COMMUNITY HEALTH NURSES’ TRAINING COLLEGE-

NAVRONGO

LECTURE NOTES ON COMMUNITY NURSING II

COMPLY

BY

AKIBEH SHIRLEY

&

DAVID A ADUGBIRE

COURSE DESCRIPTION
This course is intended to equip the student with knowledge, skills, and attitude to assist in

the delivery of primary health care, CHPS and community –based rehabilitation services at

the community level. Additionally, it will enable the student to assist the individual, family

and community members to prevent diseases and promote their health.

COURSE OBJECTIVES

By the end of course, the student will be able to;

 Explain primary health care

 Explain the concept of community –based health planning and services(CHPS)as a

strategy for the implementation of primary health care

 Explain the CHPS process

 Describe the community based rehabilitation (CBR)

 Detect minor ailments, childhood impairment and disability

 Identify agencies dealing with persons with disabilities

 Assist in the identification and referral of clients with disability

COUSRE CONTENT

1. Primary health care

 Explanation of primary health care

 Goal and objectives

 Components and challenges

 Levels of organisation strategy

 Working with various health teams

2. Community-Based Health Planning and Services (CHPS)

  Basic terminologies in CHPS

 CHPS Zones

 CHPS Compound

 Community Health Officer (CHO)

 Community Health Volunteers (CHVs)

 Community Health Management Communities (CHMC)

 CHPS Concept , strategy and process

 CHPS implementation Milestone

 Community Mobilisation And Participation

 Community Mobilisation Tools and Approaches

i. Participatory Learning and Action (PLA)

ii. Community Health Action Plan (CHAP)

 PLA Tools and Technics

i. Transect Walk

ii. Community Mapping

iii. Matrix

iv. Venn Diagram

v. Pair wise Ranking

vi. Pie Chart

vii. Mapping

viii. Semi structured interviews

 Community Diagnosis

 Benefits and challenges of CHPS program

3. Community Based Rehabilitation

  Explanation of impairment, disability and CBR

 Causes and prevention of impairment and disability

 Identification of disability

 Stigma and discrimination

 Types of rehabilitation; institutional, outreach and community-based

 Levels of rehabilitations: primary, secondary and tertiary

 Referral to agencies for rehabilitation services

 Counselling

4. Documentation and record keeping

CHAPTER ONE:
PRIMARY HEALTH CARE

DEFINITION OF PRIMARY HEALTH CARE

Primary health care is an essential health care that is based on practical, scientifically sound

and socially acceptable methods and made universally accessible to individuals and families

in the community through their full participation and at a cost the community and country can

afford to maintain at every stage of their development in the spirit of self-reliance and

determination.

According to World Health Organization (WHO), Primary Health Care refers to a package of

health care that is taken to the homes of individuals and families with an approach beyond the

traditional care system and focuses on equity- producing social policy.

It forms the nucleus (central part) of the country‘s health system. PHC therefore addresses the

health problems in the community by providing promotion, preventive, curative and

rehabilitative services accordingly.

ESSENTIAL TERMS IN THE DEFINITION OF PRIMARY HEALTH CARE

1. Essential: Health service is important or peculiar to meet the health needs of the people

2. Accessible: Bringing the health service very near or at easy reach to the people in the

community

3. Universal: Health service is provided to everyone, that is, all nations, races, ages and sexes.

4. Acceptable: The service provided should be acceptable (culturally sensitive and

acceptable) and user friendly. The health worker should be sensitive to the reaction of the

people in order to assess the acceptability of the services.

5. Affordable: The nation, community, family and the individual should be able to afford the

health service provided.

WHY AND HOW PRIMARY HEALTH WAS ADOPTED

Before this model (primary health care) was adopted in the declaration in the international

conference held Alma Ata in1978, access to health care was influenced by politics, social and

economic status/class which results in health inequalities in almost all countries. This

inspired the primary health care movement made up of professionals in institutions,

governments and civil society organizations to organize the Alma Ata Conference with the

objective of tackling the politically, socially and economically unacceptable health

inequalities in all countries. The concept primary health care was then adopted and endorsed

on 12th September 1978 under the authority of some health related agencies such as World

Health Organization (WHO), United Nations International Emergency Fund

(UNICEF),United Nations Educational, Scientific and Cultural Organization (UNESCO) with

the goal “health for all” by the year 2000. Since then primary health care forms the central

part of the health care system and addresses the main health problems in the communities

through providing promotive, preventive, rehabilitative, and curative services to individuals

in the community. The other reasons why the primary health care concept was adopted

include;

1. Many people were still getting sick in spite of the financial inputs in the health

care system.

2. There were no health facilities in the rural areas where people could access health

care services

3. Most of the budgets issued by the ministry of health (MOH) were only use to

maintain and purchase sophisticated (complex/complicated) hospital equipment

for the urban areas

 4. Health services were only available for the thirty percent (30%) of nation’s

population in the urban areas while the seventy percent (70%) of the population in

the rural areas were neglected.

REASONS FOR PRIMARY HEALTH CARE IN GHANA

Even though health delivery in the country has developed and continued to improve, even

before the advent of orthodox health services till the present. It was realized that even

scientific health care then could not address most of the health problems it was purported to

address due to the reasons stated below.

1. Emphasis was placed on construction of health facilities rather than provision of health

service

2. There was the training of sophisticated health personnel, such as doctors, nurses,

pharmacists, technologists, and so on, most of which were designed to work in the hospitals

in the urban areas at the disadvantage of the rural areas

3. Inadequate and inequitable distribution of the health staff and equipment in the health

institutions

4. Health services were more curative than preventive and had failed to decrease the

unnecessary deaths of children under one year, and also failed to control endemic diseases.

5. There was a top - down health care delivery. This means the hospitals catered for only 30%

of the total population in the cities and towns, and the rural people which form 70% were

neglected

6. There was lack of community involvement and participation in the own health care
7. Lack of collaboration with the other sectors e.g. health related agencies and other

ministries.

THE CONCEPT OF PRIMARY HELTH CARE

The realisation of the failure of the Health service and of increasing lack of equality in

distribution made it essential to adopt primary health care. The concept was formulated

(expressed) by 134 nations who met in 1978 at Alma Ata (Russia) conference by the World

Health Organization and United Nation Children Fund (UNICEF). It was known as the Alma

Ata Declaration.

The known standard of definition of PHC is’ Essential Health Care based on practical

scientifically, sound and sociably acceptable methods and technology made universally

accessible to individuals, their families and communities through their full practicing at cost

they can afford.

It aimed at providing health service to the people at their door step. It also aimed at

providing an acceptable level of health delivery for all people of the world by the year 2000.

GOAL

The ultimate goal of primary health care is better health for all by the year 2000.

ELEMENTS OF ACHIEVING THE GOAL.

The WHO identified five key elements to achieve the Goal

•Reducing exclusion and social disparities in health (Universal coverage in health)

•Organizing health service around people’s needs and expectation (service delivery reforms)

•Integrating health into all sectors (Public policy reforms)

•Pursuing collaborative models of policy dialogue (leadership reforms)

•Increasing stakeholder participation.

MAIN OBJECTIVES OF PRIMARY HEALTH CARE (PHC)

To achieve the set goal “health for all” by the year 2000, the following objectives were

adopted;

1. To extend coverage of health services from the present thirty percent (30%) to eighty

percent (80%) by the year 1990

2. To reduce or treat those conditions which causes eighty percent(80%) of unnecessary

sickness, disabilities, and deaths among Ghanaians

3. To increase community participation as far as possible in the health care delivery

4. To attain a level of health that would enable every individual to live a socially and

economically productive life by the year 2000

COMPONENTS OF PRIMARY HEALTH CARE

1. Health Education on Prevailing Problems and Prevention The health Education is

geared towards the eradication of endemic but preventable problems, which include those

related to food supply and consumption such as Protein-Calorie Malnutrition, sanitation

problems, as well as problems related to reproductive and child health issues.

2. Promotion of Food Supply and Proper Nutrition This aims at encouraging individuals

in the community to improve on their farming habits in order to increase the yield on the

same farm in order to suffice the ever increasing population. Individuals and groups were to

be taught and supported to rear domestic animals for family consumption. In addition,
modern techniques of farming and cheaper yielding crops were introduced, as well as, other

actions to improve food security.

3. Promotion of Environmental Hygiene Most of the preventable health problems and

conditions were related to insanitary environments. As such, necessary to educate the

community members on the need for adequate supply of good drinking water, proper

ventilation, good housing and good refuse disposal methods

4. Maternal and Child Health, and Family Planning

The health problems include high maternal mortality and high infant mortality, as well as,

morbidity rates. Birth intervals were also short resulting in large family sizes with attendant

problems. Measures put in place to reduce these problems included: Screening for risk factors

and giving the necessary care, health education on how to care for the child, as well as,

education on family planning and provision of the various family planning methods.

5. Prevention and Control of local Endemic Disease. Most of the endemic diseases include

malaria, malnutrition, diarrhoea diseases and tetanus of new born. They are prevented by the

use of chemoprophylaxis, case finding, and early treatment, as well as the use of oral

rehydration therapy to control diarrhoea.

5. Immunization against Communicable Diseases

This is achieved by the immunization against the killer disease of childhood. In addition to

that, the appropriate immunizations were also given during outbreaks of communicable

diseases. Mothers are educated on the importance of immunizations and also how to give first

aid management to sick children in the home.

6. Provision of Essential Drugs

Common drugs were to be made available at all times for the treatment of common diseases

and ailments. The Traditional Birth Attendants and Community Health Workers are trained to

administer simple drugs for conditions like malnutrition. Food deficiencies, malaria,

diarrhoea, worm infestation and first aid management for injuries

7. Appropriate Treatment of Common Diseases

This lays emphasis on the use of local procedures, herds, equipment and facilities to combat

most endemic conditions instead of relying on foreign drugs. These measures include the

preparation of ORS, use of local preparations like strained rice water fluid, coconut juice,

water from boiled kenkey and any such fluid, for the management of diarrhoea. Malnutrition

is also treated by using local foodstuff for complementary feeding. Prolonged breast feeding

was also to be encouraged.

8. Basic health education Health education related to disease prevention and general health

promotion in individuals, families and the community. Topics were selected for teaching and

the message prepared. Simple health education materials prepared to facilitate the process of

understanding the topics.

9. Rehabilitation and prevention of accidents

10. Mental health the activities of mental health included primary, secondary and tertiary

prevention with emphasis on practice in the community rather than practice in institutional

setting. The primary prevention activities focused on the prevention of mental and emotional

disorders. These included mental health education and mental health counselling. Secondary

activities aimed at preventing mental illness from developing in people at risk. Tertiary
prevention of mental illness is more specific and addresses the care and management of

clients who experience serious or long-term psychiatric problems.

PRINCIPLES OF PRIMARY HEALTH CARE

The rules governing the delivery of primary health care services as identified at the Alma

Ata Declaration placed emphasis on the following;

1. Equitable distribution of health care: primary health care services must be provided

equally to all individuals irrespective of their gender (sex), age, color, location (urban

or rural) and/or social status

2. Community participation: community members must be involved in all aspects of

health service delivery such as assessment, planning etc in order to make the fullest

use of local, national and other available resources to solve their problems

3. Multi-sectorial approach: primary health care service delivery must be

linked/collaborated with other sectors such as the agricultural, education, housing,

water and basic sanitation etc to promote the health and self-reliance of communities.

4. Appropriate technology: the methods used or provided must be accessible, affordable,

feasible and culturally acceptable to the recipient/individual and/or the community.

5. Manpower development: training and/or re-orientation of existing health workforce

must be included in primary health care since comprehensive health care relies on

adequate members and distribution of trained staff and other members in the health

team to support at the local and referral levels.

LEVELS OF PRIMARY HEALTH CARE

 Level A- Community level

 Level B- Health centre level

 Level C- District level

LEVEL A - COMMUNITY LEVEL

The staff of level A is selected and compensated by the community members with the help of

the district and sub district health teams.

They were resident in the communities, and trained to improve on their knowledge and skills

they already have. Continuous training in the form of refresher courses were organized for

them, and continuing technical supervision provided by the Ministry of Health. They were

trained in the preventive, promotive and therapeutic procedures.

What was the mode of compensation for the staff of level A?

STAFF OF LEVEL A

1. Trained Traditional Birth Attendant (TBA)

2. Community Clinic Attendant (CCA) or Village Health Workers (V.H.W)

3. Community Based Distributors

DUTIES OF THE TRADITIONAL BIRTH ATTENDANT (TBA)

1. Management of pregnancy and labor

2. Counsel on personal and environmental hygiene, nutrition, care of babies and family

planning.

3. They practice aseptic techniques to prevent infections

4. They keep records for the services given and report to level B

5. Early referral of cases beyond their control to level B.

DUTIES OF THE COMMUNITY CLINIC ATTENDANT (CCA)

1. He administer correct doses of approval drugs

2. He recognizes serious cases and refers to level B

3. He treats minor illnesses

4. He educates the community on environmental sanitation

5. Organizes and mobilizes the community for communal labor

FUNCTION OF THE COMMUNITY BASED DISTRIBUTOR (CBD)

The function is basically the distribution of contraceptives to the community.

LEVEL B- HEALTH CENTRE

This is the immediate referral point for level A. it is headed by the medical assistant.

STAFF OF LEVEL B

1. Medical assistant is the leader

2. The community health nurse

3. Midwife

4. Enrolled nurse

5. Disease control assistant (FT)

6. Nutrition assistant

7. Supporting staff

FUNCTION OF LEVEL B

1. Training and technical supervision of level A

2. Diagnoses and treatment of diseases and injuries

3. Immunization of children and pregnant women

4. Supervision of pregnant and delivery, identification of high risks and refer

5. Training of level A staff

6. Collection of data from both levels B and A, and collating to level C

7. Control of communicable diseases

8. Ensuring food, water and environmental protection

9. Acting as liaison between level C and A

10. Level B serves as a point of contact with MOH

11. It serves as first referral point for level A

LEVEL C OR THE DISTRICT LEVEL

The district level is the highest level of the primary health care system.

STAFF OF LEVEL C

1. District Director of the Health Services

2. The District Public Health Nurse

3. The District Disease Control Officer

4. Hospital Secretary.

5. Other members

FUNCTIONS OF LEVEL C

Most of their activities are supervisory and:-

1. Planning budgeting and general management of the district health service

2. Supervision of level B staff

3. Provision of technical expertise

4. Take care of the referrals from level B.

Working with Members of the Sub – district Team

STAFF OF THE SUB – DISTRICT

1. Medical assistant

2. Midwife

3. Community health nurse

4. Disease control officer / assistant

5. Health inspector / assistant

6. Enrolled nurse

7. Ward assistant

8. Dispensary assistant

9. Birth and death registry officer

 10. Record assistant

11. Orderly

12. Driver

13. Community members’ representatives

DUTIES OF THE WARD ASSISTANT

1. Helps in making beds

2. Helps in wound dressing

3. Runs errands for the staff

4. Daily dusting

5. Takes care of the sluice room

6. Takes vital signs

7. Helps in serving meals

8. Assists in bed bath

9. Assists the nurse and the midwife

10. Cleans the ward

DUTIES OF THE RECORD KEEPER

1. Registers both new and old patients

2. Issues OPD cards

3. Files the cards during consultation and treatment

4. Picks cards for old patient when they report to the clinic

DUTIES OF THE DISPENSARY ASSISTANT

1. Dispenses drugs to out -patients

2. Collects drugs from the district level

3. Manages the dispensary

4. Reports to the medical assistant concerning stock levels

DUTIES OF THE ORDERLY

1. Carries out daily cleaning of the wards

2. Weeds the surroundings of the health center

3. Runs errands for the staff

4. Arranges the chairs and tables for the out patients to sit on

5. Maintains cleanliness of the health center.

DUTIES OF THE DRIVER

1. Reports to the Medical Assistant

2. He is in charge of the vehicle at the Health Centre

3. Transports staff to outreach clinics

4. Runs official duties for the Medical Assistant.

DUTIES OF THE ENROLLED NURSE

1. Does Daily dressing of wounds

2. Give Daily injection to patients

3. Consults with the Medical Assistant or Medical Officer

4. Takes care of detained patient

5. Checks vital signs of patients

6. Assist the Medical Officer

7. Accompanies referred cases

8. Runs errands for the Medical Assistant or the Medical Officer

9. Gives first aid during emergencies

DUTIES OF THE MEDICAL ASSISTANT

1. Trains and gives technical supervision to level A

2. Diagnose and treat cases

3. Does Consultation and counseling

 4. Refers cases to higher level

5. Manages the day to day affairs of the clinic

6. Manages the financial aspects

7. Organizes workshop for staff

8. Write and submit report to the district

DUTIES OF THE MIDWIFE

1. Renders antenatal service

2. Renders family planning service

3. Conducts deliveries

4. Runs postnatal clinic

5. Writes and submits report to the sub-district and district.

DUTIES OF COMMUNITY HEALTH NURSE

1. Conducts Home visit

2. Runs Child Welfare Clinic

3. Family planning

4. Assists in running Ante Natal Clinics

5. Conducts school health services

6. Assists in day care inspection

7. Does community entry and collects information from the community

8. Performs Health Promotion activities.

9. Does Record keeping and report writing

10. Supervises Traditional Birth Attendants

DUTIES OF THE DISEASE CONTROL OFFICER

1. Identifies communicable disease and treat

2. Refers cases to the district level

 3. Notifies any outbreak of disease of the district level.

4. Gives immunization on specific diseases in the community

5. Manages the cold chain system and allocates vaccines.

THE PROBLEMS OF PRIMARY HEALTH CARE

The problems associated with the practicality of the Primary Health Care should not be

overlooked. These can be categorized into:

NB. Peculiar problems of staff at level A

1. Infrastructure problems

2. Socio-economic problems

1. Infrastructure Problems. The community members being generally poor could

not afford to put up a clinic.

When this problem was solved mostly with the help of benevolent groups, the

equipping and maintenance of the clinics also became a problem.

They did not also have motorable roads through which to transport the patient easily

to either level B or C.

2. Socio-Economic factor .With the inception of the cash and carry system in Ghana,

the community members especially at level A found it difficult to stock their clinic

because of their low income levels, more so when they are not paid.

Another social problem was the fact that because they are not to give injections but

oral drugs, the people were not satisfied with their care and so did not patronize the

clinic. They rather preferred going to level B where they could get the injection.

SELECTIVE PRIMARY HEALTH CARE

The AlmaAta Declaration was criticized for being too broad and having unrealistic time

especially its slogan” Health for All by the Year 2000 was thought not to be feasible.

Concerned to identify the most cost effective health strategies, the Rockefeller Foundation
sponsored in 1979held a conference entitled “Health and Population in Development at

Bellagio Conference center in Italy.

The Goal of the meeting was to examine the status and interrelation of Health and population

program when they organizers felt a “disturbing signs of declining interest in issues”

The conference was held based on a published paper by Julia Walsh and Kenneth S. Warren

entitle” Selective Primary Health Care, an Interim Strategy for Disease control in Developing

Countries” the paper sought specific causes of death, paying attention to diseases most

common among children. It also emphasized on attainable goals and cost effective planning.

In the paper and at the meeting, selective Primary Health care was introduced as the name of

a new perspective.

The term meant a package of low cost technical interventions to tackle the main disease

problems of poor countries. After a few years, these interventions/strategies were reduced to

best four GOBI.

What was the problem with this package?

James Grant is one of the participants who greatly influenced Selective Primary Health Care.

He was the executive Director of UNICEF from 1980 to January 1995. He organized a book

that proposed a “children’s revolution” and explained the four inexpensive interventions

mentioned earlier. Some agencies added FFF in later years to form GOBIFFF.

WORKING WITH OTHER HEALTH TEAMS

Primary health care is one aspect of developing the community. Others include: education,

Agriculture, communication and water development. Planning is done at the District level by

the DHMT.

Thedoctor is merely one technical adviser who co-ordinates his help planning with other

department. The Primary Health Care Worker has Health Education duties and these may

cover advice on growing food, feeding children, building houses or protecting water bodies.
There may be other workers also covering some of these aspects and so there is the need to

co-ordinate.

COMMUNITY BASED PLANNING AND SERVICES (CHPS)

INTRODUCTION:

Community Based Health Planning and Services (CHPS) is the policy and goal of the

government of Ghana to provide adequate, efficient and equitable Primary Health care to all

people living in Ghana. The Ministry of Health have been looking for an effective way of

extending Health services to most people through the use of frontline staff like Community

Health nurses and field technicians and reorienting the system of Health care Delivery to

community level with their sponsored service support and volunteer activities.

It is a process of health care provision in which health workers and community members are

actively engaged as partners in the delivery of primary health care and family planning

services.

It involves full community participation in the delivery of care through Community Health

Officers, Community Health Committees and Community Health Volunteers.

It relocates Community Health Officers in communities and further mobilizes and re-orients

the district level of the Ministry of Health, and District Assemblies to support the initiative at

the district level.

MOH adopted the strategy in 1999, after a successful trial at Navrongo Health Research

Center in 1994 as community –Based Health Family Planning Project (CHFPP). It was

replicated as CHPS at Nkwanta, Birim North and Abura in the Asebu Kwamankese district. It

was later adopted as a national policy in 2004.

The program has been accepted by the Ministry of Health after a four-year field trial at the

Navrongo health research Centre.

CHPS is also known as. CHPS-TA project through the involvement of population Council is

a Five year project funded by USAID to support the GHS and MOH to scale up the

implementation of CHPS in 30 districts and seven regions in Ghana.

New suggestions coming from health professional and community leaders are that CHOs be

allowed to conduct deliveries in order to enable the government achieved the MDG 4 and

5.This suggesting is backed by the CHPS-TA who are proposing that CHNS who are CHOs

should be recognized as Skilled Birth Attendants (SBA).

THE STRATEGIC GOAL OF COMMUNITY-BASED HEALTH PLANNING AND

SERVICES (CHPS)

The overall goal of CHPS is to improve the health status of all people living in Ghana by

facilitating actions and empowerment at household and community levels.

The vision of Ghana Health Service is to have core services defined within the CHPS

initiative available and accessible to all Ghanaian population by 2015.

OBJECTIVES OF THE CHPS CONCEPT

Within the context of Ghana Poverty Reduction Strategies (GPRS) community-based health

services delivery using the CHPS approach provides a unique opportunity for achieving the

critical intermediate performance measures of the health sector programme areas of work.

The focus of the CHPS approach is to achieve 3 broad objectives;

1. To improve equity in access to basic health care services. That is to ensure every

individual have equal access to quality basic health care services

2. To improve efficiency and responsiveness to client needs i.e qulity services should be

provided to community members that will meet their needs or desires

3. To develop effective intersectoral collaboration.

What are the challenges of the CHPS program?

JICA is also supporting and promoting CHPS I Upper West region.

SOME CONCEPTS

A CHPS Zone refers to a demarcated geographical area of a 4 kilometre radius and between

4500-5000 persons or 750 households in densely populated areas and may be conterminous

with electoral areas where feasible

A CHPS Community is a town, part of a town or a group of villages or settlements grouped

together and designated as such by the district assembly as sub-units of a CHPS Zone. These

are mapped to ease planning of itinerant services and assignment of CHOs and CHVs. A

CHPS Community in a densely populated area shall be approximately 1500 persons or 250

households.

A CHPS Compound refers to an approved structure consisting of a service delivery point

and accommodation complex both of which must be present

THE FRONTLINE STAFF OF COMMUNITY-BASED HEALTH PLANNING AND

SERVICES (CHPS)

1. Community Health Officer

2. Community Health Committee

3. Community Health Volunteers

4. Sub- district Health Management Team

5. District Health Management Team

Community Health Officer (CHO) is a trained and oriented health worker working in a

CHPS zone and may be assigned to a Community within the zone. They are redesignated as
community health officers (CHOs) and live in the communities to provide health care and

family planning services.

Community Health Management Committees are community leaders drawn from the

CHPS Community with different competencies and responsibilities who volunteer to provide

community level guidance and mobilisation for the planning and delivery of health activities

and see8u to the welfare of CHOs in their community

Community Health Volunteers (CHVs) are non-salaried community members identified

and trained persons supporting CHOs in a Community within the CHPS zone

District Health Management Teams (DHMTs) and Sub-district Health Teams (SDHTs):

Provide logistic, training, monitoring and supervisory support.

THE CORE OF THE CHPS PROCESS

At the community level, activities of the CHO, community health committees and the

volunteers form the core of the CHPS process. However the community level activities

require the support and guidance of the district health system and the District Political

Authority.

Community Health Committee

The community health committee is composed of representatives from various groups of

people from the community traditional leadership.

Responsibilities of the Community Health Committee

1. settling of deputes concerning work of the community health volunteers.

2. Organizing communal activities in support of the program.

3. Advocating community health and family planning activities.

4. Financial management of medical accounts

 5. Managing community health volunteers‘ stocks of drug and family planning

materials.

6. Supervising bicycle maintenance for community health volunteers.

The Community Health Compound

The community health compound is a housing facility where the Community Health Officer

lives and dispenses health care.

 It is a two-bedroom facility with a living room and a separate room for providing health

care. It must have water, toilet, kitchen and bathroom. Other amenities include fridge,

furniture, health materials and equipment.

Community Health Volunteers

They are men and women who are recruited by chiefs and elders with technical support from

the SDHT and the CHO on the basis of their commitment to community work.

Responsibilities of the Community Health Volunteers

1. Provision of preventive and curative services for malaria and diarrhea.

2. Provision of family planning counseling.

3. Referral of serious cases to CHO.

4. Health education using the Child health record booklet

5. Identifying children defaulting immunization and those failing to thrive

6. Early notification of disease to the CHO

The District Health Management Team

 The district director of health services (DDHS) who is a member and the head of the

DHMT functions as the director of CHPS process.

 One experienced and capable member of DHMT is selected to assist the director.

 The DHMT is the central point for health management in the district which issues

directives for community level health care provision through the SDHT.
  The DHMT develops, organizes and implement the community level health program

 It collates all field reports from CHO, CHC for decisions and effective acting.

 It also oversees the identification, orientation, training and posting of CHOs to the

sub-district locations in the communities with the assistance of the District Public

Health Nurse.

Responsibilities of the DHMT

The DDHS is responsible for the overall program management, providing guidance

and technical assistance, planning and budgeting. The DHMT Members also:

1. Assist in overall program management

2. Provide guidance and technical assistance

3. Plan and budget program activities

4. Serve as liaison and organize meetings between DHMT and SDHT.

5. Supply essential medical supplies to SDHT

6. Supervise SDHT activities

7. Co-ordinate program activities of DHMT members and service delivery units.

8. Train Community Health Officers

9. Manage data generated by CHOs, and community health volunteers and provide

feedback to SDHT.

The Sub-District Health Team

This is the authority at the sub- district level. The team supervises CHOs and CHVs and links

and the sub – district to the district level offices.

The team plans and budgets for program activities.

It manages the flow of essential drugs and family planning supply between the DHMT and

the CHC. This is distributed to CHVs to complete actual delivery.

Responsibilities of SDHT

1. Holding management meetings with community health committees and CHOs

2. Collecting data on CHO and volunteer program for the DHMT.

3. Receive information from DHMT to community members.

The Community Health Officers (CHOs)

They are equipped with motor bikes, essential drugs and family planning supplies. They are

required to serve all compounds in the communities in which they are located.

Responsibilities of the CHO

1. Community and compound level education on primary health care

2. Immunizing and providing pre and post natal care

3. Supervising and monitoring sanitation efforts

4. Provision of nutrition education and care

5. Primary care for simple cases of diarrhea, malaria acute respiratory diseases,

wounds and skin diseases

6. Providing referrals for more serious afflictions

7. Provision of education on prevention and management of STDs and HIV/AIDS.

8. Provision of family planning services and referrals

9. Supervision and monitoring of community volunteers and TBAs

10. Conducting disease surveillance

11. Submission of written reports to the SDHT.

The District Chief Executive and the District Assembly

The District Chief Executive as the head of government machinery at the district level

services acts as the link between the CHPS process and other social services developments

program in the district.

The District Chief Executive and the District Assembly through the social services sub

committee is responsible for:

1. Working with the DHMT in the selection and prioritization of communities for

participation in the CHPS process.

2. Provision of funding and other material support for operation in the CHPS process

particularly for the construction of community health compounds and motivation of

CHOs, community health volunteers and the community health committees.

3. Informing and encouraging members of parliament in the district as well as NGOs

to advocate for the CHPS process and provide material support for its

implementation.

4. Empowering district assembly, area council and unit committee, members to

provide active organizational and material support to the development of the CHPS

program in their communities.

5. Receiving quarterly progress reports on implementation of the CHPS process in the

district from the DHMT and recommending or initiating necessary action.

CONDITIONS FOR SELECTING COMMUNITIES FOR CHPS.

Every community deserves quality, adequate, accessible, and reliable health services. For

these reasons selections of CHPS compounds should be guided by the following;

1. Prevalence of high fertility and mortality.

2. Prevalence of poverty in the area.

3. Prevalence of social, religious and traditional believe that hinder development.

4. High illiteracy particularly among women.

5. Poor or no coverage of health services.

6. Community is very far away from health facility.

7. Community is hard to reach.

 8. Epidemics and other preventable disease condition common.

STEPS REQUIRED IN IMPLEMENTING THE CHPS PROCESS ARE:

IMPLEMENTATION STEPS

1. Planning

 Situation analysis and problem identification at the level of the DHMT

 Consultation with District Assembly – the Chief Executive and the Social

Services Sub Committee

 Selection of Communities.

2. Consultation and Sensitization of Health Workers.

3. Dialogue with Community Leadership

 District Assembly, Area Council and Unit

 Committee Member responsible for Communities, Chiefs, Elders, Elders,

Women Leaders etc.

4. Community Information Durbar

 Community Discussion of the program and its Implications.

5. Selection and Training of CHOs.

6. Selection and Orientation of Community Health Committee Members; and

Durbar for Approval of Community Health Committee

7. Compilation of Community Profile

 Information on Geographic and

 Demographic Characteristic,

 Existing Health Features and Facilities.

8. Construction of Community Health Compound

9. Mobilization of Logistics
 10. Durbar for Formal Launching of the CHO Program

11. Selection of Community Health Volunteers

12. Durbar for Approval of Community Health Volunteers

13. Training of Community Health Volunteers

14. Mobilization of Logistics and Equipping the Volunteers

15. Durbar to Launch Community Health Volunteer Program

STEPS CAN BE SUMMARIZED INTO 6 KEY ITERMS.

CHPS milestones

 Planning

 Community Entry

 Community Health Compound construction

 Community Health Officer(Posting)

 Essential Equipment

 Volunteers Recruitment

IMPORTANCE OF COMMUNITY BASED HEALTH PLANNING AND SERVICES

(CHPS)

1. It improves the health of the people in the communities

2. It improves health service delivery through making health information and service

accessible to every member of the community

3. Early warning systems are created for the prevention of epidemic situations and

improves referral time to major health centers

4. It is cost-effective and cost-saving in terms of prevention of diseases. Early

diagnose, detection, treatment and care of diseases also realizes cost savings.
 5. It improves the moral of health workers and enhances their work potential

COMMUNITY MOBILIZATION /PARTICIPATION

To ensure healthful living, communities must be mobilized to assume responsibility of their

health.

Community mobilization for health service promotion is therefore the deliberate process of

involving and motivating people, health workers and policy makers to organize and take

actions for common purpose of providing equitable and accessible health information.

The key elements are as follows:

 Readiness; of the community to perceive a problem, and the need for change.

 Catalysts; an event and or person(s) which sparks the desire for immediate change.

 Environmental support; the existing system that supports the desired change. An

example of environmental support is when frequent deaths of children from

preventable diseases such as measles move the community leadership to organize its

people to provide a place and appeals to health authorities for a service provider.

Limitations of community mobilization/participation

1. Volunteerism versus paid work: As community members participate in working for

the community voluntarily for a period of time, the desire for the formal remuneration

develops. This is often the case when the volunteers feel they are being cheated by

other members of the community who benefit from the same services while

contributing little or no effort to its development. The need to create some level of

reward for volunteerism should not be down played. Communities should be

encouraged to create their own relevant and practical ways of recognizing and

rewarding volunteers.
 Care, however, should be taken to avoid creating another paid-work structure while

mobilizing communities to support social services, since this is not usually

sustainable.

2. Community burn out: Continual dependence on mobilizing communities for work that

does not yield any improvement on their health delivery system may create frustration among

the people and cause them to give up.

3. Maturation and maintenance: As community members continue to participate in the

mobilization effort, there is a link to how far they could go without losing the enthusiasm and

energy to support the systems, if their mastery and ownership of the process is not

appreciated. There is therefore the need to encourage community members to establish their

own local systems and structures of organizing and maintaining the community by

mobilization processes, such as the formation of community health committees.

When does community mobilize work best?

1. During crises situations such as outbreak of diseases such as measles, cholera, cerebro-

spinal meningitis.

2. Localized issues such as inability of health workers to get to difficult to reach and isolated

communities

3. When health providers sit in static clinics to receive clients who never turn up for their

services (non-functioning large systems).

ADVANTAGES OF COMMUNITY MOBILIZATION /PARTICIPATION

1. Community mobilization helps motivate the people in the community and encourage

participation

2. It also builds community capacity and enable the community identify its own

problems and address them

 3. It promotes sustainability and long term commitment to the community change

movement

4. It promotes utilization of resources from all sectors of the community

5. It builds social support systems in the community particularly for the disadvantage

groups or families

6. It creates sense of ownership to projects in the community

COMMUNITY MOBILIZATION TOOLS AND APPROACHES

USING PLA.

 Arrange the day in advance, inform the people so that they can get themselves ready and

support the program

 Work in pairs if possible

 There are variety of ways which a community can use to survey it needs,

 Personal interviews

 Telephone interview

 Written questionnaires

 Focused group discussions

 Mapping and diagramming

 Semi- structured interviews

 Sorting out and ranking

 Transect walk and observation

 Time line, schedules and seasonal calendars

 Matrices (GHS/MOH manual 2002)

MAJOR CHALLENGES OF CHPS IMPLEMENTATION

There is evidence from field work (Binka et. al2; 2009) which indicates that although the

CHPS program is considered by policy makers, development partners and public health

provides a good pro-poor health service delivery strategy, particularly in rural areas, its

implementation has been thwarted with obstacles and/or problems that have not permitted the

full realization of its benefit.

The implementation obstacles include:

a) Lack of political will to scale up: At the national level, CHPS is not considered as a key

health delivery concept to enhance scale up. At the implementation level (i.e. district and

community), there are misunderstanding of the concept of CHPS and lack of district and

community participation. Anecdotal evidence suggests that the support for CHPS was

reduced when the MOH decided to fund High Impact Rapid Delivery (HIRD) instead of

CHPS, because they were unhappy with the progress CHPS was making to rapidly achieve

MDG 4 [reduce by two-thirds, between 1990 and 2015, the under-five mortality rate] and

MDG 5 [reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio.

b) Inadequate resources: The MOH and GHS have no specific budgets to support the CHPS

programme. This has resulted in incoherentpartnership and overemphasis on CHPS

compounds to the detriment of other components.

c) Different Understanding of CHPS among the Health Sector Leadership: The

understanding of CHPS differs among MOH and GHS leadership at all levels. This has led to

skewed implementation toward curative services to the detriment of promotive and

preventive services. This has also led districts and communities to request for ―clinics‖.
d) Insufficient CHPS zones: Even where the zones are demarcated, they are not functional

because there are no CHPS compounds.

e) Inadequate provision of basic equipment: Most CHPS compounds lack basic clinical

and communication equipment.

f) Inadequate means of transports: There are inadequate motorbikes for the CHOs for their

visits. Maintenance of broken down motorbikes is generally poor and supply of fuel is a

problem.

g) Inadequate skill mix of CHOs: CHOs need improved skill mix to improve their

functionality, such as midwifery.

h) Limited Community Mobilization Skills for CHOs: Community participation and

mobilization component of the CHPS programme is completely absent in the programme

leading to more static and curative services.

OTHER CHALLENGES OF THE CHPS

Implementation challenges

 . Implementation of CHPS is fraught with several policy and systems level challenges.

Different reviews point to a lack of clear policy direction, unclear definitions and an

unending conceptual debate. There were also issues in relation to effective leadership

and technical direction.

 Planning and budgeting for CHPS at the national, regional and district levels.

Planning as a process at the community level is also inadequate.

 . At the implementation level technical health and local government officers referred

severally to the confusion in directives received from the center. Written guidelines

were not adequately disseminated, and were difficult to understand and implement.

While local government and district assemblies are willing to take on the challenge of

scale up there is still no clarity in roles and responsibilities. It is also unclear whether

CHPS should be implemented in urban areas given its origin as a strategy for reaching

deprived rural areas.

 . The term ‘functional CHPS zone’ introduced further complication to the concept.

Under the functional CHPS zone concept compounds were no longer a mandatory

requirement. Zones were now ranked on a scale of fractional degrees of partial or

incomplete depending on how many of the six steps have been completed. Under the

new definition it was difficult to determine precisely what ‘functional’ meant

 Service delivery was in a constant flux with ever changing definitions of the standard

basic package of interventions to be delivered in a CHPS zone (MoH, 1999, GHS,

2005, GHS, 2010 and GHS, 2013). New services are constantly layered onto existing

ones with supervisors and communities coming to expect an increasing variety and

complexity of clinical services to be delivered at the CHPS level. All disease specific

programmes see the CHPS platform as an opportunity to reach the communities with

their programmes. There was also push for CHOs to include deliveries in the CHPS

portfolio of services.

 Lack of communication and engagement has led to community members not

understanding the distinction between community-based health service and services at

 a higher level health facility (Tierozie, 2011). Communities expect a facility to deliver

clinical care when required.

 The current population reached with CHPS services is 5% (GHS, 2012). Considering

investment to output this might be considered low. This raises the question as to

whether we are optimally implementing the strategy and whether CHPS is value for

money. Another issue raised by this low coverage is to examine the methods and

indicators for measuring CHPS performance. CHOs are required to fill different forms

for various programme specific activities.

 The result is an overload in reporting requirements and little use of data.

 . The ratio of functional CHPS zone to CHN points to an over production of CHNs.

Currently the ratio is about 1:11. The initial assumption was to have one CHO per

CHPS zone. It is now considered to have at least two CHOs per zone. This presents

logistic challenges in terms of accommodation and amenities resulting in many CHNs

not residing in CHPS zones. The CHN training program was developed with no

prospects of career progression while in service. Many

 CHNs desire to continue their education, leading to dissatisfaction with the location

and length of their current placement. There is no policy on how long a CHN can

remain in a deprived community or incentives in place to reward those serving in

deprived areas.

 . The selection, training and retention of volunteers have received the least attention in

the CHPS deployment framework. It is estimated that 55% of CHPS zones have no

regularly trained active volunteers working with CHOs on a regular basis (MOH,

2014). Volunteers provide a bridge for the services between patients and the CHNs

without affecting the national wage bill. The low availability can be attributed to

several factors. Different programs drawing on volunteer services have led to

 volunteers implementing different uncoordinated services. There is no policy on

reward and incentives for these volunteers leading to volunteer fatigue and various

programs introducing cash incentives. This has distorted the volunteer system in

several communities resulting in some volunteers demanding cash for services. Some

sub-districts are waiting for funding to become available for hiring community

members to perform volunteer services (Awoonor-Williams et al., 2013, Seddoh et al

2014). There are proposals from the Ministry of Health to retool existing volunteers

and regularise the payment system by providing some monetary payment.

 . Another issue that cut across all regions was Community Health Management

Committees (CHMCs). Though they were formed in most CHPS zones, members

were inactive or nottrained in 65% of the CHPS zones (MOH, 2014). Community

entry and appropriate community mobilisation to support the CHPS programme were

hardly done.

 . There are issues of inappropriate siting of CHPS compounds. In some instance land

allocated for CHPS are either in sacred groves, insanitary environments and not

sensitive to the cultural setting and taboos. There are also issues of security and

availability of water and electricity.

 Financing CHPS is not clear. Different development partners have funds for

supporting the development and scale up of CHPs but there is no coordination and

harmonization of the various funds. The NHIA does not reimburse for CHPS services

directly. Where services are provided and qualify for NHIA reimbursement, the cost

is claimed through the Health Centers as part of the services provided by the Health

Centre. Under capitation, individuals will prefer to select health centres and hospitals

as their preferred primary provider.

Community Diagnosis

In clinical medicine, diagnosis is the basis for effective management of the patient; therefore,

wrong diagnosis will lead to wrong management of the patient. The clinician asks about the

symptoms of the patient, conducts a physical examination and carries relevant laboratory and

other investigations. On the bases of these assessments, appropriate treatment is instituted and

the cycle repeated thereafter to monitor the patient‘s progress and to guide future

interventions. Diagnosis which is the foundation pillar of clinical medicine is equally very

important in community health because like the clinician, the community health nurse

assesses the health needs/problems to establish diagnosis as a base for effective action. As the

clinician monitors the course of illness in the patient, so the public health workers

continuously assess the progress of the community.

The community diagnosistherefore is the process of assessing health needs, type of services

provided, program management and the total health care delivery system of a particular,

geographical and ecological zone. After gathering information, using the community profile,

guide and tools, the data collected is analyzed and given a title (diagnosis).

Health diagnosis can be used to define the health status of an environment, it can also be used

to identify health problems, as well as, device appropriate interventions and use resources

adequately. This approach is however used to evaluate health program and services.

It further enables health workers and their partners to gather and disseminate information on

the health and well-being of the community. It promotes the collection of appropriate

information for effective program planning and also raises the awareness on the key issues

confronting the people in the community, as well as service provision.

DISABILITY, HANDICAP AND REHABILITATION

Definition of Disability
Disability can be defined as follows:

1. Disability is inability to perform some key life functions

2. Disability is limited ability to function physically or mentally

3. Disability is impairment in one or more important areas of functioning

These persons are unable to perform. They have some limitation in their major life activity

(play, school, work, and self-care).

Impairment

Impairment refers to a medical condition that leads to disability. In health, it refers to any loss

or abnormality of physiological, psychological, or anatomical structure or function, whether

permanent or temporary.

Identifying impairments that contribute to a functional problem for a patient is a key factor

for a health professional to determine appropriate treatment.

Impairment is the correct term to use to define a deviation from normal, such as not being

able to make a muscle move or not being able to control an unwanted movement.

Handicap

Handicap is any social disadvantage that exists because of the disability.

Handicap is the term used to describe a child or adult who, because of the disability, is unable

to achieve the normal role in society commensurate with his age and socio-cultural milieu.

For example, a sixteen-year-old who is unable to prepare his own meal or care for his own

toileting or hygiene needs is handicapped.

Causes of Disability
1. Congenital defects

2. Use of drugs like cocaine, tetracycline, quinine

3. Traumatic injuries like RTA, industrial accidents

4. Diseases like hypertension, diabetes, measles, poliomyelitis, brain disease, gonorrhoea

5. Broken love affairs

6. Over dependency

7. Bereavement

8. Alcoholism / business worries / frustrations

9. Child birth

10. Industrial hazard: poison, gases

11. Loneliness

12. Marriage and parenthood

TYPES OF DISABILITIES

The various types of disabilities are;

1. Hearing impairment e.g deafness

2. Intellectually challenged/learning disabilities e.g senile dementia

3. Mobility difficulty e.g cripple

4. Visual impairment e.g blindness

5. Speech impairment e.g dumbness, autism

CLASSIFICATION OF DISABILITIES

Disabilities are broadly grouped into two(2) main classes as;

1. CONGENITAL DISABILITIES : this a class of disability a person is born with e.g

hare lip, cleft palate, dislocation of the hip, mental retardation etc

2. ACQUIRED DISABILITATION: this is a class of disability an individual gets as a

result of a disease condition, accident or over dependence, amputated limbs, deafness,

etc.

13.

14. Maternal age: less 18 years and 35 over years can cause disability

15. Poor nutritional status of the mother

Levels of Disability

1. Disease or injury / congenital defects

2. Loss of function

3. Disability

REHABILITATION

Definitions

1. Rehabilitation can be defined and explained in so many ways: it is a latin word

meaning restoration. In medical terms it implies the restoration of patient’s to their

fullest physical, mental and social capability (Mair 1973)

 2. WHO definition for rehabilitation. “The combined and co-ordinate use of medical

social, educational and vocational measures for training or retraining the individual to

the highest possible level of functional ability”. The medical component of

rehabilitation includes, diagnosis, surgical treatment and prosthetic and orthopaedic

appliances and physical and mental therapy

Aims of Rehabilitation: Rehabilitation aims at training a disabled person to make the

best “of his remaining capacities to earn a living, to care for his own body, to participate

in social relationships and to enjoy pleasurable activities

THE VARIOUS ASPECTS OF REHABILITATION

The various aspects of rehabilitation of a person with disability are;

1. FUNCTIONAL REHABILITATION--- this is an aspect of rehabilitation which

deals with the restoration of the individual’s function. The measures use here aims at

helping the individual reuse body and/or live.

2. SOCIAL REHABILITATION: this aspect deals with restoring a person’s ability to

fit or relate with family and society

3. VOCATIONAL REHABILITATION: this deals with restoring the individual’s

capability to earn a living/ livelihood. that is training or retraining aims at helping the

individual learn a new skill

4. PSYCHOLOGICAL REHABILITATION: this aspect of rehabilitation deals with

restoration of the person’s dignity and confidence.

BENEFITS/IMPORTANCE OF REHABILITATION

1. Rehabilitation helps to reduce complication

2. It makes disabled independent and responsible in society

3. It help prevent stigmatization

 4. It help restore individuals physical, mental, and social life as normal as possible

RESOURCES NEEDED FOR REHABILITATION

1. Finance( money)

2. Material

3. Facilities

4. Personnel.

TYPES OF TOOLS AND GARGETS USE TO REHABILITATE THE DISABLED IN

SOCIETY

DISABILITY TOOL/GARGET

Mobilitydisability Clutches,calipers,prostheses,tricycle wheel chairs etc

Visual impairment Brailles watches, brailles for writing and reading, reading glasses

Hearing loss/ impairment Audio cassettes, hearing aids, audiometers

TYPES OF REHABILITATION

The various types of rehabilitation include;

1. INSTITUTIONAL/ACTIVE BASED REHABILITATION: this is a type of

rehabilitation where functional training, schooling and vocational training are given to

lead to independent and better social integration e.g special schools and hospitals. Under

this type of rehabilitation, specialized services are rendered in a well-structured and

organized institution, facility or home to the disabled.

 2. COMMUNITY BASED REHABILITATION: this is s type of rehabilitation where

strategies are put in place to ensure that people with disabilities are involved in the

development of their communities by having equal access to rehabilitation and

opportunities as other members in the community/society.

COMMUNITY BASED REHABILITATIION (CBR)

 CBR was initiated in the mid-1980s but has evolved to become a multi-sectorial

strategy that empowers persons with disabilities to access and benefits from

education, employment, health and social services. CBR is implemented through the

combined efforts of people with disabilities, their families, organizations and

communities, relevant

 Community-based rehabilitation (CBR) was imitated by WHO following the

Declaration of Alma Ata in 1978 in an effort enhance the quality of life for people

with disabilities and their families, meeting basic needs and ensuring inclusion and

participation government and non-government health, education, vocational social

and other services

 It is a strategy within general community development for the rehabilitation,

equalization of opportunities and social inclusion of all people with disabilities. The

primary objective of CBR is the improvement of the quality of life of people with

disability/ marginalized persons.

NB. Key principles relating to CBR are equality, social justice, solidarity,

integration and dignity.

Community-based Rehabilitation should not be:-

 1. An approach that only focuses on the physical or medical needs of a person or

delivering care to disabled people as passive recipients.

2. Outreach from a centre

3. Determined by the needs of an institution or group of professionals.

4. Segregated and separate from services for other people.

 Conversely CBR involves partnership with disabled people, adults and children, their

families and careers. It involves capacity building of disabled people and their

families, in the context of their community and culture. It is a holistic approach

encompassing physical, social, employment, educational, economic and other needs.

It promotes the social inclusion of disabled people in existing mainstream services.

Components of CBR

1. Creation of positive attitude towards people with disabilities

2. Provision of rehabilitation services

3. Provision of education and training opportunities

4. Creation of micro and macro income-generation opportunities

5. Provision of long term care facilities

6. Prevention of causes of disabilities

7. Provision of care facilities

8. Provision of functional rehabilitation services

9. Empowering, provision of education and training opportunities

10. Management / monitoring and evaluation of CBR project

DEFINITIONS OF STIGMA AND DISCRIMINATION

What is stigma?

Stigma refers to attitudes and beliefs that lead people to reject, avoid, or fear those they

perceive as being different. Stigma is a Greek word that in its origins referred to a kind of

mark that was cut or burned into the skin. It identified people as criminals, slaves, or traitors

to be shunned.

What types of stigma affect people with mental health conditions?

There are three major categories of mental health related stigma: Public Stigma,

Institutional Stigma, and Self Stigma.

What is public stigma?

“Public Stigma” refers to the attitudes and beliefs of the general public towards

persons with mental health challenges or their family members. For example, the

public may assume that people with psychiatric conditions are violent and dangerous.

What is institutional stigma?

“Institutional Stigma” refers to an organization’s policies or culture of negative

attitudes and beliefs. For example, stigma is often reflected in the use of clinical

terms, such as a “schizophrenic.” It is preferable to use “people first” language, such

as “a person experiencing schizophrenia.”

What is self-stigma?

“Self-stigma” occurs when an individual buys into society’s misconceptions about

mental health. By internalizing negative beliefs, individuals or groups may

 experience feelings of shame, anger, hopelessness, or despair that keep them from

seeking social support, employment, or treatment for their mental health conditions.

What is discrimination?

While “stigma” is an attitude or belief, “discrimination” is behavioral because of

those attitudes or beliefs. Discrimination occurs when individuals or institutions

unjustly deprive others of their rights and life opportunities due to stigma.

Discrimination may result in the exclusion or marginalization of people and deprive

them of their civil rights, such as access to fair housing options, opportunities for

employment, education, and full participation in civic life.

How does discrimination occur?

Discrimination includes “disparate or different treatment” on the basis of disability.

For example, neighborhood groups often organize to block housing for people with

mental health challenges.

Discrimination also includes a failure to provide a reasonable accommodation to a

person with a disability and making changes in physical aspects of the workplace, re-

structuring of job duties, and adjustments in policies.

Chapter 6;

VACCINE MANAGEMENT

COLD CHAIN MANAGEMENT

Cold chain management is the measures taken to maintain the cold chain system.
Cold chain system is the system of distribution of vaccines in their potent state from the

manufacturer to the final/actual recipient. The cold chain is necessary because the

effectiveness of the vaccine depends on the effectiveness of the cold chain system.

ESSENTIAL ELEMENTS OF THE COLD CHAIN SYSTEM

1. Staff/people

2. Storage facilities e.g refrigerator , cold man

3. Transport e.g cold vans

VACCINES

A vaccine is an antigenic preparation used to produce immunity to a particular disease in the

human body. Vaccines are either suspension or powder of attenuated or killed organisms that

are not capable of inducing disease but can stimulate the production of antibodies.

Antigens are modified micro-organisms incapable of causing the disease but can induce the

production of a specific antibody to a disease. Vaccines come in vials and ampoules.

TYPES OF VACCINES AND THE DISEASES THEY PREVENT

VACCINES DISEASE

1. BCG(Bacillus Calmette Tuberculosis

Guerin)

2. Polio(OPV) Poliomyelitis

3. DPTHep-Hib Diphtheria, pertusis, tetanus, hepatitis B,

haemophilus influenza type b

4. Measles vaccine Measles

 5. Yellow fever vaccine Yellow fever

6. Pneumococcal Pneumonia

7. Meningococcal conjugate (men CSM

A)

8. Rota virus vaccine(rotarix) Diarrhea

CATEGORIES OF VACCINES

The expanded programmes on immunization (EPI) vaccines have been categorized into three

(3) classes.

1. Live/attenuated vaccine: These are vaccines prepared from live but weaken

organisms. The live organisms are passed through a media repeatedly till they lose

their capacity to induce the disease but retain the capacity to trigger the immune

system. E.g BCG vaccine, measles vaccine, rotavirus vaccine, yellow fever vaccine,

polio vaccine, and pneumococcal vaccine.

2. Killed/dead vaccines: These are vaccines prepared from killed/dead organisms. The

killed organisms used to prepare the vaccine have the capacity to induce/stimulate the

immune system. E.g. DPT Hep-Hib

3. Toxoids: These are vaccines prepared from the toxins are treated during preparation

to suppressed its capacity to induce the disease but stimulate the production of

antibodies. E.g tetanus diphtheria (TD)

EXAMPLES OF VACCINES THAT COME IN VIALS

1. DPT Hep-Hib

2. Measles vaccine

3. Pneumococcal vaccine
 4. Polio vaccine

5. BCG

6. Meningococcal conjugate (men A)

NB. EXAMPLES OF RECONSTITUTED VACCINES

1. Yellow fever vaccine

2. Measles vaccine

3. BCG vaccine

4. Meningococcal conjugate (men A)

NB. The solution/water use for reconstituting/mixing is called DILUENT

VACCINE NO. OF DOSES IN VIAL/AMPOULE

POLIO(OPV 20

BCG 20

DPTHep-Hib(penta) 10

MEASLES 10

YELLOW FEVER 10

PNEUMOCOCCAL(PCV13/PREVENAR13) 4

ROTAVIRUS VACCINE(ROTARIX) 1
MONITORING AND CARING FOR VACCINES IN THE COLD CHAIN SYSTEM

It is the process of checking/observing and managing vaccines to ensure they are safe for use.

To monitor and care for vaccines, certain tools and/or equipments are needed known as

monitoring tools.

MONITORING TOOLS

1. Thermometer

2. Temperature recorders/chart

3. Alarms(horns, light)

4. Freeze watch indicator

5. Vaccine vial monitor

REQUIREMENT NEEDED FOR THE MANAGEMENT OF COLD CHAIN

1. Vaccine Refrigerator

2. Cold rooms/stores

3. Vaccine carries/cold box

GENERAL RULES TO MAINTAIN THE POTENCY OF VACCINES

1. Ensure you have enough cold chain equipments to store vaccines at your level

2. When collecting vaccines, check if the types and amount of vaccines and diluents are

the same as estimated.

3. Check that the expiry date on each vaccine is not due

 4. When moving vaccines to an outreach point/station, pack the vaccines and diluents

into a cold chain container quickly and properly.

5. Keep vaccines carriers under a shade as much as possible

6. Convey your vaccines to an outreach point using the shortest possible route

7. Select a vaccination site that is cool/shady

8. Open vaccine carrier/container only when it is necessary.

THE VACCINE REFRIGERATOR

It is a specially designed refrigerator to store vaccines and other medical products at stable

temperatures to ensure they do not degrade.

HOW TO CARE FOR THE VACCINE REFRIGERATOR

To care for the vaccine refrigerator, the following measures must be put in place;

1. The refrigerator should be placed in a shady, cool and well ventilated room.

2. Ensure the distance between the refrigerator and the wall is at least 30cm

3. If the refrigerator has no wheels, it should be placed on supplied stand to elevate it to

about 3.5cm from the ground/floor but must be level.

4. Defrost the refrigerator if the ice on the walls of the freezing compartment becomes

more than 5cm thick. As ice builds up, the refrigerator gets rather warmer, but not

colder.

HOW TO DEFROST YOUR REFRIGERATOR

1. You need another refrigerator or a cold box to keep your vaccines in.
 2. If you need extra ice packs, freeze them the day before. Let the ice packs stay in the

room temperature for 10 minutes before loading them into the cold box.

3. Put a thermometer in the cold box to check and ensure that the temperature is within

+2 and +8 degree Celsius before packing DPT/Hib/HepB vaccines into the cold box.

4. Turn off the refrigerator, and leave all doors open

5. As soon as it is possible to remove ice with your fingers, do so.

6. Never use knives or sharp instruments.

7. When all the ice has melted, wipe the inside walls with a clean cloth.

8. Clean and dry the lid / door rubber seals and put some talcum powder on them if

available.

9. Close the refrigerator, turn it on and wait until the temperature inside the main

compartment is +2 degrees before putting the vaccines back.

10. The oldest vaccines should be placed in front, so as to be used first.

Note: if you have to defrost your refrigerator more than once a month, the door is probably

open too often. If this is not the case, contact your supervisor for technical check-up by a cold

chain technician.

If Your Refrigerator Fails

1. Be prepared for an emergency.

2. If possible, identify in advance another refrigerator where you can store the vaccines.

3. You must always have a cold box and enough frozen icepacks ready in storage. 

4. Report immediately to your supervisor in case of problems with the refrigerator.

5. Regulating the Temperature in the Refrigerator If the temperature rises above +8

degrees or falls below +2 degrees, turn the thermostat knob to colder or warmer, just a
 little and check again every six hours, until the temperature has stabilized. It takes one

day for the temperature inside the fridge to change.

6. Check the power supply, the door, hinges and seals, for any defect. Be sure that the

door is opened as few times as possible.

ARRANGING VACCINES CORRECTLY IN A VACCINE REFRIGERATOR

Vaccines must be arrange or stock neatly to allow adequate air circulation between the boxes.

Vaccines should be arranged in the order below;

1. Put live/attenuated vaccines (measles, bacillus calmette geurin (BCG),polio, rotarix

and yellow fever vaccines) at the top shelve near the freezing compartment.

2. Keep DPT Heb-Hib, pneumococcal and tetanus toxoids vaccines in the middle

compartment away from the freezing compartment.

3. Diluents should be kept in the middle compartment or any other shelve of the

refrigerator but ensure they will not freeze

4. Place frozen ice packs and/or bottle of salt water at the lower/bottom shelve of the

refrigerator to keep the refrigerator cold and maintain the temperature of the vaccines

of +2 to +8 degree Celsius

THE VACCINE CARRIER

It is a specially designed square or rectangular container/box to temporary store and transport

vaccines and other medical products that require safe temperatures. The vaccine carrier has

high heat insulating materials/properties. The temperature is usually controlled by ice packs

and careful handling.

HOW TO PACK VACCINES INTO THE VACCINES CARRIER FOR

IMMUNIZATION SESSIONS/SERVICES

When packing vaccines for immunization sessions, the following steps must be followed;

1. Clean the vaccine carrier and ensure it has no cracks

2. Take ice packs from the freezer and leave on a table or any clean surface for about

five (5) to ten (10) minutes to warm a little if too cold because they may freeze the

DPT Hep-Hib and pneumococcal vaccines

3. Arrange the ice packs in the vaccine carrier accordingly depending on the type of

carrier

4. Put a small polythene bag of ice cubes at the bottom of the vaccine carrier

followed by the most heat sensitive ,less heat sensitive vaccines and the diluents at

the top
 5. Wrap DPT Hep-Hib, pneumococcal and tetanus toxoids vaccines with a news

paper or place a foil between the above listed vaccines and the ice packs to

prevent freezing or damage.

6. Close the lid tightly

7. Keep the vaccines and diluents in the carrier until you are ready to use them

COLD CHAIN THERMOMETER

These are specially designed thermometers to determine the temperatures of vaccines and

other medical products during cold chain management by indicating the temperature readings

either through the rise and fall of fluid, colour change and/or indicating the figure that

correspond to the temperature.

TYPES OF COLD CHAIN THERMOMETERS

1. The dial thermometer: it is a type of cold chain thermometer use to monitor the

temperature of vaccines. The dial thermometer has a needle which moves around the

scale indicating the temperature. On the scale are positive and negative numbers. The

needle of the thermometer points at the positive numbers when the temperature is

warmer and points at negative numbers when the temperature is colder.

2. The bulb thermometer: this is type of cold chain thermometer use to monitor the

temperature of vaccines. The bulb thermometer has a coloured fluid in its bulb which

moves up the scale as the temperature become warmer and down when the

temperature become cooler.

3. The liquid crystal thermometer: this type of thermometer has fluid or liquid crystals

in a circle which changes colour with changing temperatures. When the temperature is

warmer, the colour changes to green and the temperature is cooler, the colour changes
 to blue. But when the green colour is on the numbers 2, 4, 6, or 8, it indicates that the

vaccines are safe.

THE VACCINE VIAL MONITOR

The vaccine vial monitor (VVM) is a label that contains a heat sensitive material which is

place on the vaccine vial to register cumulative heat exposure over time. The vaccine vial

monitor is a circle with a small square box inside it. The inner square is brighter than the

outer circle in normal vaccine temperature. The effect of temperature over time causes the

inner square box to be become darkened gradually and irreversibly.

HOW TO READ AND INTERPRETE THE VACCINE VIAL MONITOR

1. If the inner square box is brighter than the outer circle, it indicates that the vaccine is

safe to be use any time.

2. If the inner square box is slightly darken but not as compared to the outer circle, it

indicates that the vaccine is losing its potency and must be used immediately

3. If the inner square box is completely dark compare to the outer circle, it indicates that

the vaccine has lost its potency and cannot be used again.
WHAT DAMAGES VACCINES

1. Vaccines can be damaged if not properly cared for.

2. All vaccines lose their potency after a certain period of time even with adequate

care (expire).

3. Heat destroys vaccines e.g. BCG (live vaccines).

4. Sunlight destroys all vaccines.

5. Disinfectants (dettol, izal) and other detergent, antiseptics like spirit destroy

vaccines.

6. All vaccines have their expiry date printed on the vial or ampoule.

7. It loses its potency when it expires. 15. Freezing can also damage some vaccines

e.g. T.T

RECOMMENDED STANDARD PERIODS VACCINES CAN STAY AT VARIOUS

LEVEL

LEVEL STANDARD PERIOD

Central/national Six (6) months

Regional Three (3) months

District 1 (one) month

Sub-district/health 1 (one) month

centers
 Chapter 7;

DOCUMENTATION, REPORT WRITING AND REFERRAL

a. DOCUMENTATION

Documentation is one of the main communication tools that both regulated and unregulated

health care providers use to exchange client information.

Documentation (sometimes called reporting, charting or recording) can be described as any

electronic or written information or data about client interactions or care events that meet

both legal and professional standards (College of Registered Nurses of British Columbia,

2012). Meeting legal standards refers to how your documentation would be examined by the

legal process or the court system and your employing facility or agency may also examine

your documentation to see if it meets their policies and procedures.

Purposes of Documentation

Documentation by health care providers has several purposes. These include:

1. Communicating and providing continuity of care – If another health care provider

had to step in and care for the client on a moment's notice, does your documentation
 provide the necessary information for easy transfer of care to the second care

provider?.

2. Accountability – Care providers are responsible and accountable for their own

practice and documentation is part of that accountability.

3. Legal implications – Was the care provided competent and safe, did it meet

acceptable standards, and was it timely and consistent with the employing agency or

facility’s policies? A chart or client record is one of the main documents of evidence.

4. Provides quality improvement and risk management – Accurate documentation

provides a way to measure and improve health services and client outcomes. Your

documentation is used to manage risks in a health care setting and is investigated if

adverse events occur.

5. Facilitates evidence informed practice – Accurate documentation can be an important

source of data for improving client outcomes and practice. Many medical studies and

client care research projects gather data from your documentation.

Perceptions of Documentation

Health care providers have varying perceptions of documentation. Many say that this skill

takes years to become proficient at. You may have learned documentation on the job by

copying what other care providers have written about the client. This method perpetuates

deficiencies and is a dangerous practice. You may have learned the basics of accurate

documentation in formal education, but were not proficient when you started your career as a

health care provider. During your practicum, you may have adopted inappropriate

documentation practices from other care providers.

Some documentation frameworks or systems do not accurately reflect the type of care that a

specific individual requires nor do they work well in a particular health care setting. This may

make it difficult for you to document in a clear, concise, comprehensive and timely manner.

From another viewpoint, documentation may not be as glamorous or popular as other aspects

of care provider activities. In some health care settings, tasks usually take priority to

documentation and little time is devoted to it.

Health care providers who are most successful with documentation are those who view

documentation as an integral part of the nursing process. Can you recall the nursing process?

Are you able to reflect on each step and how it corresponds with accurate documentation?

Challenges of Documentation

1. Time factors – Because you work in an extremely demanding health care environment,

care interactions and professional skills may take priority to documentation. You may find it

extremely difficult to document client care contemporaneously (at the time of occurrence or

shortly thereafter) when you are multi-tasking.

2. Fatigue – Warren and Creech-Tart (2008) discussed that care provider fatigue contributes

to deficiencies in documentation. Since some care providers work long hours and have

demanding client assignments, they may not have clear thinking processes required for

documentation. You may think about what needs to be documented, but often do not write it

down but Being too busy in a health care setting is not an excuse for poor documentation.

3. False beliefs – With technology becoming more common in the health services industry,

many care providers have a false belief that computers will do their “thinking” required for

documentation. Some care providers may lack writing or keyboarding skills to complete
clear, concise and comprehensive entries. Whether electronic documentation is used or not

every care provider should strive for accurate documentation, not just “good” charting.

4. Employer support – Some care providers have suggested that employing facilities and

agencies take a more active and supportive role in assisting employees to become more

proficient in documentation. Does your employer have up-to-date and clear policies and

procedures? Do you know your employer policies and procedures on documentation? Does

your employer provide education and training?

5. Societal factors –There are societal factors that create added pressures for care providers.

With increased media and consumer health awareness, there is an intense demand for safe,

quality care with client involvement. The public expects care providers to be flawless in

delivery of care, even when there are increased numbers of clients, particularly the frail

elderly who have complex and chronic medical conditions that require intensified time for

care.

6. Costs and budgets – With an increased emphasis on outcomes and cost containment,

documentation has become one of the main mechanisms for gathering data.

Standards of Documentation

Health care provider organizations have standards for documentation that generally

encompass similar characteristics:

1. Client focused – Your documentation should be about the client and this includes the

extension of his family or someone who is legally named if there is no family.

2. Relevant – Do you chart events that are relevant to a particular client’s care and progress?

Do you document the most important details?

3. Confidential

4. Clear, concise, and comprehensive – These are the 3Cs of accurate documentation. Is your

hand writing clear and legible? How does your grammar and expressions of client care enable

others to understand what have you written?

5. Permanent and retrievable – You need to remember that client notes become a permanent

and retrievable health record. These could be retrieved several months or years later by a

lawyer or doctor for examination.

6. Accurate – One of the most common deficiencies in documentation is accuracy of missing

details. Lack of significant detail is also the most highly criticized in the legal process.

7. Chronological and timely – It is important to document in order of occurrence and chart

contemporaneously (as soon as possible after the event or care). This can be extremely

demanding for a health care provider who is caring for several clients with complex and

multiple health issues.

8. Record of care – Documentation must include assessments, perhaps planning,

implementation or interventions and evaluation or results of client events or ones that involve

their families). This is an excellent way to keep focused on your documentation and improve

your accuracy.

b. REPORT WRITING

A report is a document which presents an information or event. Or a report is any

informational work made with specific intension of relaying information or recounting

certain events in a presentable form. Reports are simply information about an activity done

by an individual e.g community health nurse/officer.

Report writing keeps both subordinates and superiors of an organization informed of the

progress of the organization. Reporting on an activity is one of the tools used in measuring

the progress of work. Reports differ from unit to unit, organization to organization, and even

country to country.

TYPES OF REPORTS

There are two (2) main types of reports;

1. Statistical reports: this is a type of report where the information/data is in the form

of figures. E.g a table on antenatal care (ANC) service coverage, immunizations,

family planning monthly report etc.

2. Narrative reports: these are reports written in words

SAMPLES OF REPORT FORMATS

 MONTHLY HOME VISITING/OUTREACH REPORTING FORM

SUB-MUNICIPAL………………………

FACILITY…………………………………..MONTH…………………….YEAR…………………..

Topics treated

Referrals
No. of NO. of No. of Total No.

Name of No. of No. of No. of outreaches pregnant children of people

community houses routine special No. of visited this women under five who

visited visited visits visits outreaches month seen seen benefited Remarks
Name of reporting Officer………………………………………. Signature……………………………………..

Date……………………………………

Referrals

No. pregnant………………….

No. of children under five………………..

No. of newborns

seen…………….
 QUARTELY PERFORMANCE OF CHPS ZONES

NO. of people who benefited

NO. of people in household
Reporting month………………………………………… CHPS Compound……………………………………….. Reporting Date……………………………………………
Clinical Care(Minor
conditions treated) Immunizations 0-11mths Safe motherhood Home Visits Health Education Staff strength

NO.of houses visited

No, of topics treated

Target population

ANC Rrgistration

category of staff
CHO Deliveries
Others specify

TBA Deliveries
Yellow fever

FP Acceptor

NO. of staff
Diarrhoea

Referrals

Remarks
Measles
Malaria

Penta3
OPV3

TT2+
BCG
ARI
MONTHS

JAN

FEB

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

NOV

DEC

TOTAL
Name of reporting offi cer…………………………………………………… Signature………………………………….. Date…………………………………………….. Category of staff
No. of CHN……………
Countersignuted by DDHS………………………………………………….. Signature………………………………….. Date……………………………………………. DCO…………………….
Midwives………………………
 M ON THLY CHILD HEALTH R ETUR N S
NAME OF FACILITY........................................................... SUB DISTRICT……………………………………………………….

DISTRICT…………………………………………………………………………………………………………………………………………………………………………………………………………………….
REGION………………………………………………………. YEAR…………………………….. MONTH:……………………

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS ( IMCI)

# of Sick Chn given 1st dose of

# of Prescribers # trained in IMCI # of children Referred # Given Pre Referral Treatment # of Sick Children Weighed
prescribed drugs in clinic

SCHOOL HEALTH SERVICES

Number of schools
Number of Schools Number of Schools Visited
receiving 3+ Health Talks

TARGET CLASSES # Enrolled # Examined # of chn Referred # of Environmental Certificates Awarded

Type A Type B None

Pre School

P1

P3
JSS1

* REFERRALS
CONDITION NUMBER

1 Ear Problems

2 Eye Problems

3 Oral Health Problems

4 Skin Problems

Name................................................... Rank …………………………………………………………

Submit to: (1) DISTRICT DIRECTOR OF HEALTH SERVICES Date ……………………../…………………../……………

OUTLINE OF A NARRATIVE REPORT

1. Introduction(objectives and targets )

2. Activities carried out with sub headings ( including activities planned and carried out

e.g CWC, Family planning services , disease surveillance, home visiting, community

meeting etc)

3. Resources used (these include staff strength, money and material used e.g fuel bought,

vaccines collected and used, dressings. Syringes and health education materials

distributed.

4. Achievements and success or progress made on a planned activity carried out

successfully target were met or exceeded, high level of community participation

5. Constraints/limitations/challenges are the problems or obstacles encountered by the

health worker in the course of his/her work e.g. break down of fridge for vaccines ,

non-functioning BP apparatus or no impress to buy fuel for outreach programmes,

rainfall, poor road network etc.

6. Follow –up activities

7. Summary

8. Conclusion : this is where recommendation are made on progression or retrogression

of services rendered, name of reporter, date of writing and signature of reporter.

TYPES OF REPORTS WRITTEN BY COMMUNITY HEALTH NURSES/OFFICERS

1. Ghana health service reports e.g family planning reports, EPI, reproductive and child

health monthly returns etc

2. Reports of non-governmental organizations(NGOS) such as comprehensive abortion

care reports, reports on safe motherhood etc

 3. Written reports e.g report on a Durban held etc

IMPORTANCE OF REPORT WRITING AND RECORD KEEPING

1. Reports helps higher levels of organizations to Plan their activities/ work such as

supervisory schedules and distribution of resources

2. During budgeting, reports are used to estimate the cost of needed resources such as

fuel by BMCs, training

3. Reports helps superiors at higher levels of an organization to assess or evaluate the

performance of their staff

4. Reports and record keeping serves as record bank for future reference

5. Reports serve as source of criteria for rewarding hard working staff or facilities.

USES OF REORTS

1. references purposes

2. evaluation of work- to assess work performance

3. budgeting- it can be used to estimate the cost of needed resources.

4. Good reports can be used as a criterion for awarding hard working staff or a whole

facility.

RECORD KEEPING

This is the act of preserving data/information for future reference. Before reports can be

written and kept as records, information or data must be collected or gathered. Data is factual

information from surveys, experiments and use as bases for making calculations or drawing

conclusions. To collect or gather data, the following tools or techniques must be used;
 1. Questionnaire

2. Interviews

3. Focus group discussion: this is where a discussion is held between six (6) to twelve

(12) participants who share common characteristics to talk about a certain topic

guided by a skilled facilitator/person.

4. observation

a. REFERRALS

Referral means sending someone to a different place or person having more knowledge and

power for information, help, a decision etc.

A referral letter or note is a special letter asking for help or care for a patient or client. Its

content should be:

1. Details of the client ( name, age , sex, address. Date and time)

2. Clients’ complaints

3. Your observation on extermination

4. Your provisional diagnosis

5. Treatment given

Referral is an important aspect of health activities. The health service provider should decide

when to refer a client and write a referral not for the client and his relative on time.

TYPES OF REFERRAL

1. Vertical- this is a form of referral where client is referred from a lower level to higher

level for assistance or health care. That is, from CHPS compound to the sub- district,

from sub-district to district.

 2. Horizontal-this is referral of a client from one health facility to another on the same

level with high capacities. That is, from one district hospital to another district

hospital.

3. Internal- this is form of referral that is done within a particular health facility that is

referring a client from female medical ward to gynecological ward.

REASONS FOR REFERRAL

1. To obtain the needed assistance from a colleague

2. To co-manage the case

3. For continuity of care

4. To receive good care

5. To save life on time

PROCEDURE FOR REFERRAL

1. Explain the referral process to the client. Tell the client the referral is part of the

health service delivery, reassure and tell the client the need for the referral

2. Serve pre-referral medication

3. Call the facility you are referring the patient to in advance and give the client

feedback to relief anxiety.

4. Write referral note for the patient and relatives stating the patient’s name, age,

sex, address, history, findings from observation and physical examination, vital

signs, date and time of arrival

FACTORS INFLUENCING REFERRAL

1. Health status of the client, that is, good or bad.

 2. Availability or unavailability of equipment, drugs and supplies

3. Capabilities and competence of service provider

4. Distance from the referring point to the next level.

5. Condition of the road

6. Readiness of the patient and family to agree on the referral

7. Emergency support

8. Financial position of family members.

DUTIES OF FAMILY MEMBERS DURING REFERRAL

1. To provide psychological support

2. To provide financial support

3. To assist the patient to next level

4. To provide basic needs ( food, water, clothes etc,)

5. To take care of other family members left at home

6. Support sick person to recover after discharge

REFERRAL LEVELS FOR RNAP

Level E (teaching or specialist hospital)

Level D (regional hospital)

Level C (District hospital)

Level B (Health centre)

↑
Level A (community/CHPS zone)
Explain the PLA tools as use in need assessment and need prioritization

i. Mapping and diagramming

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

ii. Sorting and ranking

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………
…………………………………………………………………………………………………

…………………………………………………………………………………………………

………………………………………………………………………………………………..

iii. Matrice

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………..

NB. DUE DATE : 02/10/2018 CLOSING DATE: 09/10/2018

REFERENCES

Asiedu, C. and Bilson, S. A.(2016). Principles and practice of Community Health Nursing

and Issues in Public Health Practice.(Seventh edition). Ghana

Blair, W. & Smith, B. (2012). Nursing documentation: Frameworks and barriers.

Contemporary Nurse, 41(2), 163.

WHO (2010). Weekly Epidemiology Record. Available at

http://www.who.int/wer/2009/wer8449/en/index.html

WHO (2009). State of the world’s vaccines and immunization. (Third edition). Geneva:

World Health Organization