn’t you take your pills?’ Rather say ‘Did you not take your
pills?’
Interruption of the interview
When a patient is interrupted, his train of thought or feelings are disrupted and he
often finds it difficult to return to the subject. He could also interpret your interruption
as a lack of interest in his problem.
Hasty reassurance
A comment like: ‘I am sure everything will turn out alright, ’ may shock the patient and
suggest a lack of insight. It can also block attempts to get more information about the
problem. Rather discuss a problem with the patient, than make meaningless
comments.
 53

Different types of patients

 Quiet
 Talkative
 Anger / aggressive
 Nervous
 Tired / uncomfortable
 Patient with multiple symptoms
 Confused patient who has obscure (unclear) history
 Evasive
 Infant / young child
 Adolescent
 Elderly

Framework for history Taking

A comprehensive history has eight components:
1. Socio graphic data
2. Main complaint / reason for consultation
3. History present illness
4. Previous history – medical, obstetrical, surgical history
5. Family history – disease, genetic
6. Overview of systems
7. Nutritional history
8. Daily living activities

Component 2:
Main complaint or reason for visit
The main complaint or the reason for a patient’s visit comprises a statement in the
patient’s own words.
Record the complaint exactly in the patient’s own words, or as close to his own words
as possible, using quotation marks. The main complaint serves only as a lead to a more
detailed history.
Use the following guidelines to record the main complaint:
 Limit the main complaint to a brief statement about a single symptom (two at
the most). If more symptoms stand out, rather record them under the
component discussing the assessment of the present illness.
 Record the patient’s own words or as close to his own words as possible, using
quotation marks.
 Refer to a concrete complaint.
 Avoid using diagnostic terminology or names of diseases, except if the patient
uses them himself.
 Include the length of time the patient has experienced the symptom.

When you get the patient’s main complaint in his own words, it continually makes you
aware of the patient’s reasons for his visit and as well as his needs. If you identify a
more serious problem in addition to the main complaint, the patient will not be
satisfied if you do not attend to what he thinks is his main problem.
 54

Once you have found out about the patient’s main complaint, start to assess the
complaint in more detail under the next component of the history taking framework.
In the case of a healthy care user, state the patient’s request for a routine examination
as the reason for the visit.
Component 3: Present illness
The history of the present illness is an extension of the main complaint and describes
how each symptom developed in a chronological order. The data should be
comprehensive but concise, and should include the patient’s opinions and feelings
about the illness.
Analyse the symptoms in terms of three aspects:
 onset or start of the symptom,
 characteristics of the symptom, and
 course of the symptom.

In addition to the analysis of symptoms, and as part of the history of the current illness,
find out how much the disease has influenced the patient’s life at physical, social and
economic levels. This will also give you an indication of the patient’s insight into the
seriousness of his illness. Then find out how the patient is coping with his illness. Finally,
find out what the patient thinks is the cause of his illness. You can frequently get
valuable information from this. On the other hand, if the patient’s concept of his illness
is totally incorrect, his remarks give you the opportunity to observe his train of thought
and his feelings, and puts you in a position to correct his misunderstandings.
While you assess the patient’s current illness, you will probably need to know a bit more
about his background such as the illnesses or operations he has had in the past, as
these might have an effect on his problem today.
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Component 2 and 3:
Data be collected during the analysis of a symptom of the main complaint and
present illness
Analysis of a symptom Appropriate question

Onset
 Date of onset On what date did the symptom start?
What time did it begin?
 Nature of onset How did it begin: gradually, suddenly?
 Precipitating or predisposing Under what circumstances did it start:
factors during exercise, sleep, driving a car, tension
or during a holiday?
Characteristics
 Nature What does it look like (e.g. sputum?)
What does it feel like (a stabbing pain,
burning pain)?
 Localisation and spread (e.g. Where does it present in the body and
pain, rash, secretion) where does it spread to?
 Intensity or seriousness (quality) How serious is the symptom?
Does it interfere with activities and to what
degree?
Does it force you to sit or lie down?
 Frequency (quantity) How often does it occur? Hourly, daily,
periodically, repeatedly, continuously?
 Duration How long does it last? A few minutes, an
hour or does it persist?
 Factors that aggravate or relieve What makes the symptoms better or worse?
it Change of position, change in diet, taking
medications?
 Associated symptoms Does the symptom lead to something else?
Are there other problems that accompany
it, such as nausea, temperature or difficulty
in breathing?
Course
 Progress Is the symptom getting worse or better or
does it stay the same?
 Effect of treatment Does the symptom improve or remain the
same with treatment?

Recording the data

The written is the most effective method for transferring permanent data. The written
record is a working document of all findings, and all the health care givers looking
after the patient share this information. They will manage and later examine the
patient according to this baseline information.
Although writing reports is time-consuming, it is efficient because it eliminates the
possibility of the data being forgotten and the consequent repetition of data
collection. It is available to everyone involved and can easily be consulted.
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If many health care practitioners are going to be using the same record, it makes
sense that the record must communicate the data clearly and effectively. This
enables all health care practitioners to understand the information in the record and
to give the patient the best possible treatment.
Interpreting the data
When recording, you should avoid interpreting observations or measurements or
making assumptions, particularly when the information is incomplete. Only interpret
the data after you collect all the relevant information. This includes the information
you still need to get during the physical examination.
Interpreting the data has cognitive sub-components, such as the analysis and
synthesis of the collected data. You need to analyse and synthesise the collected
data so that you can properly interpret it and identify the patient’s health problem.
This is when it will become clear that the information you have collected is not enough
to establish what the problem is and that it is necessary to collect more information.
Use an organised, systematic method of data collection to resolve this problem.
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References
Aday, L.A. (Ed.). (2005). Reinventing public health: Policies and practices for a healthy
nation. San Francisco, CA: Jossey-Bass.
Allender, J.A., Rector, C., and Warner, K.D. (2010). Community Health Nursing
Promoting and Protecting the Public’s Health 7th Edition Lippincott Williams & Wilkins

American Academy Paediatrics (AAP) (2020). Understanding the Economics of the

Health Care Environment

www.aap.org › en-us › practice-transformation › economics › Pages

Kernick, D.P. (2000). The Impact of Health Economics on Healthcare Delivery

Pharmacoeconomics 18, 311–315 (2000). https://doi.org/10.2165/00019053-
200018040-00001