CHN FINALS

ENVIRONMENTAL HEALTH

"No amount of medical knowledge will lessen the accountability for nurses to do
what nurses do; that is, to manage the environment to promote positive life
processes." Sister Calista Roy, Commentary on Notes on Nursing, 1992
To enable the public health nurse to use the environment to assist the community in
improving its state of wellness, it is necessary to study the various relationships
between the components of the environment and human health. This chapter discusses
the geophysical, social, biological, and built environments of people that affect
their health.

In 1998, the Department of Health (DOH), in its Implementing Rules and Regulations
of Chapter XX (Pollution of the Environment) of the Code of Sanitation of the
Philippines, defined environmental health as:
The characteristics of environmental conditions that affect the quality of health.
It is the aspect of public health that is concerned with those forms of life,
substances, forces, and conditions in the surroundings or person that may exert an
influence on human health and well-being.
In 1993, the World Health Organization (WHO) described environmental health through
a consultation in Sofia, Bulgaria:
Environmental Health comprises of those aspects of human health, including quality
of life, that are determined by physical, chemical, biological, social, and
psychosocial factors in the environment. It also refers to the theory and practice
of assessing, correcting, controlling, and preventing those factors in the
environment that can potentially affect adversely the health of present and future
generations.
Note that environmental health could refer either to the components of the
environment that affect human health or to the components of human health that are
affected by the environment. To provide emphasis that an individual is the client
of the public health nurse (i.e., instead of the environment), this chapter shall
take this definition: Environmental health is the component of the individual's
well-being that is determined by interactions with the physical, chemical,
biological, social, and psychosocial factors external to him or her.
As the government takes the responsibility for providing an environment that
supports the right of people to lead healthy lives, it will seek the various
expertise of its members including that of the public health nurses. The Philippine
government takes this course of action through Executive Order No. 489:
Institutionalizing the InterAgency Committee on Environmental Health (IACEH). The
member agencies are represented by the various secretaries and directors of the
executive branch of the government, headed by the Secretary of the DOH as
chairperson, and the Secretary of the Department of Environment and Natural
Resources (DENR) as vice chairperson.
The various roles of IACEH specified by law include the task of coordinating,
monitoring, and evaluating environmental health programs initiated by the
government and private agencies to achieve environmental protection for health
promotion. To perform these roles, the National Environmental Health Action Plan
(NEHAP) had been developed.

NEHAP identified seven components of environmental health that will be assigned to

the leadership of the members of the IACEH, namely, solid waste, water, air, toxic
and hazardous waste, occupational health, food safety, and sanitation (SWATOFS). In
July 2010, this has been expanded to include climate change.

ENVIRONMENTAL HEALTH RECORDS MANAGEMENT

In the Philippines, the maintenance of environmental health records is one of the
responsibilities given to city, municipal, and provincial health nurses. The
current data management system being used by the DOH is the Field Health Service
Information System (FHSIS). Data collection begins with the midwife and the
barangay health workers. In the 2008 version of the FHSIS, the midwife is tasked to
maintain a monthly record of the environmental health program accomplishments in
the "Summary Table" form. The eight environmental health indicators that need to be
monitored are as follows:
1. Households with access to improved or safe water - stratified to
Levels I, II, and Ill
2. Households with sanitary toilets
3. Households with satisfactory disposal of solid waste
4. Households with complete basic sanitation facilities
5. Food establishments
6. Food establishments with sanitary permits
7. Food handlers
8. Food handlers with health certificates
At the end of each year, the midwife would have already completed the 12-month
columns of the summary table. On the second week of January of the following year,
the midwife must submit her Annual Barangay Health Station Report "A-BHS" form to
the city/municipal health nurse. The city/ municipal health nurse then consolidates
all A-BHS forms into an annual report of the city/ municipality using the "A1" form
that is due by the third week of January. The provincial health nurse performs the
same task and submits a consolidated "A1" report form of all the cities and
municipalities of the province to the DOH Regional FHSIS Coordinator on the fourth
week of January. The consolidated regional annual reports are submitted to the DOH
National Office on the second week of March that year.
The public health nurse must therefore be abreast with the definition of these
records that must be maintained. The 2008 version of the FHSIS presents the
following
definitions:

• Households with access to improved or safe water supply - refers to

those covered by or have access to any of the three levels of safe water sources
that conforms to the national standards for drinking water.
• Level I (point source) - refers to a protected well (shallow or deep
well), improved dug well, developed spring, or rainwater cistern with an outlet but
without a distribution system. A Level I facility is generally adaptable for rural
areas where the houses are thinly scattered. It would normally serve 15-25
households and its outreach must not be more than 250 meters from the farthest
user. The yield or discharge is generally from 40 to 140 liters/minute.
The point of consumption of Level I systems is at the source itself, placing the
water reservoir at higher risk of contamination. In the FHSIS, if the Level I
reservoir (e.g. a protected rainwater cistern) is piped into the tap of households,
they are then considered to have a Level Ill access as the risk of reservoir
contamination is minimized.
• Level II (communal faucet system or standpost) - refers to a system composed of a
source, a reservoir, a piped distribution network, and a communal faucet located
not more than 25 meters from the farthest house. It is generally suitable for rural
and urban areas where houses are clustered densely enough to justify a simple piped
water system. For reporting purposes in the FHSIS, Level I system may also include
a communal faucet where a group of households get their water supply even if the
said faucet is connected to a Level III source. The typical Level Il system is
designed to deliver 40-80 liters per capita per day to an average of 100
households, with one faucet per 4-6 households.
The piped distribution network takes the point of consumption away from the
reservoir, thus decreasing the risk of pollution coming from the consumers.
Contamination of water from Level Il sources would more likely take place during
its transport and storage in the individual households.
• Level III (waterworks system) - refers to a system with a source,
transmission pipes, a reservoir, and a piped distribution network for household
taps. It is generally suited for densely populated areas. This level of facility
requires minimum treatment of disinfection. Examples of this include water
districts with individual household connections. For reporting purposes, a Level
Ill system may also include a Level I system with piped distribution for household
taps, serving a group of housing dwellings such as apartments or condominiums.
• Households with sanitary toilets - refer to households with their own
flush toilets connected to septic tanks and/or sewerage system or any other
approved treatment system, sanitary pit latrine, or ventilated improved pit
latrine. The national target for this component is 91% (96% for urban and 86% for
rural areas).
• Households with complete basic sanitation facilities - refers to
those that satisfy the presence of the following basic sanitation elements, namely,
1. access to safe water,
2. availability of a sanitary toilet, and
3.
4. satisfactory system of garbage disposal.
• Food establishments - refer to those where food or drinks are
manufactured, processed, stored, sold, or served, including those that are located
in vessels.
• Sanitary permit - the written certification of the city or municipal
health officer or sanitary engineer that the establishment complies with the
existing minimum sanitation requirements upon inspection conducted in accordance
with Presidential Decrees Nos. 522 and 856 and local ordinances.
• Food handlers- refer to persons who handle, store, prepare, or serve
any food item, drink, or ice, or who come in contact with any eating or cooking
utensil or food vending machine.
As food handlers are taken as any human source of food contamination other than the
consumer, the interest of public health nurses as collators and consumers of FHSIS
data is to compare the number of food handlers with the number of those who have
active health certificates.
• Health certificate - a written certification, using the prescribed form, and
issued by the municipal or city health officer to a person after passing the
required physical and medical examinations and immunizations.

SOLID WASTE MANAGEMENT

The Philippine Development Plan (PDP) for the year 2011-2016 aspires to get a 50%
increase of the solid waste diversion (SWD) rate of 33% level in the year 2010.
SWD refers to activities that reduce, and possibly eliminate, the potentially
recyclable materials in the waste stream before they end up as added undesirable
matter on the land known as land pollution.
This act to reduce the contamination of land supports the work of the public health
nurse in enabling the community to increase its level of wellness, as it
necessarily protects some of the health-supporting functions of land, such as:
1. Platform for human activities: Polluted soil may be contaminated
with disease-causing parasites and microbes.
2. Agricultural production: Alteration of soil composition can make the
land unsuitable for growing crops and threaten food security. Hazardous materials
such as cadmium, lead, and mercury from disposed batteries and mine tailings can
accumulate in the land and be present in the harvested products.
3. Habitat of members of the food chain: As hazardous materials
accumulate in the soil; they affect the lower life-forms in a process called
"bioaccumulation." As these creatures in the bottom of the food chain are consumed
by the more superior creatures, hazardous chemicals increase in concentrations in
the food chain in a process called "biomagnification." At the top of the food
chain, the human is at risk of consuming the hazardous materials.
4. Filter for surface water: Natural bodies of water and storm water
percolate through the layers of the soil until it finds its way to the groundwater.
Soil saturated with pollution not only acts as a poor filter but may also
contaminate the seeping water. The nurse in communities that rely on ground water
must be interested in the routine testing of these sources.
Through the definitions used by Republic Act 9003 otherwise known as the
"Ecological Solid Waste Management Act of 2000" and the DOH Manual on Healthcare
Waste Management of 2011, a way by which solid wastes may be classified is as
follows:
• Municipal waste refers to all discarded nonhazardous household
commercial and institutional waste, street sweepings, and construction debris.
• Health care waste (or biomedical wastes) refers to the refuse that is
generated in the diagnosis, treatment, or immunization of human beings or animals
together with those related to the production or research of the same. This can be
classified as follows:
1.
2. "Infectious wastes" refer to those suspected to contain bacterial,
viral, parasitic, or fungal pathogens in sufficient concentration so as to cause a
disease in susceptible hosts. These include, but are not limited to, laboratory
cultures, contaminated wastes from clients with infectious disease, and any other
dressing, swabs, instruments, or materials that have been in contact with infected
persons or animals.
3. "Pathological wastes" refer to tissues, organs, body parts, human
fetuses, animal carcasses, and blood and body fluids. Within this category,
recognizable human and animal body parts are also called anatomical waste. This
category should be considered as a subcategory of infectious waste, even though it
may also include healthy body parts.
4. "Pharmaceutical wastes" include pharmaceutical products such as
drugs, vaccines, and sera that are no longer required and need to be disposed of
appropriately for any reason. This category also includes discarded items used in
handling of pharmaceuticals such as bottles or boxes with residues, gloves, masks,
connecting tubes, and drug vials.
5. "Chemical wastes" include the varied states of chemical matter from
clinical or laboratory activities, environmental work, housekeeping, and
disinfecting procedures. This subcategory has any of the five properties of
hazardous wastes and is therefore termed as "hazardous chemical wastes."
6. "Sharps" include biomedical wastes that could cause cuts or puncture
wounds. These include, but are not limited to, needles, broken glass, and scalpel
blades.
7. "Radioactive wastes" include sealed radiation sources typically used
in cancer treatments, liquid, and gaseous materials contaminated with
radioactivity, and excreta of patients who underwent radionuclide diagnostic and
therapeutic applications, together with the related paraphernalia and tap water
washings.
• Industrial waste refers to the refuse that arise from production and
from agricultural, and mining industries. Aside from rubbish, industrial wastes can
be mixed with contaminated soil, ashes, and hazardous wastes.
• Hazardous wastes are substances that pose either an immediate or
long-term substantial danger to human because of possessing any of the following
properties:
1. Toxic
2. Corrosive such as acids of pH <2, and bases of pH >12
3. Flammable
4. Reactive such as those that can cause explosions
5. Genotoxic such as cytostatic drugs.

RA 9003 also defines solid waste management as the discipline associated with the
control of generation, storage, collection, transfer and transport, processing, and
disposal of solid wastes in a manner that is in accordance with the best principles
of public health, economics, engineering, conservation, aesthetics, and other
environmental considerations, and that is also responsive to public attitudes. It
is the discipline that governs over the solid waste stream.
The pathway of municipal solid waste (solid waste stream) begins with waste
generation. At this stage, waste reduction can be done through the reuse of
materials.
Materials that cannot be used should be segregated in trash bins with color-coded
and labeled linings, so that each form of waste item could be managed accordingly.
In the third edition of the Manual on Healthcare Waste Management, published by the
DOH in December 2011, the following color coding of hospital waste bins were
prescribed:
• Black or colorless: Nonhazardous and nonbiodegradable wastes
• Green: Nonhazardous biodegradable wastes
• Yellow with biohazard symbol: Pathological/ anatomical wastes.
• Yellow with black band: Pharmaceutical, cytotoxic, or chemical wastes
(labeled separately)
• Yellow bag that can be autoclaved: Infectious wastes
• Orange with radioactive symbol: Radioactive wastes
The segregated wastes are collected and transported accordingly. Recyclable wastes
and such as metals, plastics, paper, and glass can be sent to a materials recovery
facility to generate recycled raw materials for producers. Biodegradable and
organic wastes can be sent to a composting unit for processing and subsequent
agricultural use.
Only residual wastes (if any) should be dumped into the sanitary landfill.
There are various waste processors that could be utilized by institutions,
organizations, and local government units (LGUs) including shredders, biological
reactors, and thermal processors. Individuals responsible for community surveys
should note that the law excludes incineration from the acceptable processes, as it
is known to emit toxic and poisonous fumes. Public health officers should also keep
in mind that the Implementing Rules and Regulations of Republic Act 9003 has
declared the following as some of the prohibited acts:
• Open burning of solid wastes
• Open dumping
• Burying in flood-prone areas
• Operation of landfills on any aquifer, groundwater reservoir, or
watershed
• Construction of any establishment within 200 meters from a dump or
landfill

WATER SANITATION
Increase in access to safe water supply is one of the crucial steps to the
achievement of the health-related Millennium Development Goals (MDGs). According to
the PDP of 2011-2016, the percentage of households in the Philippines with access
to safe water in the year 2007 was 82.9%. By 2016, the PD aims to increase this
ratio to 86.6%.
The DOH had identified three levels of access to safe water supply and had set the
standards of the quality of drinking water through the DOH Administrative Order No.
2007-0012, otherwise known as the Philippine National Standards for Drinking Water
of 2007.
The general requirements of safe drinking water cover the following:
1. Microbial quality tested through the parameters of total coliform,
fecal coliform, and heterotrophic plate count.
2. Chemical and physical quality tested through the parameters of pH,
chemical-specific levels, color, odor, turbidity, hardness, and total dissolved
solids.
3. Radiological quality tested through the parameters of gross alpha
activity, gross beta, and radon.
DOH A.O. 2007-0012 directs all drinking water processors from large water systems
to water refilling stations to create a water safety plan. The three key components
of water safety plans include:
1. System assessment - to determine if the drinking water supply chain
as a whole can deliver water of quality that meets health-based targets.
2. Operational monitoring - to identify control measures in a drinking
water system that will collectively control identified risks and ensure that the
health-based targets are met, and to rapidly detect any deviation from the required
performance.
3. Management plans - to describe actions to be taken during normal
operations or incident conditions.
The national law on water quality management is Republic Act 9275, otherwise known
as the Philippine Clean Water Act of 2004. It directed the DENR to act as the lead
agency in the implementation and enforcement of this law. It also directed the DOH
to be primarily responsible for the promulgation, revision, and enforcement of
drinking water quality standards.

Other than the concern on the standards of the quality of drinking water, DOH has
also produced the Implementing Rules and Regulations of the Code of Sanitation of
the Philippines Chapter II: Water Supply. Some of the provisions include:
1. Washing and bathing within a radius of 25 meters from any well or
other source of drinking water is prohibited.
2. No artesians, deep, or shallow well shall be constructed within 25
meters from any source of pollution (including septic tanks and sewerage systems).
Drilling a well within a 50-meters distance from a cemetery is also prohibited.
3. No radioactive source or material shall be stored within a radius of
25 meters from any well or source of drinking water unless the radioactive source
is adequately and safely enclosed by proper shielding.
4. No dwellings shall be constructed within the catchment area of a
protected spring water source, and it shall be off limits to people and animals.
Emergency water treatment
Water that needs treatment during emergencies is the one that is used for drinking
and preparing foods. This is estimated to amount to about 5 liters per person per
day. In 2011, the WHO published the Technical Notes on Drinking Water, Sanitation,
and Hygiene in Emergencies created by the Water, Engineering, and Development
Center (WEDC). It provides the following prescriptions for emergency treatment of
drinking water:
Pretreatment Processes:
• Aeration is done to remove volatile substances, reduce carbon dioxide
content, and oxidize dissolved minerals in preparation for sedimentation and
filtration. A method for aeration is to rapidly shake a container that is partially
full of water for about 5 minutes.
• Settlement is done by allowing water to stand undisturbed in the dark
for a day. This process causes death to more than 50% of most harmful bacteria and
settling of suspended solids. Repetition of settlement in another container or pot
increases the effectiveness of the process, as water is made to settle for longer
periods.
• Filtration is done by utilizing filters to block particles while
allowing water to pass through. Filters include clean cloth, sand, and ceramics.
Disinfection Processes:
• Boiling, despite being energy consuming, is considered as a very effective method
for water disinfection. The water should be brought to a "rolling boil" and kept in
that state for at least 1 minute at sea level. At higher altitudes, the water
should be kept in a rolling boil state for at least 3 minutes. This process causes
the water to change taste. This can be improved by performing aeration after the
water has been cooled.

• Chemical disinfection can be done using various chemicals but the

most widely used remains to be chlorine as it can kill all viruses and bacteria.
However, some species of protozoa and helminths have been seen to be resistant to
chlorination. Chlorine is available in various size and strength; thus, it is
important to follow the manufacturer's instructions on their use.
• Solardisinfection (SODIS) follows the principle that ultraviolet rays
from the sun destroy harmful organisms in water. This can be done by filling
transparent plastic containers 1 to 2 liters in size with clear water, and exposing
them to direct sunlight for about 5 hours. If the skies are cloudy, the bottles are
exposed for two consecutive days.
Water Storage and Consumption
• Wide-necked containers with tight-fitting lids are best for water
storage as they are easy to clean between use.
• Hands and utensils may come in contact with water, therefore
educating people about proper washing techniques is of high importance.

AIR PURITY
Public health nurses must be sensitive to the various sources of air pollution in
their community. The DENR, in its Administrative Order 2000-81, defines an air
pollutant as any matter in the atmosphere other than the natural concentrations of
oxygen, nitrogen, water vapor, carbon dioxide, and inert gases that may be
detrimental to health or the environment.
The first 11 kilometers of the atmosphere from the earth is the troposphere where
we live in. In this layer, the temperature profile is warmest at sea level and
coolest at higher altitudes. Public health nurses serving mountainous communities
should keep in mind that these communities are generally exposed to cooler weather.
Having in mind that as the air gets cooler, the less water vapor it is able to
carry, the public health nurse should be sensitive to the rise of respiratory
infections in these communities, as the moist "mucociliary blanket" protection of
the airways could be interrupted by the dry air.
The troposphere near sea level has a typical composition of gases that support
healthy human life. In general, it is thought to be 78% nitrogen, 21% oxygen, and
1% other gases (such as carbon dioxide, argon, and water vapors). As the altitude
increases, oxygen percentages decrease.
The typical composition of air can be disturbed by pollutants. Pollutants can be
suspended in particulate matter or the gases themselves. Particulate matter that is
of public health concern is approximately 10 pm in size (PM 10) as they can be
suspended in air. Gases that exceed their normal concentrations are considered as
pollutants to healthy air.
The DENR A.O.2000-81: Implementing Rules and Regulations for R.A. 8746 identified
some of the pollutants that should concern communities such as ozone-depleting
substances, chlorofluorocarbons, particulate matter that refer to any material that
exists in a finely divided form as a liquid or solid other than water, greenhouse
gases that can potentially induce global warming such as carbon dioxide, methane,
and oxides of nitrogen, chlorofluorocarbons, and fuel components such as aromatics,
benzene, and sulfur.
Then, there is the stratosphere where the ozone layer is found. The stratosphere
has an inverted vertical-temperature profile, that is, it gets warmer as you
increase altitude. Public health nurses of communities with airports know that this
is the layer where most airplanes fly and emit most of the products of jet fuel
combustion.
A.O.2000-81 defines an emission as any measurable pollutant gas or unwanted sound
from a known source, which is passed into the atmosphere.

As public health nurses identify possible sources of air pollution, they should be
aware of the two major sources identified by the Clean Air Act, namely, mobile and
stationary sources.
• Mobile source - refers to any vehicle/machine propelled by or through
oxidation or reduction reactions, including combustion of carbon-based or other
fuel, constructed and operated principally for the conveyance of persons or the
transportation of property or goods, that emit air pollutants as a reaction
product.
• Stationary source - refers to any building or fixed structure,
facility, or installation that emits or may emit any air pollutant.
Other than air pollution, contamination with microorganisms is a public health
concern in terms of clean air. Infections with microbes generally follow the
principles of particulate matter invasion of the respiratory tract, in that the
smaller the particle is, the more efficient it becomes in reaching the lower
airways. The American Conference of Governmental Industrial Hygienists has defined
a criteria depending on the efficiency of various particle sizes in entering the
respiratory tract as
1. Inhalable particulate matter starting at 100-um diameter.
2. Thoracic particulate matter starting at 10-um diameter.
3. Respirable particulate matter starting at 4-um diameter.
The Pollution Prevention and Abatement Handbook by the World Bank says that the
particles most likely to cause adverse health effects are the fine particulates
PM10 and PM2.5-particles smaller than 10 and 2.5 pm. Prevention of exposure to such
is facilitated by the use of high-efficiency particulate filters such as that of
used in the branded N-95 Mask.
In the Philippines, the Air Quality Management Section of the DENR Environmental
Management Bureau (DENR-EMB) monitors air quality. It maintains 42 air quality
- monitoring stations nationwide, which measure the total suspended particulates
(TSP). Healthy air has a TSP that does not exceed 90 um/m3. The direction of air
quality monitoring is toward building technical capacity to monitor PM10 and PM2.5.
DENR-EMB acts as the chairperson of the air management, whereas the Department of
Transportation and Communication (DOTC) acts as the vice chairperson.
Several programs have been initiated to address air pollution:
• Bantay Tsimineya Program that monitors point-source air pollution
from industries.
• Bantay Tambutso Program and Standard Setting that adopted Euro-ll
emission standards for motorized vehicles. This program penalizes vehicle owners
who fail to meet the set-standard.
•
• Improved Fuel Quality Program that phased out leaded gasoline, and
regulated the sulfur, benzene, and aromatic content of fuels.
• National Research and Development Program for the Prevention and
Control of Air Pollution whose development was directed by DENR Administrative
order
2000-81 to the DENR-EMB, in coordination with the Department of Science and
Technology (DOST).
Public health nurses serve as an expert resource not only for the mayors and
governors of their respective localities but also for the "Airshed" to whom the
city or municipality belongs. An airshed refers to an area with a common weather or
meteorological condition and a common source of air pollution. The DENR Secretary,
on the recommendation of the Environmental Management Bureau, has the legal mandate
to divide the geopolitical regions of the country into airsheds for a more
effective air quality management. The designation of airsheds shall be revised as
additional data, needs, or situations arise. Each airshed is tasked to develop and
implement a common action plan.
Other than outdoor settings, indoor air pollution in-built spaces intended for
public use is a concern of community health providers. Public health nurses,
together with the city or municipal health officer, are at a key position to make
recommendations to the LGU regarding the air safety in built public establishments.
In the evaluation of such areas, Rule 1000 can be used as a guide.
Rule XXIX, Section 1 of DENR A.O.2000-81 "Ban on Smoking" had already directed the
LGUs to:
... implement or enforce a ban on smoking inside a public building or an enclosed
public place including public vehicles and other means of transport or in any
enclosed area outside of one's private residence, private place of work or any duly
designated smoking area which shall be enclosed."
The public health nurse is tasked to be both a nurse who advocates for the client
community, and a government officer who must assure that the rights of the people
are protected. People's right to clean air has been clearly defined by the Republic
Act 8749 also known as the "Philippine Clean Air Act of 1999." Pursuant to the
principles of the said law, following rights of citizens are sought to be
recognized:
1. The right to breathe clean air.
2. The right to utilize and enjoy all-natural resources according to
the principle of sustainable development.
3. The right to participate in the formulation, planning,
implementation, and monitoring of environmental policies and programs and in the
decision-making process.
4. The right to participate in the decision-making process concerning
development policies, plans, and programs projects or activities that may have
adverse impact

area outside of one's private residence, private place of work or any duly
designated smoking area which shall be enclosed."
The public health nurse is tasked to be both a nurse who advocates for the client
community, and a government officer who must assure that the rights of the people
are protected. People's right to clean air has been clearly defined by the Republic
Act 8749 also known as the "Philippine Clean Air Act of 1999." Pursuant to the
principles of the said law, following rights of citizens are sought to be
recognized:
1. The right to breathe clean air.
2. The right to utilize and enjoy all-natural resources according to
the principle of sustainable development.
3. The right to participate in the formulation, planning,
implementation, and monitoring of environmental policies and programs and in the
decision-making process.
4. The right to participate in the decision-making process concerning
development policies, plans, and programs projects or activities that may have
adverse impact on the environment and public health.
5. The right to be informed of the nature and extent of the potential
hazard of any activity, undertaking, or project and to be served timely notice of
any significant rise in the level of pollution and the accidental or deliberate
release into the atmosphere of harmful or hazardous substances.
6. The right of access to public records which a citizen may need to
exercise his or her rights effectively under this Act.
7. The right to bring action in court or quasi-judicial bodies to
enjoin all activities in violation of environmental laws and regulations, to compel
the rehabilitation and cleanup of affected area, and to seek the imposition of
penal sanctions against violators of environmental laws.
8. The right to bring action in court for compensation of personal
damages resulting from the adverse environmental and public health impact of a
project or activity.

TOXIC AND HAZARDOUS WASTE CONTROL

The government accounts the chemicals that it monitors in the Philippine Inventory
of Chemicals and Chemical Substances (PICCS). To date, there are 44,600 substances
in the list, five of which are controlled chemicals, namely, asbestos, cyanide,
mercury, polychlorinated biphenyls, and ozone-depleting substances.
The country has several poison control centers nationwide, headed by the National
Poison Management and Control Center (NPMCC) based in the Philippine General
Hospital (PGH). In 2009, the centers reported a total of 1,286 poisoning cases. The
top causes of poisons are the following: jewelry cleaners (high in cyanide),
pesticides, button batteries, Watusi firecracker, Jatropha seeds, multivitamins,
malathion and xylene, camphor with methyl ASA, and turpentine.

TSP and PM10 specific statements for the general public

1. Unhealthy for sensitive groups. People with respiratory disease,
such as asthma, should limit outdoor exertion.
2. Very unhealthy pedestrians should avoid heavy traffic areas. People
with heart or respiratory disease, such as asthma, should stay indoors and rest as
much as possible. Unnecessary trips should be postponed. People should voluntarily
restrict the use of vehicles.
3. Acutely unhealthy People should limit outdoor exertion. People with
heart or respiratory disease, such as asthma, should stay indoors and rest as much
as possible. Unnecessary trips should be postponed. Motor vehicle use may be
restricted. Industrial activities may be curtailed.
4. Emergency Everyone should remain indoors, keeping windows and doors
closed unless heat stress is possible. Motor vehicle use should be prohibited
except for emergency situations. Industrial activities, except that which are vital
for public safety and health, should be curtailed.

1. Unhealthy for sensitive groups People with cardiovascular disease,

such as angina, should limit heavy exertion and avoid sources of CO, such as heavy
traffic.
2. Very unhealthy People should stay indoors and rest as much as
possible. Unnecessary trips should be postponed. People should voluntarily restrict
the use of vehicles and avoid sources of CO, such as heavy traffic. Smokers should
refrain from smoking.
3. Acutely unhealthy People with cardiovascular disease, such as
angina, should avoid exertion and sources of CO, such as heavy traffic, and should
stay indoors and rest as much as possible. Unnecessary trips should be postponed.
Motor vehicle use may be restricted. Industrial activities may be curtailed.
4. Emergency Everyone should avoid exertion and sources of CO, such as
heavy traffic, and should stay indoors and rest as much as possible.

The DENR accounts for the ratio of hazardous waste treatment plants and hazardous
waste-generating facilities. In 2010, there were 108 privately owned hazardous
waste treatment facilities serving 11,162 hazardous waste-generating facilities.
Primary health care facilities should be capable of following the WHO
recommendations on essential symptomatic and supportive treatment of acute
poisoning. Health care workers and trained volunteers should wear personal
protective equipment (PPE) to evacuate victims from the contaminated environment.
In the event of skin contamination, the clothing is removed and the skin is washed
with the appropriate fluid. Interventions that may be considered thereafter include
gastric aspiration and lavage of adults, induced emesis of children, administration
of a high dose of activated charcoal into the stomach, and administration of
protective agents such as:
• Atropine for carbamate and organophosphate pesticides
• Methylene blue for chlorates and nitrites
• Acetylcysteine or methionine for paracetamol overdose
• Hydroxocobalamin or sodium thiosulfate for cyanide in silver cleaners
Referral to higher institutions allows the safe toxicological analysis and
subsequent administration of specific antidotes, anticonvulsants, antiarrhythmics,
and analgesics. The Toxic and Environmental Health Working Group is headed by the
DENR (chairperson) and the Department of Agriculture (vice chairperson).

FOOD SAFETY
The NEHAP defined food safety as the assurance that food will not cause any harm to
the consumer when it is prepared and eaten according to its intended use. To gear
toward the food safety, the DOH formed an interagency committee that is led by the
Food and Drug Administration (FDA). In 2009, Republic Act 9711 was enacted and is
now known as the Food and Drug Administration Act, which strengthened the FDA in
safeguarding the safety and quality of processed foods, drugs, diagnostic reagents,
medical devices, cosmetics, and household substances.
The DOH has published the Implementing Rules and Regulations to define the
sanitation requirements for the operation of a food establishment.
The food establishment must have a sanitary permit from the city or municipality
that has jurisdiction over the business. In the case of food-establishments on-
board sea-crafts, the application must be filed in the vessel's port of origin. The
permit must be posted in a conspicuous place in the establishment, available for
inspection by health and other regulatory personnel.
The implementing rules state that no person shall be employed in any food
establishment without a health certificate properly issued by the city/municipal
health officer. This must be clipped on the upper left front portion of the garment
of the employee while working. No person shall be allowed to work on food handling
if afflicted with a communicable disease, including boils, infected wounds,
respiratory infections, diarrhea, and gastro-intestinal upset.
Particular guidelines on sources, transportation, preparation, storage, and serving
have been set by the implementing rules and regulations. All of which are geared
toward the preservation of the quality and cleanliness of food, as well as the
safety of the service and consumption of the same.
The food preparation and storage rooms should never be used or be directly
connected to a sleeping apartment or a toilet. No animals can be kept in the food
areas. The display of any live animal in the food area is strictly prohibited.
Floors, walls, and ceilings must be made of materials that can be cleansed. The
rules have set standards for the adequacy of lighting, sufficiency of ventilation,
and minimum space requirements. It requires hand washing basins, appropriate toilet
facilities, water supply, and refuse management systems.
Utensils must be scraped of all food particles and be washed in warm water (49°C)
with soap. If running water is not available, the wash water shall be changed
frequently. The utensils are then subjected to one of the following bactericidal
treatments:

1. Immersion for at least 30 seconds in clean hot water (77 °C).

2. Immersion for at least 1 minute in lukewarm water containing 55-100
ppm of chlorine solution.
3. Exposure to steam for at least 15 minutes to 77 °C, or for 5 minutes
to at least 200 °C.
It shall be the duty of the Sanitation Inspector of the city, municipality, or
province to perform an inspection and evaluation of the compliance of food
establishments to the set standards at a frequency specified by the implementing
rules and regulations.
Ambulant food vendors shall sell only bottled drinks, and prepacked food. They are
prohibited from selling food that requires the use of utensils.
As monitored by the FHSIS, all food handlers must maintain an updated health
certificate. The public health nurses are at an advantageous position to
participate in the monitoring and implementation of the ordinance on food handlers
as they are given the task to collate and report data in the FHSIS system.

SANITATION
• 00:00:11
The Philippines Sanitation Sourcebook and Decision Aid developed by the DENR, the
DOH, and the Local Water Utilities Administration (LUA) in 2005 limited the
definition of sanitation to "the hygienic and proper management, collection,
disposal, or reuse of human excreta (feces and urine) and community liquid wastes
to safeguard the health of individuals and communities". This is proof of the
development of the arts and sciences involved in the various fields of sanitation,
that is, a singular code on sanitation such as the Presidential Decree 856: the
Code on Sanitation of the Philippines of 1976 may need to be revisited and updated
to provide a more comprehensive coverage to this growing discipline.
The government keeps track on the proportion of the population that does not have
the approved types of sanitation facilities. One may observe fluctuations in the
figures through the years as the problem of service coverage is aggravated by the
effect of disasters that damage existing sanitary facilities. The DOH is the chair
of the sanitation sector, whereas the Department of Interior and Local Government
serves as the vice chair. It is to the nation's advantage that the public health
nurses working for or with the DOH become well-abreast with the various concepts on
sanitation. For example, microorganisms in human excreta and agricultural run-off
may contaminate water systems and cause an epidemic.
In 2005, the Sanitation and Hygiene Promotion Programming Guidelines developed the
F-Diagram that proposed the 6 Fs that form part of the means to transmit
microorganisms in fecal materials to a new host, namely, feces, fingers, fluids,
flies, fields/ floors, and food. It featured the primary and secondary barriers
that public health practice could implement to prevent the transmission of the
pathogens. Primary barriers are the structures and facilities that prevent the
fecal contamination of fingers, fluids, flies, and fields/floors. Secondary
barriers are practices that prevent contaminated fingers, fluids, flies,
fields/floors from coming in contact with food or the new host. Secondary barriers
include, but are not limited to, handwashing practices, insect and vermin control,
water treatment, and proper food handling. The following text focuses on the
primary barriers.
Sanitation facilities generally have four components, namely, toilet, collection,
treatment, and disposal/reuse. The toilet could either be a receptacle (bowl) where
the user sits down or a squatting plate. Collection systems, also known as sewerage
systems, transport the wastewater for treatment or disposal. Treatment is the
process of reducing liquid and solid waste to nonpolluting matter. Disposal or
reuse finally releases the treated waste to the environment. The disposal can mean
discharge to water bodies such as rivers, application to soils, or release to the
atmosphere in the form of gas. Ecological sanitation moves for the reuse instead of
the disposal of treated wastewater as they can be safely used for irrigation of
agricultural and landscaped plants and firefighting.

A general classification of sanitation systems could be done according to water

reliance. Water-reliant systems make use of water to flush and transport the waste
material to the collection system, thus requiring a continuous supply of water.
Communities or resettlement areas that do not have access to continuous water
supply may have problems in compliance to the use of these facilities.
On the other hand, nonwater-reliant systems make use of "dry" storage for urine and
feces. It is important to note, however, that a small amount of water may be used
to cleanse the parts of the dry system, such as that of vacuum-flush toilets of
buses and airplanes. These toilet systems treat or store the materials on-site as
they are not connected to sewerage systems. A toilet system that is not connected
to a sewerage system is called a privy.
The Implementing Rules and Regulations of the Sanitation Code of the Philippines
developed by the DOH describes three components of a sanitary privy, namely, an
earthen pit, a floor covering the pit, and a water-sealed bowl. Wooden floors and
seat risers are not to be used anymore. The flooring should cover the pit tightly
and joined to the bowl with a water-tight and insert-proof joint. The pit should be
at least 1 m' wide.
The following are some of the sanitation facilities that a nurse or sanitation
officer may encounter in the community:
• Box-and-can privy (or bucket latrine): Fecal matter is collected in a
can or bucket, which is periodically removed for emptying and cleaning.
• Pit latrine (or pit privy): Fecal matter is eliminated into a hole in
the ground that leads to a dug pit. Generally, a latrine refers to toilet
facilities without a bowl. It can be equipped with either a squatting plate or a
riser with a seat. The pit reduces the volume of its contents as the liquid
infiltrates the surrounding soil.
• Antipolo toilet: It is made up of an elevated pit privy that has a
covered latrine. The elevation ensures that the bottom of the pit is at least 1.5
meters above the water table.
• Septic privy: Fecal matter is collected in a built septic tank that
is not connected to a sewerage system. The septic tank contains water but there is
no drop pipe from the latrine that is dipped into the water.
• Aqua privy: Fecal matter is eliminated into a water-sealed drop pipe
that leads from the latrine to a small water-filled septic tank located directly
below the squatting plate. The drop pipe extends below the septic tank water level
to form a simple water seal. An effluent pipe is installed in the septic tank to
prevent the overflow of water through the squatting plate. Water loss is then
replaced by adding water with each toilet use. A ventilation pipe with a fly screen
on top is part of the design of the housing of this facility.
• Overhung latrine: Fecal material is directly eliminated into a body
of water such as a flowing river that is underneath the facility. Public health
organizations such as the WHO recognize the acceptability of the use of such in
disaster situations like heavy flooding when the body of water's deemed polluted.
The chosen body of water should be large and freely flowing. The public health
nurse should coordinate with downstream communities on releasing advisory that the
body of water is polluted.
• Ventilated-improved pit (VIP) latrine: It is a pit latrine with a
screened air vent installed directly over the pit. The ambient air that enters the
pit hole pushes the foul air onto the air vent. The screen on top of the vent
prevents entry of insects attracted by the smell. Filled pits are then covered with
soil for composting, and the facility is redirected or relocated to another pit.
• Concrete vault privy: Fecal matter is collected in a pit privy lined
with concrete in such a manner so as to make it water tight.
• Chemical privy: Fecal matter is collected into a tank that contains a
caustic chemical solution, which in turn controls and facilitates the waste
decomposition.
• Compost privy: Fecal matter is collected into a pit with urine and
anal cleansing materials with the addition of organic garbage such as leaves and
grass to allow biological decomposition and production of agricultural or fishpond
compost (or nightsoil).
• Pour-flush latrine: It has a bowl with a water-seal trap similar to
the conventional tank-flush toilet except that it requires only a small volume of
water for flushing.Feces at the water-sealed trap are washed-off by small
quantities of water hand-poured from a container.
• Tank-flush toilet: Feces are excreted into a bowl with a water-sealed
trap. The water tank that receives a limited amount of water empties into the bowl
for flushing of fecal materials through the water-sealed trap and into the sewerage
system. The trap retains an amount of the flush to maintain the water seal.
• Urine diversion dehydration toilet (UDDT): It is a waterless toilet
system that allows the separate collection and on-site storage or treatment of
urine and feces.The site could be made up of a urine separation toilet with the
urine side leading to a collecting container for agricultural use and the fecal
side leading to a ventilated vault. The fecal vault is kept "dry" and, the feces
are left to dehydrate for agricultural use.
In 2010, the DOH published the Philippine Sustainable Sanitation Roadmap and
defined the three sanitation facilities that are considered sanitary under the DOH
and the National Statistics Office (NSO) definitions:
1. Water-sealed toilet connected to a sewer or septic tank, used
exclusively by the household.
2. Water-sealed toilet connected to other depository type, used
exclusively by the household.
3. Closed pit used exclusively by the household.
The same considers the following as unsanitary facilities:
1. Water-sealed toilet connected to a sewer or septic tank, shared with
other households.
2. Water-sealed toilet connected to other depository type, shared with
other households.
3.
4. Closed pit used exclusively by the household.
The same considers the following as unsanitary facilities:
1. Water-sealed toilet connected to a sewer or septic tank, shared with
other households.
2. Water-sealed toilet connected to other depository type, shared with
other households.
3. Closed pit, shared with other households.
4. Open pit.
5. Hanging toilet.
 6. Other unsanitary types of practice.
7. Open defecation.

VERMIN AND VECTOR CONTROL

The DOH had also prepared the Implementing Rules and Regulations of Chapter XVI
Vermin Control of the Code of Sanitation of the Philippines (P.D. 856). This
document defined the following terms:
1. Vermin: A group of insects or small animals such as flies,
mosquitoes, cockroaches, fleas, lice, bedbugs, mice, and rats, which are vectors of
diseases.
2. Insects. Flies, mosquitoes, cockroaches, bedbugs, fleas, lice,
ticks, ants, and other arthropods.
3. Pest. Any destructive or unwanted insect or other small animals
(rats, mice, etc.) that cause annoyance, discomfort, nuisance, or transmission of
disease to humans and damage to structures.
4. Rodent: Small mammals such as rats and mice, characterized by
constantly growing incisor teeth used for gnawing or nibbling.
5. Vector. Any organism that transmits infection by inoculation into
the skin or mucous membrane by biting; or by deposit of infective materials on
skin, food, or other objects; or by biological reproduction within the organism.
The DOH identified the strategies of a vermin abatement program, namely:
1. It must be community-wide and community-participated.
2. It must be technically coordinated.
3. It must be continuing.
4. It must be basically a partnership between the private and
government sectors.
5. It should preferably utilize indigenous technology and resources to
attain self-reliance.
The DOH outlined the various vermin control and disinfestation methods, which
include:
• Environmental sanitation control: The maintenance of cleanliness of
the immediate premises and proper building construction and maintenance so as to
prevent access of pests into human dwellings. Clean-up drives are aimed at altering
or eliminating the breeding sites of the vectors.
•
• Naturalistic control: A pest control method that utilizes nature and
nature's systems without disturbing the balance of nature.
• Biological and genetic control: A method that utilizes living
predators, parasites, and other natural enemies of the pest species to reduce or
eliminate the pest populations. It is aimed at killing the larvae without polluting
the environment.
• Mechanical and physical control: A method that utilizes mechanical
devices such as rodent traps, fly traps, mosquito traps, air curtain, and
ultraviolet light.
• Chemical control: A method that utilizes rodenticides, insecticides,
larvicides, and pesticides.
• Integrated control: A method that controls pests through the use of
different methods and procedures that are used to complement each other. These
procedures may include the use of pesticides, environmental sanitation measures,
and natural, as well as mechanical and biological control methods.

BUILT ENVIRONMENTS
The built environment refers to the man-made structures that provide a setting for
human activities. In the Philippines, Presidential Decree Number 1096 (P.D. 1096),
also known as the National Building Code of the Philippines, governs the design of
built environments. In 2004, the Department of Public Works and Highways developed
the Revised Implementing Rules and Regulations of the National Building Code of the
Philippines. Some of the provisions enacted to protect public health are as
follows:
 • Minimum air space shall be provided as follows:
• School rooms - 3.00 m3 with 1.00 m2 of floor area per person.
• Workshops, factories, and offices -12.00 m3 of air space per person.
• Habitable rooms - 14.00 m3 of air space per person.
• Minimum sizes of rooms and their least horizontal dimensions shall be
as follows:
• Rooms for human habitations - 6.00 m2 with a least horizontal
dimension of 2.00 m.
• Kitchen - 3.00 m2 with a least horizontal dimension of 1.50 m.
• Bath and toilet - 1.20 m2 with a least horizontal dimension of 900
mm.
• Ceiling height of habitable rooms:
• Rooms provided with artificial ventilation shall have ceiling heights
not less than 2.40 m (8 ft) measured from the floor to the ceiling.
• Rooms with natural ventilation shall have ceiling heights of not less
than 2.70 m (9 ft).
• Mezzanine floors shall have a clear ceiling height not less than 1.80
m above and below it.
•
• Rooms for human habitations - 6.00 m2 with a least horizontal
dimension of 2.00 m.Kitchen - 3.00 m2 with a least horizontal dimension of 1.50 m.
• Bath and toilet - 1.20 m2 with a least horizontal dimension of 900
mm.
• Ceiling height of habitable rooms:
00:00:30
• Rooms provided with artificial ventilation shall have ceiling heights
not less than 2.40 m (8 ft) measured from the floor to the ceiling.
• Rooms with natural ventilation shall have ceiling heights of not less
than 2.70 m (9 ft).
• Mezzanine floors shall have a clear ceiling height not less than 1.80
m above and below it.
• Minimum window sizes:
• Rooms intended for any use, not provided with artificial ventilation
system, shall be provided with a window or windows with a total free area of
openings equal to at least 10% of the floor area of the room, provided that such
opening shall be not less than 1.00 m2.
• Toilet and bathrooms, laundry rooms, and similar rooms shall be
provided with window or windows with an area not less than 1/20 of the floor area
of such rooms, provided that such opening shall not be less than 240 mm2.
• Such window or windows shall open directly to a court, yard, public
street or alley, or open watercourse.

INTRODUCTION
Communities throughout the world experience an emergency or disaster incident of
one kind or another on an almost daily basis. The media may only mention these
events or may report on them in great detail, depending on the number of deaths or
injured, the degree of devastation or damage to the area involved, and the extent
of normal activity disruption in the community that the event has brought about.
The increasing severity of recent disasters is multifaceted and is generally
attributable to a number of societal and environmental changes.

The health of a community can be affected significantly by disasters. Tropical

Storm (TS) Ondoy (international code name Ketsana), which hit 26 provinces in the
Philippines in September 2009, is an example of how communities and health
facilities are directly affected as a result of a disaster. TS Ondoy brought heavy
rains that caused widespread flooding in almost all parts of Metro Manila and
Central and Southern Luzon. The floods also affected some parts of Visayas and
Mindanao.
Landslides occurred in the Cordillera Administrative Region. A total of 993,227
families/4,901,234 persons were affected. The storm left in its wake 1,030
casualties:
464 dead, 529 injured, and 37 missing persons. The estimated cost of damage was
about Php 11 billion, including damage to health facilities. The total number of
houses damaged was 185,004.
During TS Ondoy, as is typical in widespread notable disasters, medical and nursing
personnel, medicines, and needed supplies were unavailable, scarce, or depleted
because of the increased demand. Damaged health facilities had to evacuate
patients. Evacuation centers and temporary health care services were established in
schools, churches, and a variety of other facilities. Because many houses were
completely destroyed, many evacuees had to stay in the evacuation centers for
weeks, resulting in a high incidence of acute respiratory and gastroenteritis cases
because of overcrowding and lack of sanitary facilities in evacuation centers. The
extensive flooding resulted in panic for food, water, and rescue in the seriously
affected areas. First responders and rescue teams were overwhelmed in their
attempts to assist the victims.
Because of its geographical location, the Philippines frequently experiences
natural disasters such as typhoons, floods, and earthquakes. Industrial accidents
may also lead to disasters, such as mining disasters. Further, in recent years,
terrorist attacks have become more common. Terrorist attacks occur all over the
world on an almost daily basis, and concerns about potential terrorist attacks have
increased the focus on what needs to be done in terms of prevention, preparedness,
response, and recovery —not only in the event of terrorist attacks but also in the
event of disasters of all kinds.
Nurses are uniquely positioned to provide valuable information for the development
of plans for disaster prevention, preparedness, response, and recovery for
communities. Nurses, as team members, can cooperate with health and social
representatives, government bodies, community groups, and volunteer agencies in
disaster planning and preparedness programs (i.e., drills). Nurses can utilize
their knowledge of nursing, public health, and cultural-familial structures, as
well as clinical skills and abilities, in order to actively assist or participate
in all aspects and stages of an emergency or disaster, regardless of the setting in
which the event may occur.
Nurses have a significant role in meeting the health care needs of the community,
not only on a day-to-day basis but also in relation to disasters.

Disaster definitions
An emergency is any event endangering the life or health of a significant number of
people and demanding immediate action. An emergency situation may result from a
natural, man-made, technological, or societal hazard.
A disaster is any event that causes a level of destruction, death, or injury that
affects the abilities of the community to respond to the incident using available
resources.
Emergencies differ from disasters in that the agency, community, family, or
individual can manage an emergency using his or her own resources. But a disaster
event, depending on the characteristics of the disaster, may be beyond the ability
of the community to respond and recover from the incident using their own
resources.
Disasters frequently require assistance from outside the immediate community, both
to manage resulting issues and to recover completely.
Some disasters (e.g. a house fire) may affect only a few persons, whereas others
(e.g. a hurricane) can impact thousands. A mass casualty event is one in which 100
or more individuals are involved; a multiple casualty event is one in which more
than 2 but fewer than 100 individuals are involved. Casualties can be classified as
a direct victim, an indirect victim, a displaced person, or a refugee. A direct
victim is an individual who is immediately affected by the event; the indirect
victim may be a family member or friend of the victim or a first responder.
Displaced persons and refugees are special categories of direct victims. Displaced
persons are those who have to evacuate their home, school, or business as a result
of a disaster, and refugees are a group of people who have fled their home or even
their country as a result of famine, drought, natural disaster, war, or civil
unrest.

Disaster definitions
An emergency is any event endangering the life or health of a significant number of
people and demanding immediate action. An emergency situation may result from a
natural, man-made, technological, or societal hazard.
A disaster is any event that causes a level of destruction, death, or injury that
affects the abilities of the community to respond to the incident using available
resources.
Emergencies differ from disasters in that the agency, community, family, or
individual can manage an emergency using his or her own resources. But a disaster
event, depending on the characteristics of the disaster, may be beyond the ability
of the community to respond and recover from the incident using their own
resources.
Disasters frequently require assistance from outside the immediate community, both
to manage resulting issues and to recover completely.
Some disasters (e.g. a house fire) may affect only a few persons, whereas others
(e.g. a hurricane) can impact thousands. A mass casualty event is one in which 100
or more individuals are involved; a multiple casualty event is one in which more
than 2 but fewer than 100 individuals are involved. Casualties can be classified as
a direct victim, an indirect victim, a displaced person, or a refugee. A direct
victim is an individual who is immediately affected by the event; the indirect
victim may be a family member or friend of the victim or a first responder.
Displaced persons and refugees are special categories of direct victims. Displaced
persons are those who have to evacuate their home, school, or business as a result
of a disaster, and refugees are a group of people who have fled their home or even
their country as a result of famine, drought, natural disaster, war, or civil
unrest.

TYPES OF DISASTERS
Disasters may result from natural, biological, technological, or societal hazards.
A natural hazard is a physical force, such as a typhoon, flood, landslide,
earthquake, and volcanic activity. A biological hazard is a process or phenomenon
of organic origin or conveyed by biological vectors, including exposure to
pathogenic microorganisms, toxins, and bioactive substances. Examples are disease
outbreaks and red tide poisoning. A technological hazard arises from technological
or industrial conditions, including accidents, dangerous procedures, and
infrastructure failures. A societal hazard results from the interaction of varying
political, social, or economic factors, which may have a negative impact on the
community. Examples are stampedes, armed conflicts, terrorist activities, and
riots.
A NA-TECH (natural-technological) disaster is a natural disaster that creates or
results in a widespread technological problem. An example of a NA-TECH disaster is
an earthquake that causes the structural collapse of roadways or bridges that, in
turn, brought down electrical wires and caused subsequent fires. Another example is
a chemical spill resulting from a flood. Types of natural disasters and man-made
disasters, particularly those that are experienced in the Philippines.

Injury or death from a disaster may be direct or indirect. For example, injuries
from typhoons occur because people fail to evacuate or take shelter, do not take
precautions in securing their property, and do not follow guidelines on food and
water safety or injury prevention during recovery.
Drowning, electrocution, lacerations or punctures from flying debris, and blunt
trauma from falling trees or other objects are some of the morbidity concerns.
Heart attacks and stress-related disorders also occur. Injuries also may occur from
activities in the recovery phase, for example, from use of equipment for recovery
and reconstruction or from bites from animals, snakes, or insects.
Acts of terrorism have become a frequent occurrence in different countries, which
have resulted in considerable loss of lives and destruction of property. The United
Nations has exerted efforts to define terrorism, but a definition acceptable to all
member states is yet to be formulated. In a resolution, the UN Security Council,
although not directly defining terrorism, described terrorism as, "criminal acts,
including against civilians, committed with the intent to cause death or serious
bodily injury, or taking of hostages, with the purpose to provoke a state of terror
in the general public or in a group of persons or particular persons, intimidate a
population or compel a government or an international organization to do or to
abstain from doing any act".
Threats of terrorism, assassinations, kidnappings, hijackings, bomb scares and
bombings, computer-based attacks, and use of chemical, biological, nuclear, and
radiological weapons are considered acts of terrorism. From a global perspective,
examples of terrorist acts are the September 11, 2001 terrorist attacks in the
United States, which caused unprecedented destruction and death; the nerve gas
(sarin) attack in the Tokyo subway in March 1995, which killed 12 and injured more
than 6,000 people; the bombing of the commuter train in Spain in March 2004, which
killed 191 people; the suicide bombing in the London subway in July 2005, which
killed
52 commuters and 4 terrorists; and the shooting and bombing attacks in Mumbai's
financial district in November 2008, which killed more than 170 people. In the
Philippines, notable terrorist acts include the ferry bombing in Ozamis City on
February 25, 2000, which claimed 39 lives; the so-called Rizal Day bombings on
December 30, 2000 where 22 people perished; and the Superferry bombing at Manila
Bay on February 27, 2004 that killed 116 people.
Concerns now are increasingly focused on weapons of mass destruction. Weapons of
mass destruction refer to any weapon that is designed or intended to cause death or
serious bodily injury through the release, dissemination, or impact of toxic or
poisonous chemicals, or its precursors; any weapon involving a disease organism; or
any weapon that is designed to release radiation or radioactivity at a level
dangerous to human life.

INTRODUCTION
Communities throughout the world experience an emergency or disaster incident of
one kind or another on an almost daily basis. The media may only mention these
events or may report on them in great detail, depending on the number of deaths or
injured, the degree of devastation or damage to the area involved, and the extent
of normal activity disruption in the community that the event has brought about.
The increasing severity of recent disasters is multifaceted and is generally
attributable to a number of societal and environmental changes.

The health of a community can be affected significantly by disasters. Tropical

Storm (TS) Ondoy (international code name Ketsana), which hit 26 provinces in the
Philippines in September 2009, is an example of how communities and health
facilities are directly affected as a result of a disaster. TS Ondoy brought heavy
rains that caused widespread flooding in almost all parts of Metro Manila and
Central and Southern Luzon. The floods also affected some parts of Visayas and
Mindanao.
Landslides occurred in the Cordillera Administrative Region. A total of 993,227
families/4,901,234 persons were affected. The storm left in its wake 1,030
casualties:
464 dead, 529 injured, and 37 missing persons. The estimated cost of damage was
about Php 11 billion, including damage to health facilities. The total number of
houses damaged was 185,004.
During TS Ondoy, as is typical in widespread notable disasters, medical and nursing
personnel, medicines, and needed supplies were unavailable, scarce, or depleted
because of the increased demand. Damaged health facilities had to evacuate
patients. Evacuation centers and temporary health care services were established in
schools, churches, and a variety of other facilities. Because many houses were
completely destroyed, many evacuees had to stay in the evacuation centers for
weeks, resulting in a high incidence of acute respiratory and gastroenteritis cases
because of overcrowding and lack of sanitary facilities in evacuation centers. The
extensive flooding resulted in panic for food, water, and rescue in the seriously
affected areas. First responders and rescue teams were overwhelmed in their
attempts to assist the victims.
Because of its geographical location, the Philippines frequently experiences
natural disasters such as typhoons, floods, and earthquakes. Industrial accidents
may also lead to disasters, such as mining disasters. Further, in recent years,
terrorist attacks have become more common. Terrorist attacks occur all over the
world on an almost daily basis, and concerns about potential terrorist attacks have
increased the focus on what needs to be done in terms of prevention, preparedness,
response, and recovery-not only in the event of terrorist attacks but also in the
event of disasters of all kinds.
Nurses are uniquely positioned to provide valuable information for the development
of plans for disaster prevention, preparedness, response, and recovery for
communities. Nurses, as team members, can cooperate with health and social
representatives, government bodies, community groups, and volunteer agencies in
disaster planning and preparedness programs (i.e., drills). Nurses can utilize
their knowledge of nursing, public health, and cultural-familial structures, as
well as clinical skills and abilities, in order to actively assist or participate
in all aspects and stages of an emergency or disaster, regardless of the setting in
which the event may occur.
Nurses have a significant role in meeting the health care needs of the community,
not only on a day-to-day basis but also in relation to disasters.

CHARACTERISTICS OF DISASTERS
Several characteristics have been used to describe disasters. These characteristics
are interdependent and therefore important to consider in plans for managing any
disaster event. Each is discussed briefly in the following text.
Frequency
Frequency refers to how often a disaster occurs. Some disasters occur relatively
often in certain parts of the world. Terrorist activities are occurring on an
almost daily basis in Iraq, Pakistan, and elsewhere in the world. Other examples
are tropical cyclones, which occur with variable frequency between the months of
June and November. However, because of climate change, the occurrence of typhoons
has become more variable than in previous years.
Earthquakes occur periodically throughout the world. The Philippines runs along the
so-called Ring of Fire, which encircles the Pacific Ocean and is known for frequent
earthquakes and volcanic eruptions. The Philippine Institute of Volcanology and
Seismology (PHILVOCS) records daily earthquakes occurring in different parts of the
country with variable intensity, with only a very small proportion of the quakes
felt by people. The most destructive earthquake in recorded history occurred almost
three decades ago on July 16, 1990 affecting Northern and Central Luzon. The quake
had an intensity of 7.8 on the Richter scale. More than 1,600 people lost their
lives in the earthquake.
Other disasters, such as volcanic eruptions, are far less frequent and are
geographically limited to certain regions of the country. PHIVOLCS has listed 23
active volcanoes in the country. Mayon in the province of Albay, Taal in the
province of Batangas, and Kanlaon in the province of Negros Oriental are the top
three most active volcanoes.
The eruption of Mount Pinatubo (located at the boundaries of Pampanga, Tarlac, and
Zambales) in June, 1991 is the second largest volcanic eruption of the 20th
century. PHIVOLCS, together with the US Geological Survey, was able to forecast the
eruption, saving at least 5,000 lives. Mount Pinatubo released a large amount of
gas cloud into the atmosphere, causing global temperature to drop by 0.5 °C from
1991 to 1993 (USGS, 2005).

Predictability
Predictability relates to the ability to tell when and if a disaster event will
occur. Some disasters, such as floods, may be predicted based on the expected
volume of rainfall, sometimes in conjunction with tide changes. Weather forecasters
can predict when conditions are right for the development of typhoons and with the
monsoon rains. These generally occur between June and November, but climate change
has made their occurrence more variable. Because of advances in technology, weather
forecasters can predict hurricanes with increasing accuracy. Other disasters (e.g.
fires and industrial explosions) may not be predictable at all.
Preventability
Preventability is a characteristic indicating that actions can be taken to avoid a
disaster. Some disasters (e.g. typhoons and earthquakes) are not preventable,
whereas others can be easily controlled if not prevented entirely. For example,
flooding can be controlled or prevented through proper refuse disposal, maintenance
of waterways, control of indiscriminate logging, and construction of infrastructure
for flood control.
Primary prevention is aimed at preventing the occurrence of a disaster or limiting
consequences when the event itself cannot be prevented. Primary prevention occurs
in the nondisaster and the predisaster stage refers to the period immediately
before the disaster or when a disaster is pending. Preventive actions during the
nondisaster stage include assessing communities to determine potential disaster
hazards, developing disaster plans at local and national levels, conducting drills
to test the plan, training volunteers and health care providers, and providing
educational programs of all kinds.
The disaster plan is initiated predisaster or when a disaster is imminent. Primary
prevention actions during this stage include notifying the appropriate officials,
warning the population, and advising what response to take (e.g. shelter in place
or evacuate).
Secondary prevention strategies are implemented once the disaster occurs. Secondary
prevention actions include search, rescue, and triage of victims and assessment of
the destruction and devastation of the area involved.

Tertiary prevention focuses on recovery of the community, that is, restoring the
community to its previous level of functioning and its residents to their maximum
functioning. Tertiary prevention is aimed at preventing a recurrence or minimizing
the effects of future disasters.
Nurses are involved in all stages of prevention and related activities. In order to
respond effectively, personally, and professionally during different types of
disasters, nurses need to know the:

1. Kind of disasters that threaten the communities,

2. Injuries to expect from different disaster scenarios
3. Evacuation route,
4. Location of shelters or evacuation centers
5. Warning systems.
Nurses must also be able to educate others about disasters and how to prepare for
and respond to them. Finally, nurses must be updated on the latest recommendations
and advances in lifesaving measures (e.g. basic first aid, cardiopulmonary
resuscitation, and use of automated external defibrillators).
Imminence
Imminence is the speed of onset of an impending disaster and relates to the extent
of forewarning possible and the anticipated duration of the incident. Weather
forecasters can tell when a weather disturbance may be developing days ahead of its
expected arrival and can give the approximate time of arrival, the general
direction it will take, and the location for its landing and forward movement.
Weather disturbances like typhoons, however, are subject to other weather variables
and can change direction and intensity several times before actual landfall.
In the Philippines, the imminence of weather disturbances, typhoons in particular,
is announced to the public in terms of Public Storm Warning Signals (PSWS). The
PSWS is raised to warn the public of an incoming weather disturbance. The
Philippine Atmospheric, Geophysical and Astronomical Services Administration
(PAGASA), a service institute under the Department of Science and Technology
(DOST), issues the PSWS.

Some disastrous incidents (eg. terrorist attacks) have no warning time.

Bioterrorist attacks are generally silent, and the first awareness may be days or
even weeks after exposure. For example, individuals exposed to a pathologic agent
(e.g. anthrax, smallpox) may arrive at health care facilities at various times and
to various providers, making diagnosis and early treatment difficult. Nurses and
medical personnel need to know the signs and symptoms of biological, chemical,
radiation, and nuclear exposure in order to identify the nature of the threat and
then to treat and control the spread of both biological and chemical agents.
Scope and number of casualties
The scope of a disaster indicates the range of its effect. The scope is described
in terms of the geographic area involved and in terms of the number of individuals
affected, injured, or killed. From a health care perspective, the location, type,
and timing of a disaster event are predictors of the types of injuries and
illnesses that might occur. For example, several factors brought about contrasting
effects of TS Ondoy in 2009 and TS Sendong (international code name Washi) in 2011.
The casualty count of TS Ondoy totaled to 1,030, with 464 deaths. The widespread
flooding caused by TS Ondoy in 2009 happened in Luzon during the daytime. In
addition to the fact that flood waters started to rise during the daytime, floods
occur frequently in many areas in Luzon like Metro Manila and Central Luzon. People
were more conscious of tropical cyclones causing floods.
In contrast, the casualties that resulted from TS Sendong were far greater, with a
total number of reported casualties of 7,520: 1,268 persons reported dead, 6,071
persons injured, and 181 missing. The last time Cagayan de Oro City and its
surrounding areas had a flood was 75 years before 2011. Most of the casualties
resulted from flash floods brought about by heavy rainfall in the evening of
December 16 which continued until the early morning of December 17, when people
were mostly asleep.
Tropical cyclones generally affect a large geographic area. Despite this, they may
cause few if any deaths if sufficient preventive measures are taken.
Intensity
Intensity is the characteristic describing the level of destruction and devastation
of the disaster event. Tropical cyclones that affect the country are categorized
according to intensity in terms of wind speed near the center of the cyclone.

Factors contributing to the amount of damage from a disaster event such as a

typhoon are the distance from the zone of maximum winds, degree of exposure of the
location to the disaster, building standards, vegetation type, and resultant
flooding. For instance, the casualties and damage to property (estimated at more
than Php 2 billion) are the result of a combination of factors. The intense
rainfall in the upstream portion of the Cagayan De Oro River resulted in the
swelling of the river and created a strong current that uprooted trees along the
river banks. The muddy water full of sediment and debris flowed downstream. Heavy
rainfall was coupled with the occurrence of a high tide that restricted the flow of
flood waters.

DISASTER MANAGEMENT
When one is aware of the types and characteristics of disasters, the question then
becomes: What can be done to prevent, prepare for, respond to, and recover from
disasters? Disaster management requires an interdisciplinary, collaborative team
effort and involves a network of agencies and individuals to develop a disaster
plan that covers the multiple elements necessary for an effective plan. Communities
can respond more quickly, more effectively, and with less confusion if the efforts
needed in the event of a disaster have been anticipated and plans for meeting them
have been identified. The result of planning is that more lives are saved and less
property is damaged. Planning ensures that resources are available and that roles
and responsibilities of all personnel and agencies, both official and unofficial,
are delineated.
Nurses need to know their personal, professional, and community responsibilities.
They should realize that conflicts may arise between their personal and
professional responsibilities if these have not been considered and planned for in
advance. In addition, nurses may be direct or indirect victims and may even be
displaced persons themselves as a result of a disaster event. Recognizing this
possibility, nurses need to plan, prepare, practice, and teach their family and
significant others how to respond.
During a disaster, a nurse might face an ethical dilemma because of competing
responsibilities to family, employer, and patients, for example, a nurse who is a
single parent with young children and has a limited support system may be forced to
decide between his or her responsibility to care for his or her children or a
mandate to report to work to care for patients. Choosing may result in loss of
employment or danger to the children. Potential conflicts such as this should be
considered, discussed, and decisions be made in conjunction with the employer
before a disaster event.
Disaster management stages
Prevention stage
The first stage in disaster management occurs before a disaster is imminent and is
known as the nondisaster stage. Potential disaster risks should be identified and
risk maps created. For example, geohazard maps are used in identifying areas prone
to natural dangers like landslides, flooding, and ground subsidence or sinking. The
maps are used in preparing government authorities and the people for possible
disasters. The Department of Environment and Natural Resources (DENR) spearheaded
the creation of the geohazard maps through its Mines and Geosciences Bureau.

The population demographics and vulnerabilities, as well as the community's

capabilities, should be analyzed. Primary prevention measures include educating the
public regarding what actions to take to prepare for disasters at the individual,
family, and community levels. Further, based on the assessment of potential risks,
the community must develop a plan for meeting the potential disasters identified.
• 00:00:47
With regard to bioterrorist attacks, prevention means that health care providers
need to be knowledgeable about the biological and chemical agents that might be
used. In addition, health care providers need to know the signs and symptoms of the
various biological and chemical agents that have been recognized as potential
threats. As mentioned, unlike other disasters, biochemical terrorist threats may be
identified only when events raise the suspicions of health care providers, rather
than first responders at a particular site.

The population demographics and vulnerabilities, as well as the community's

capabilities, should be analyzed. Primary prevention measures include educating the
public regarding what actions to take to prepare for disasters at the individual,
family, and community levels. Further, based on the assessment of potential risks,
the community must develop a plan for meeting the potential disasters identified.
• 00:00:47
With regard to bioterrorist attacks, prevention means that health care providers
need to be knowledgeable about the biological and chemical agents that might be
used. In addition, health care providers need to know the signs and symptoms of the
various biological and chemical agents that have been recognized as potential
threats. As mentioned, unlike other disasters, biochemical terrorist threats may be
identified only when events raise the suspicions of health care providers, rather
than first responders at a particular site.

Although there will be some variation according to the individual community's

needs, all community disaster plans should address the following elements:
authority, communication, control, logistical coordination of personnel, supplies
and equipment, evacuation, rescue, and care of the dead. The plan should indicate
who has the power to declare that there is a disaster and who has the power to
initiate the disaster plan.
Authority should be designated by the title of the person; it should not specify a
person by name. There should also be backup positions identified in the event the
first individual is not available. Every individual should be equally informed
about the role and responsibilities that go with this authority. A clear chain of
authority for carrying out the plan is critical for successful implementation of
the plan. Authority may change, depending on whether the disaster is natural or
man-made as a result of some criminal action, and the change of authority should be
addressed in the plan.
Communication is recognized as a very significant problem during disasters.
Misinformation and misinterpretation can occur when communication is ineffective.
Reliance on telephone systems or cell phones should not be the sole planned means
of communicating because these may not work or the systems might be overloaded.
The communication section of the disaster plan should address how the authority
figure will be notified of the disaster, how the emergency management team members
will be notified, how the community residents will be warned about the incident,
and what actions will be required. This section needs to address how communication
between relief workers and authorities will be maintained. Also, it should include
information on the role of the media in keeping people informed and in letting
people know what assistance and supplies are needed. In case of electric power
interruptions, the use of battery-operated portable radios is advised so residents
may listen for instructions and updates about the disaster. One of the most
important elements to consider in communication is the early warning stage. This
generally impacts on how the community will respond to warnings of possible
disaster, which eventually will be very crucial in preventing the loss of lives.
The analysis of the population during the nondisaster stage should identify groups
that need special attention as to the process of notification. These people include
those who speak different languages, are homeless or poor, are without television
or other means of communication, and are in institutions such as prisons, custodial
care facilities, day care settings, or schools. Effective communication during a
disaster must be credible, current, and authoritative and must give some indication
of future events.
The logistical section should specify where supplies and equipment are located or
where additional supplies and equipment can be obtained from, where these will be
stored or found, and how these will be transported to the disaster site. Essential
human resources (e.g. emergency and disaster specialists, officials of governmental
and voluntary agencies, engineers, weather specialists, and community leaders)
should be identified and tracked where they will be located. The plan should
include information about transportation for evacuation and rescue (particularly
taking into account vulnerable groups), documentation and record keeping, and plans
for evaluation of the success or failure of the plan.

A disaster plan is a dynamic entity. Planning is a continuous process, and plans

change with circumstances and when gaps are identified during drills or from
previous disaster incidents. The plan should set realistic expectations of effects
and needs, should be brief and concise, and should establish priorities and
timelines for actions.

For a plan to be effective, it must be tested by having different disaster scenario

drills. The more times realistic scenarios are created to test the plan in actual
practice sessions, the more problems with the plan will be identified, and
solutions for those problems can be found. Without practice drills, plans may have
many unrecognized faults and, as a result, many more individuals may be harmed and
communities damaged when an actual disaster occurs.
Response stage
This stage begins immediately after the disaster incident occurs. The community
preparedness plans that have been developed are initiated. If a disaster occurs,
people should remain calm and exert patience, follow the advice of local emergency
officials, and listen to the radio or television for news and instructions. If
people nearby are injured, one should give first aid, seek help, and check the area
for dangerous hazards. Those at home should shut off any damaged utilities, confine
or secure pets, call family contact(s), and check on neighbors, especially the
elderly or disabled.
The plan may call for people to shelter in place or to evacuate, or for search and
rescue to begin. If the only response needed is shelter in place, then people need
to know what to do if they are at home, at work, at school, or in their vehicle.
Evacuation
Each community should have established evacuation routes for the residents to use
if evacuation from the area is necessary. In some instances, mandatory evacuation
may be implemented. However, there are always some individuals who will not leave
their home for any numbers of reasons (e.g. fear of vandalism, denial of the
potential extent of the disaster, pride in their home and belongings). Education of
residents as to the potential damage, deaths, and injuries that will be incurred
from the potential disasters that may affect their community needs to be done in
the preparedness stage and not when evacuation is ordered. In some extreme cases,
it may be necessary for hospitals and other facilities, such as nursing homes, to
evacuate patients. This requires significant advance planning, as health
practitioners must determine how to move seriously, and even critically ill people
and coordinate transportation and placement for their disposition to safe
facilities.
Search and rescue
Before search and rescue should begin, safety must be considered. In some
instances, if a criminal action is suspected, law officials will be among the first
to respond in order to secure the area and possibly gather evidence. While the area
is being checked and then cleared of potential threats, a staging area can be set
up at or near the site of the incident to direct on-site activities. Search and
rescue of victims can begin once clearance is given, a disaster triage area is
established, and an emergency treatment area is set up to provide first aid until
transportation for victims to hospitals or health care facilities for treatment can
be coordinated.
Staging area
The staging area is the on-site incident command station. Disaster responders
should report to this area to "check in" so that everyone is accounted for and can
be given an assignment. This will allow for the most effective use of the skills
and abilities of those responding. No one should go to the disaster site unless
directed to do so by the staging area commander. The staging area is also where the
authority rests for decisions as to additional resources to be called to the area
to manage the disaster incident. Resources may include construction equipment to
move building materials, rescue dogs to locate humans who are buried in the debris,
or more fire, police, or medical personnel.
Disaster triage
Triage at the site and again at the treatment area is very different from triage
that is routinely conducted in the emergency department. The focus of disaster
triage is to do as little as possible, for the greatest number, in the shortest
period of time. One triage system that is used by first responders is the START
triage system. START stands for "simple triage and rapid treatment. This system
describes what to do when first arriving at a multicasualty or mass casualty
incident. Disaster triage of an injured person should occur in less than 1 minute.
This system also describes how to enlist people with minor injuries to assist. As a
decision is made regarding the status of an individual, the person is tagged with a
colored triage tag. Depending on what type of tag is available, the tags may simply
be pieces of colored paper.
Green on the triage tag is for the walking wounded or those with minor injuries
(e.g. cuts and abrasions) who can wait several hours before they receive treatment;
yellow is for those with systemic but not yet life-threatening complications who
can wait 45 to 60 minutes (e.g. simple fractures); red is considered top priority
or immediate and is for those with life-threatening conditions but who can be
stabilized and have a high probability of survival (e.g. amputations); black is for
the deceased or for those whose injuries are so extensive that nothing can be done
to save them (e.g. multiple severe injuries).
A new classification of victim, those who are contaminated, will require a hazmat
(for "hazardous materials") tag. To assess an individual within the 1-minute
guideline, the system uses three characteristics. First, respirations are checked;
if they are over 30 per minute, the individual is tagged red or immediate. If the
individual has fewer than 30 respirations per minute, then the assessor moves to
the second step-perfusion. Pinching the nail bed and observing the reaction are
done to check perfusion; color should return to normal within 2 seconds. The third
step is checking mental status. The assessor should ask the individual simple
questions (e.g. Who

are you?). By doing these steps, the individual responsible for triage can very
quickly assess an individual and decide which color tag fits his or her condition.
Further, the steps are easy to remember by thinking "30-2-can do," where "30" is
the number of respirations, "2" is the number of seconds needed to check for
perfusion, and "can do" relates to checking mental status.
Following triage, victims are then moved to the treatment area where their
condition is checked again. First aid may be provided there, until transportation
is available.
Ambulances, helicopters, buses, or all three may be used to transport the victims
to various hospitals or health care facilities. Some victims, such as those in the
surrounding area that may have been affected by the incident, may even go by
private vehicle to a hospital or medical facility. This process may go on for days
as it did in the September 11 incidents, the 2005 tsunami in South Asia, and
Hurricanes Katrina and Rita in the United States. Search and rescue eventually will
be called off, and the recovery stage will begin.
While search and rescue is going on, other agencies (e.g. public health agencies)
are checking for threats such as contaminated water, vectors, and air quality. They
also disseminate data on what has been found and relate health information to
officials, the media, and the public as appropriate. Designated agencies measure
the occurrence and distribution of health-related events associated with the
disaster, describe factors contributing to health-related effects, and assess the
needs of populations and facilities. They will allocate resources and work to
prevent further adverse health problems that may result from the disaster. For
example, following disasters, especially those that require evacuation,
immunization is provided, particularly to the young children in temporary shelters
or evacuation centers.
Although triage of individuals exposed to chemical warfare agents is basically the
same as for any multiple or mass casualty incident, it poses special challenges.
For these events, the triage area is set up in the "hot zone" to assist in
determining priorities for resuscitation, decontamination, pharmacological therapy,
and site evacuation. Only specially trained emergency personnel who are familiar
with chemical agents and the use of personal protection equipment should triage
chemical agent victims. The same triage categories can be assigned to these
victims.
Psychological triage presents the challenge of determining who most needs help and
deciding what interventions will help. Mental health disorders related to disasters
can include anxiety disorders, exacerbation of existing substance abuse problems,
somatic complaints, depression, and, later, posttraumatic stress disorder (PTSD).
Research has identified four keys to gauging the mental health impact of such
events, any two of which may result in severe, lasting, and pervasive psychological
effects.
The key factors are as follows:
• Extreme and widespread property damage.
•
• Serious and ongoing financial problems.
• High prevalence of trauma in the form of injuries, threat to life,
and loss of life.
• When human intent caused the disaster. In addition, panic during the
disaster, horror, separation from family, and relocation or displacement are
factors that may play a part in psychological impairment.Nurses need to evaluate an
individual's danger to self or others. Nurses need to know the symptoms to look for
and know what resources are available for people who need help.
Recovery stage
The recovery stage begins when the danger from the disaster has passed and
concerned local and national agencies are present in the area to help victims
rebuild their lives and help the community restore public services. Cleanup of the
damage and repair of homes and businesses begin. Evaluation and revision of the
disaster plans based on lessons learned from the experience are made. Understanding
the financial impact on the community and agencies involved is essential in
developing future public health policy. Research is needed on all aspects of
prevention, preparedness, response, and recovery stages of disasters. Research is
also needed on the education and training needs of first responders, health care
providers, and community populations. Nurse researchers, in partnership with
researchers from other disciplines, can play a significant role in these research
endeavors.
Governmental responsibilities
The government is responsible for the safety and welfare of its citizens.
Emergencies and disaster incidents are handled at the lowest possible
organizational and jurisdictional level. Police, fire, public health, public works,
and medical emergency services are the first responders responsible for incident
management at the local level. Local officials and agencies are responsible for
preparing their citizens for all kinds of emergencies and disasters and, where and
when possible, for testing disaster plans with mock drills.
The local government manages events during an incident by carrying out evacuation,
search, and rescue and maintaining public health and public works responsibilities.
Local communities should have contingency operation plans for multiple disaster
situations and for various aspects of the plan. For example, landline telephone
service and cell phone service may not work because of being restricted for
emergency use only or damage to the infrastructure; therefore, other forms of
communication should be available.
© 00:02:11
For a biological or chemical terrorist incident, the process is very different.
First responders generally are not involved. Rather, nurses and doctors in health
care facilities may be the first to suspect that a biological or chemical agent has
been released into the community.
In an incident other than a biological, chemical, radiation, or nuclear event, in
most cases, it is the fire or police department that gets the initial message. The
emergency telephone number for the Philippines is 117, also called Patrol 117,
which is under the management of the Department of Interior and Local Government
(DILG).
Executive Order No. 226, s. 2003 institutionalized Patrol 117 as the nationwide
emergency hotline number for police assistance, fire protection, Philippine Red
Cross (PRC), among others.
Public health system
The public health system's mission is the promotion of health, prevention of
disease, and protection from threats to health. The public health system is a broad
term used to describe all of the governmental and nongovernmental organizations and
agencies that contribute to the improvement of the health of populations. Public
health agencies are the primary agencies for the health and medical response to
disaster incidents and therefore are a part of the initial response activities.
Public health officials provide advice and assistance to other public officials
related to environmental and health matters. Preparedness includes vigilance and
reporting of suspicious illnesses (e.g. signs and symptoms of biological agents,
food-borne diseases, and communicable diseases) in the community by physicians and
nurses in local health care facilities or private offices and clinics. Public
health officials then have the responsibility of detecting outbreaks, determining
the cause of illness, identifying the risk factors for the population, implementing
interventions to control the outbreak, and informing the public of the health risks
and preventive measures that need to be taken. These relate both directly and
indirectly to the essential public health services.
The Philippine Red Cross
When it was officially founded in 1947, the PRC carried out two main functions:
blood provision and disaster-related services. Embodying the fundamental principles
of the International Red Cross and Red Crescent Movement (i.e., humanity,
impartiality, neutrality, independence, voluntary service, unity and universality),
the present-day Red Cross offers she major services:
1.
2. National Blood Services - provision of safe blood for medical
purposes.
3. Safety Services - conduct of training in first aid, basic life
support, water safety, accident prevention, and other basic rescue courses.
4. Social Services - among its wide range of services, social services
relevant to disaster and postdisaster situations include:
• Guidance and counseling.
• Psychosocial support program or critical incident stress management -
helps in stress during disasters.
• Tracing service - assists in locating displaced or missing person (s)
during a disaster that occurred either in the Philippines or in a foreign country
where normal channels of communication have become difficult for the families
concerned.
• Referral service.
• Early livelihood recovery program -supports restoration of livelihood
after a disaster.
• Hot meals - facilitates a feeding program to prevent malnutrition
among calamity victims, especially children.
1. Volunteer services - provides training courses for volunteers.
2. Community health and nursing services - offers training programs in
Basic Health Education Program and Primary Health Care (Community-Based Health
Program) for professional nurses and student nurses.
3. Disaster management services - involves disaster relief operations
and services of identifying hazard-prone areas and making vulnerability assessment
of these areas. The PRC offers several courses on Disaster Management, including
Community-Based Disaster Management Training. Specific disaster management services
offered include:
• Relief operations
• Deployment of disaster response teams
• Organization of barangay disaster action team
• Pre-position of relief supplies
The PRC is one of the major nongovernmental agencies that work hand-in-hand with
government agencies in disaster risk reduction. This purpose of the PRC is
specifically stated in R.A. 10072 or the Philippine Red Cross Act.

THE NATIONAL DISASTER RISK REDUCTION AND MANAGEMENT PLAN

Signed into law in 2010, R.A. 10121, also known as the Philippine Disaster Risk
Reduction and Management Act, brought about a paradigm shift from disaster
preparedness and response to disaster risk reduction and management (DRRM). It also
mentioned disasters brought about by climate change. The law specified the policy
of developing and implementing a National Disaster Risk Reduction and Management
Plan (NDRRMP)
The NDRRM framework envisions a country that has "safer, adaptive and disaster-
resilient Filipino communities toward sustainable development." The goal is to
shift from being reactive to proactive in DRRM. This means the focus is on:
1. Building individual, collective, and institutional capacities to
adjust to situations (increased resilience)
 2. Decreasing vulnerabilities. Filipinos will continue to be subjected
to risk factors (hazards), but in due time, resources will be invested more on
disaster prevention, mitigation, preparedness, and climate change adaptation,
rather than on response and rehabilitation and recovery.

The NDRRMP aims to:

• Strengthen the capacity of the government-national and local -
together with partner stakeholders.
• Build the disaster resilience of communities.
• Institutionalize arrangements and measures for reducing disaster
risks.
The plan has four priority areas:
• Disaster prevention and mitigation by reducing vulnerabilities and
exposure and enhancing capabilities of communities. Examples of activities that
prevent and mitigate disasters are hazard and risk mapping (geohazard mapping),
construction of dams or embankments that eliminate flood risks, regulations that do
not permit any settlement in high-risk zones, improved environmental policies, and
increased public awareness.
• Disaster preparedness - the capacity to effectively anticipate,
respond to, and recover from the impacts of hazardous events or conditions. This
includes such activities as contingency planning, stockpiling of equipment and
supplies, development of arrangements for coordination, evacuation drills, and
associated training.
• Disaster response - the provision of emergency services and public
assistance during or immediately after a disaster in order to save lives, reduce
health impacts, ensure public safety, and meet the basic subsistence needs of the
people affected. It is sometimes called "disaster relief."
• Rehabilitation and recovery - measures that ensure the ability of
affected communities to restore their normal level of functioning by rebuilding
livelihood and damaged infrastructure and increasing the communities'
organizational capacity.

R.A. 10121 has designated the Office of Civil Defense, an attached bureau of the
Department of National Defense, as the operating arm and the Secretariat of the
NDRRMC. A focal agency has been assigned to each of the four priority areas, and
the heads of these agencies shall serve as Vice Chairperson in the NDRRMC.

The other member of the Cabinet of the President, including the Secretary of
Health, together with the heads of various government offices and representatives
of civil society organizations, complete the composition of the NDRRMC.
The NDRRMC provides national leadership. Disaster Risk Reduction and Management
Councils exist at the regional, provincial, city, and municipal levels. The NDRRMP
is the document formulated and implemented by the Office of Civil Defense, the
agency that sets out goals and specific objectives for reducing disaster risks
together with related actions to accomplish these objectives.
A Community-Based Disaster Risk Reduction and Management (CBDRRM) describes the
process of DRRM in which at-risk communities are actively engaged in the
identification, analysis, treatment, monitoring, and evaluation of disaster risks
in order to reduce their vulnerabilities and enhance their capacities. In the
CBDRRM, the people are at the heart of decision-making and implementation of DRRM
activities.
The local DRRM offices at the provincial, city, and municipal levels and the
Barangay Development Councils are responsible for developing the local DRRM plan of
their respective LGUs.
Incident Command System
The Incident Command System (ICS) is a standardized, on-scene, all-hazard incident
management concept. It allows its users to adopt an integrated organizational
structure to match the complexities and demands of single or multiple incidents
without being hindered by jurisdictional boundaries. ICS is a nonpermanent
organization and is activated only in response to disasters or emergencies. The
establishment of an ICS was also provided for by the Implementing Rules and
Regulations of R.A. 10121.
Whenever possible, the local DRRMCs manage incidents with their own emergency teams
and material resources. The following criteria are used in defining which level of
DRRMC should take charge of a particular incident:
• The Barangay Development Committee (BDC), if a barangay is affected.
• The city/municipal DRRMC, if two or more barangays are affected.
• The provincial DRRMC, if two or more cities/municipalities are
affected.
• The regional DRRMC, if two or more provinces within the region are
affected.

• The NDRRMC, if two or more regions are affected.

• 00:12:55
The NDRRMC and intermediary local DRRMCs shall always act as support to local
government units (LGUs) that have the primary responsibility as first disaster
responders to any incident occurring within their jurisdictions.
The DRRMC, through its chairperson or responsible official, provides the Incident
Commander the mission and authority to achieve the overall priorities of the on-
scene disaster response operations, namely, life safety, incident stabilization,
and property/ environmental conservation and protection.
The Incident Command is responsible for the overall management of the incident. It
is headed by the Incident Commander and made up of the Command Staff and the
General Staff. The command function may be done either as a Single Incident Command
or as a Unified Command. The Single Incident Command may be applied when the
incident occurs within a single jurisdiction and there is no functional agency
overlap. The Unified Command for incident management may be applied when a disaster
or emergency affects several areas or jurisdictions or requires multiagency
engagement. Here, agencies work together through the designated members of the
Unified Command to establish a common set of objectives and strategies and a single
Incident Action Plan.
The Command Staff, composed of people who report directly to the Incident
Commander, usually includes:
• The Public Information Officer who is responsible for providing the
public, media, and/or other agencies with required information related to the
incident. Even a Unified Command has a single Public Information Officer.
• The Safety Officer who monitors operations related to the incident
and advises the Incident Command on matters of operational safety, including the
health and safety of responding personnel. The Safety Officer is responsible for
the safe conduct of the incident management and has the authority to stop any
unsafe act.
• The Liaison Officer who takes charge of coordinating with
representatives from cooperating and assisting agencies or organizations.
The General Staff is responsible for the functional aspects of the incident command
structure. It usually consists of the operations, planning, logistics, and finance/
administration.
The DRRMC Emergency Operations Center (EOC), which is generally located away from
the disaster site, supports the Incident Commander by making executive/policy
decisions, coordinating interagency relations, mobilizing and tracking resources,
collecting, analyzing, and disseminating information, and continuously providing
alert advisories/ bulletins and monitoring of the obtaining situation. The EOC does
not command the on-scene level of the incident. The Incident Command takes charge
of the operations at the scene.

RESPONSES TO A DISASTER
Community responses to a disaster
The classic four phases of a community's reaction to a disaster are the heroic
phase, honeymoon phase, disillusionment phase, and reconstruction phase.
Heroic phase
During the heroic phase, nearly everyone feels the need to rush to help people
survive the disaster. Medical personnel may work hours without sleep, under very
dangerous and life-threatening conditions, in order to take care of their patients.
Medical personnel may help out in areas in which they are not familiar and have no
experience. Disaster medical assistance teams, consisting of professionals and
paraprofessional medical personnel, provide emergency relief during a disaster and
may travel long distances to help out in a disaster. This was illustrated by the
people who volunteered to help in the immediate aftermaths of the Luzon earthquake
of 1990 and TS Ondoy.
Honeymoon phase
Individuals who have survived the disaster gather together with others who have
simultaneously experienced the same event; this is known as the honeymoon phase.
People begin to tell their stories and review over and over again what has
occurred. Bonds are formed among victims and health care workers. Gratitude is
expressed for being alive.
Disillusionment phase
When time has elapsed and a delay in receiving help or failure to receive the
promised aid has not occurred, feelings of despair arise. Medical personnel and
other first responders may begin to experience depression due to exhaustion from
many long days of long hours. Depression may set in as a result of knowledge of
what has happened to the community, friends, and family. People realize the way
things were before the disaster is not the way things are now and may never be the
same again.
They recognize that many things are different and much needs to be done to adjust
to the current situation.

Reconstruction phase
Once the community has restored some of the buildings, businesses, homes, and
services, and some sense of normalcy is returning, feelings of despair will
subside.
Counseling support for victims and helpers may need to be initiated to help people
to recover more fully. During this phase, people begin to look to the future.
Common individual reactions to a disaster
The reactions by individuals to a disaster vary. Some of the more commonly
encountered emotional, cognitive, physical, and interpersonal reactions to a
disaster that may be experienced. It should be noted that both victims and helpers
are under stress as a result of a disaster, thus disaster planning becomes futile
if it fails to account for possible intra- and intergroup conflicts.

Posttraumatic stress disorder

The reactions mentioned usually resolve in 1 to 3 months after the disaster event
but, in some cases, may lead to PTSD. PTSD is a psychiatric disorder that can occur
following an individual's experiencing or witnessing a life-threatening event, such
as a disaster. Men and women, adults and children, and all socioeconomic groups can
experience PTSD. People who have PTSD often relive the experience through
nightmares and flashbacks. The social and psychological symptoms can be severe
enough, and last long enough, to significantly impair a person's daily life. If
PTSD occurs in conjunction with related disorders (e.g. depression, substance
abuse, and other problems of physical and mental health), the situation becomes
more complicated. Individuals experiencing PTSD require medical attention.
Research is needed on all aspects of prevention, preparedness, response, and
recovery stages of disasters. Research is also needed on the education and training
needs of first responders, health care providers, and community populations. Nurse
researchers, in partnership with researchers from other disciplines, can play a
significant role in conducting research on disaster management.

INTRODUCTION
Innovations in health care are continuously introduced. Health care providers apply
best practices from latest researches and use appropriate tools to enhance the
quality of health care delivered.
Patients appear to become more engaged in their care, through information available
on the Internet, radio, and television. Communication problems between patients and
health care providers, brought about by geographical disparity, are easily solved
by mobile phones. Computers are used to store, retrieve, and process important
health data for better decision making. Information and Communications Technologies
(ICT) ares becoming indispensable tools in addressing some challenges in health
care.
ICTs are defined as, "diverse set of technological tools and resources used to
communicate, and to create, disseminate, store, and manage information." These
technologies include computers, the Internet, broadcasting technologies (radio and
television), and services, health surveillance, health literature, telephony. This
chapter explores the actual and potential applications of ICTs geared toward
improving people's access and utilization of health care in the Philippine
community health setting.
What is eHealth?
eHealth is the use of ICT for health. On May 25, 2005, during the Fifty-Eighth
World Health Assembly (WHA), a resolution was adopted by the World Health
Organization (WHO) member states recognizing Health as the cost-effective way of
using ICT in health care services, health surveillance, health literature, health
education, and research.
Given the extensive capabilities of ICT, Health can be considered in any of, but
not limited to, the following:
• Communicating with a patient through a teleconference, electronic
mail (e-mail, short message service (SMS).
• Recording, retrieving, and mining data in an electronic medical
record (EMR).
• Providing patient teachings with the aid of electronic tools such as
radio, television, computers, smartphones, and tablets. eHealth, often confused
with telehealth or telemedicine, is the overall, umbrella term. According to the
WHO, Health encompasses three main areas:
1.
2. The delivery of health information, for health professionals and
health consumers, through the Internet and telecommunications.
3. Using the power of information technology (IT) and e-commerce to
improve public health services, for example, through the education and training of
health workers.
4. The use of e-commerce and e-business practices in health systems
management.
The power of data and information
Nurses are knowledge managers. They constantly process raw patient data into
valuable information to deliver evidence-based and individualized interventions. It
is imperative for every Health practitioner to know the importance and difference
between the two.
Data are the fundamental elements of cognition and are defined as unanalyzed raw
facts that do not imply meaning. When meaning is attributed to data and when data
are processed and analyzed, then data become information.
Consider, for instance, the number 39. It can be an age, house number, jersey
number, etc. This is data. The school nurse noted that it was written on the
respiratory rate field of the record of Grade 5 student Rosemarie. Number 39 now
has a meaning to the nurse and has become information. Based on the nurse's
knowledge that Rosemarie's respiratory rate is above normal and considering other
findings, the nurse concludes that she is hyperventilating. The nurse gave
Rosemarie a brown paper bag to breathe into.
The health care system builds heavily on accurate recording of obtained data.
Paper-based methods may bring inconvenience especially when it comes to
interoperability of health services, information backup, and instant data access. A
number of bigger problems may also emerge:
 1. Continuity and interoperability of care stops in the unlikely event
that a record gets misplaced. If the patient suffers from a chronic condition,
previous findings supporting this diagnosis, drug allergies, preexisting
conditions, or even past accounts of the patient's previous visits may no longer be
accessed unless the health providers have made several copies of the same record.
The patient may also need to recount his/her condition for every transfer of care.
2. Illegible handwriting poses misinterpretation of data. A direct
observational study of medication administration found opportunities for errors
associated with incomplete or illegible prescriptions.
3.
4. Patient privacy is compromised. Traditional, paper-based patient
records are vulnerable to unauthorized viewing since there is no audit trail of the
usage of the chart. The disclosure of highly private information arising from such
an incident can lead to loss of trust in the health facility or even legal risks.
5. Data are difficult to aggregate. Manual data recording and tallying
significantly delays implementation of interventions and targeted health programs.
Health care
6. Actual time for patient care gets limited. Time spent by the
community health worker searching for a paper-based record is time lost for actual
care.
Likewise, for both clinical and community settings, the overall impact of the
problems related to manual/traditional data-gathering is articulated as follows:
Internal and external changes affecting health care informatics:
1. The ability to manipulate large amounts of data
2. The ability to relate data to cohorts of people who share similar
health problems
3. The ability to link to genomic data
In contrast, having a well-managed patient information system can have the
following benefits:
1. Data are readily mapped, enabling more targeted interventions and feedback.
• Through a system that delivers real-time and accurate patient and
community information, health care providers are able to deliver patient-centered
care and targeted disease prevention and management programs. The facility and
staff are also provided feedback on their performance through computer alerts,
enabling them to continually comply with standard guidelines and monitor monthly,
quarterly, or yearly health targets. From the societal public health perspective,
adhering to these guidelines keeps individuals healthy and lowers the risk of
disease outbreaks in communities.
• Health professionals can also track the frequency and locale of
diseases in real time through an EMR and Geographic Information System (GIS) like
the Philippine Health Atlas of the Department of Health. GIS technology enables
detailed maps to be generated with relative speed and ease. In turn, this provides
public health practitioners with the ability to provide quick responses to
questions or concerns raised in a community meeting. GIS is not the complete
solution to understanding the distribution of disease and the problems of public
health, but at is an important way in which to better illuminate how humans
interact with their environment to create or deter health.

2. Data can be easily retrieved and recovered.

• In the event of force majeure, retrieval of patient information is not a problem
since data are automatically backed-up periodically in a secure server.
3. Redundancy of data is minimized.
• Patient data that are frequently required in various health forms such as unique
identifying information (e.g. name, birthday, age, gender) need to be recorded only
once. These can be linked and organized automatically into related record types
through a database, allowing a better record management and ease-of-use.
4. Data for clinical research becomes more available.
• The potential impact of health research in the country is often hindered by the
lack of quality data. Whenever data is gathered, it is often not communicated to
the rest of the research community. Having quality data stored in databases
provides faster and more reliable research outputs that may eventually be
translated to health care innovations and actual interventions.
5. Resources are used efficiently.
• By making patient information more readily available, EMRs reduce costs related
to chart pulls as well as supplies needed to maintain paper charts. Studies have
also shown that having an EMR as opposed to a paper file can result in reduced
transcription costs through point-of-care documentation and other structured
documentation procedures. In developing countries, health care information systems
have been driven mainly by the need to report aggregate statistics for government
or funding agencies. Improvements in drug supply management using medication data
from EMR systems can offer the most measurable cost benefits at present; a well-
managed drug supply also improves availability and quality of patient care.
Good data qualities

The nursing process begins with obtaining data through assessing the patient's
signs and symptoms. These data are interpreted by the health care professional into
useful information and a diagnosis. This is then followed by necessary
interventions and again ends with gathering new data from evaluating the results.
Without data, it will be difficult for a health professional to assist the patient.
Human error, viruses, bugs, and hardware issues pose a great threat to the
integrity of data. ICT can help decrease these errors by putting safeguards in
place, such as backing up files on a routine basis and error detection. In order
for information to be valuable, data must have the following characteristics:

CHARACTERISTICS OF GOOD DATA

Accuracy - This ensures that documentation reflects the event as it happened. All
values should be correct and valid. In a computerized system, a computer can be
instructed to check specific fields for validity and alert the user to a potential
data collection error. In electronic systems format requirements must be followed
(e.g., if date required is mm-dd-yyyy, then it should be presented as 03-24-1989).
Accessibility - This is a data characteristic which ascertains data availability
should the patient or any member of the health care staff needs it. An example is
readily available reports or statistics when needed by decision makers.
Comprehensiveness - Data inputted should be complete. This is done by making sure
that all required fields in the patient's record are properly filled up.
Consistency/Reliability - Having no discrepancies in data recorded makes it
consistent.
This means that when John Lloyd Dela Cruz is written on the first page of the
patient record, it should not be Jon Loyd Dela Cruz in the next. This potential
error is reduced through error detection and alerts by the computer.
Currency All data must be up-to-date and timely. This is exemplified when the
community health nurse records data at the point of care or when it happened.
Definition - Data should be properly labeled and clearly defined. For example, 36
is just an ordinary number unless it is labeled as an age of a person.

EHEALTH SITUATION IN THE PHILIPPINES

The developing world suffers from inadequate health care and medical services. Lack
of health care professionals and infrastructure contributes to this problem, making
it more difficult to deliver health care to people in rural and remote communities
of the developing world.
The ubiquity of mobile technologies and availability of Internet services in the
Philippines create a promising ground for Health access. In 2001, roughly 2.5% of
the country's population had Internet access. In the span of 10 years, this rate
steadily increased to 29%. The Philippines has also a mobile phone penetration rate
of 80%, with 73 million subscribers as of 2009. In addition, the country is ranked
first in terms of short messaging service (SMS) usage in the entire world.
ICT has changed how Filipinos access information and how the government has
utilized this to inform its citizenry. Examples of these include regular updates of
traffic conditions, current events, and critical weather reports through various
social media.
The health sector has also begun utilizing ICT to improve its services. The DOH has
introduced a number of health information systems that aim to improve the access of
health data, such as the Electronic Field Health Service Information System, Online
National Electronic Injury Surveillance System, the Philippine Health Atlas, and
the Unified Health Management Information System.
Factors affecting Health in the country
As mentioned earlier, numerous limitations impede the development of Health in the
country, especially in the community setting. However, various innovations have
allowed Health implementations to gain ground. Both limiting and advancing factors
are discussed in this section.
Limited health budget
As mentioned previously, the budget allocation for health care is relatively small.
This is one of the many reasons advancements in Health are postponed. ICT projects
usually require a huge budget, take a long period to implement, and are
occasionally seen as risky endeavors.
An example of a "failed" Health project was the United Kingdom's National Health
Service (NHS) National Program for IT (NPfIT), which was launched in 2002 with a An
example of a "failed" Health project was the United Kingdom's National Health
Service (NHS) National Program for IT (NPfT), which was launched in 2002 with a
budget of £11.4 billion. The objective of the program was to "ensure every NHS
patient had an individual electronic care record which could be rapidly transmitted
between different parts of the NHS". However, after 9 years in development and
after spending almost £7 billion, the UK government decided to revise NPfiT as it
was regarded as incapable of meeting its target objective, given the limited
available remaining resources.
The emergence of free and open source software
In Health, the cost of software procurement or development often takes up a huge
portion of the budget. In addition, using ready-made proprietary software can be
limiting at times, especially when users want to modify the software to fit their
workflow better.
To modify the software, its source code needs to be changed. The source code is
like the ingredients of a recipe. If one wants to modify the recipe, one will need
to adjust some of the ingredients. Like some recipes, some source codes are kept
secret too, which may cause the buyer of the proprietary software to remain locked
in to the seller's support and maintenance. Since the sellers own the source code
of the program, they are the only ones who can modify the program. This may entail
additional and unplanned costs, adding to the problem of health budgetary
limitations.
An emerging trend all over the world is the development and increasing popularity
of Free and Open Source Software (FOSS). In a nutshell, FOSS makes the source code
of a program freely available for everyone, hence the name "open source." Using the
same recipe analogy, information on the ingredients is made accessible to the
public, allowing anyone to "cook something up." This allows anyone with the
knowledge of programming to contribute to the source code, improving the program
and sharing the improvement with everyone. To some extent, FOSS can theoretically
cut costs in developing the software.
A perfect example of a successful FOSS for health in the Philippines is the
Community Health Information Tracking System (CHITS), currently managed by the
University of the Philippines Manila-National Telehealth Center (UPM-NTHC).
Interested software developers and students from UP Manila, taking into
consideration recommendations of community health professionals, are able to
contribute to the development and improvement of CHITS because its source code is
made openly available.

Decentralized government

Under R.A. 7160 or the Local Government Code of 1991, local government units (LGUs)
are autonomous, and therefore in control of their own basic health services,
including the budget. Because of this, it is typical to see diverse and unrelated
Health projects developing all over the country such as the Wireless Access for
Health (WAH) in Tarlac, the Secured Health Information and Network Exchange (SHINE)
in Iloilo, and the numerous CHITS installations in municipalities all over the
Philippines. LGUs may develop their own systems. These efforts have accelerated the
development of Health in community health. However, to maximize advantages derived
from these systems and to produce a nationwide impact, the different health
information systems will eventually need to connect with each other. Having one EMR
system for all health centers will make consulting in different facilities easier.
But unifying and harmonizing the different existing systems for this future
benefit, though not impossible, will expectedly be difficult.
Target users are unfamiliar with the technology
eHealth is not only about technology. Along with software development and hardware
procurement, staff training and maintenance of the system are key factors in
determining its effectiveness. Recognition of the cultural aspects of community
life is important in starting them off into a new direction such as computerization
and automation.
One possible pitfall of Health implementations is focusing on software development
before accomplishing an assessment of the needs of health professionals in the
field. Most health center personnel are not familiar with the use of computers.
Implementing an Health system requires training of health personnel on basic
computer skills, use of software, and maintenance of the equipment. No matter how
technologically advanced the tools are, the success of an Health implementation
will eventually depend on the end-user's willingness to learn and accept the
technology.
The benefits of Health and telemedicine occur to communities when the technology
presents itself:
1. As an enhancement to existing human relationships that have been
established through conventional routes
2. As a solution to a long-felt community need.
To illustrate, in 2004, the National Telehealth Center initiated the BuddyWorks
project, which was funded under the eGov Fund from the Commission on Information
and Communications Technology (CICT). Its aim was to provide medical specialist
support through a structured telereferral system for physicians situated in
geographically isolated communities. Initially the project utilized a web-based
system. However, the lack of a reliable Internet connection in remote areas made
the system unreliable. The physicians were also unfamiliar with the use of the
system. Thus, in a 2-year period, the project was only able to process eight
referrals.

Based on lessons learned from the early BuddyWorks experience, the project switched
to the use of technology that is more appropriate to Filipinos - mobile phones.
The switch made BuddyWorks more accessible as it utilized preexisting communication
systems such as SMS offered by mobile phone service providers. After the
transition, the number of referrals drastically increased to 1,939 in a period of
17 months.
Surplus of "digital native" registered nurses
"Not too long ago we had nothing to think about except the board exams. And before
that, we had to make sure we were qualified to take the exams by completing the
requirements, along with many other adversities. Sure, passing the exams was a
reason to celebrate, but / was celebrating yesterday, not tomorrow.
I knew darker days lay ahead. The United States was in the midst of trying to
reform their health care system (again). US President Barack Obama wanted to solve
their nursing shortage from within instead of importing foreign nurses. Other
countries were not accepting new graduates and required a minimum of one year's
experience.
This created a domino effect no one wanted. With the foreign-bound staff nurses
choosing to keep their local jobs, the 30,000 new registered nurses of Batch 2009
were basically left with just their Professional Regulation Commission licenses to
be proud of" From the article "Cleaning Up." Published by the Philippine Daily
Inquirer, September 6, 2011.
Because of logistic limitations, government hospitals and health centers are mostly
understaffed despite the estimated 200,000 underemployed or unemployed nurses in
the country.
One of the measures of the DOH to address the accumulation of unemployed
professional nurses is the Registered Nurses for Health Enhancement and Local
Services
(RN Heals) Project. It aims to provide nurses with one-year employment in
underserved and remote areas in the country as well as to provide underserved areas
with additional professional health workers. A term coined by educator and writer
Marc Prensky, digital native describes a person who grew up and is familiar with
digital technologies, and who uses them in daily living. The entry of digital
native nurses into the profession and their nationwide deployment to communities
may potentially aid the implementation of various ICT projects in health care.
Overall, the Philippines is progressing in its use of Health for the benefit of its
citizens. How Health specifically affects community health will be taken up in
greater detail in the next section.

Graphic. USING EHEALTH IN THE COMMUNITY. Universal Health Care and ICT. Electronic
medical records. Telemedicine. Learning. End of Graphic.
USING EHEALTH IN THE COMMUNITY
As mentioned earlier, the major goal of community health nursing is to preserve the
health of the community. This is best achieved by focusing on health promotion and
health maintenance of individuals, families, and groups within the community. This
section gives details as to how eHealth enables the community health nurse in
contributing towards the achievement of this goal.
Universal Health Care and ICT
In the Philippines, making health care accessible to all remains a great challenge.
Lack of financial health care coverage leads to high out-of-pocket expenses. The
marked mass migration of health professionals leaves the remote and rural areas of
the country with limited access to specialized health care. The archipelagic
distribution of the country-with 7,107 islands-makes health care delivery even more
challenging.
A series of health reforms have been implemented. The DOH, through Administrative
Order No. 2010-0036, outlined the policy directions of Universal Health Care.
Also known as Kalusugan Pangkalahatan (KP), this reform agenda has three priority
health directions:
1. Financial risk protection through expansion in National Health
Insurance Program enrolment and benefit delivery
2. Improved access to quality hospitals and health care facilities
3. Attainment of the health-related Millennium Development Goals (MDGs)
One of the aims of KP is to attain efficiency by using IT in all aspects of health
care.
One of the key instruments it underlines is the use of Health Information to
establish a modern information system that shall provide evidence for policy and
program development and support for immediate and efficient provision of health
care and management of province-wide health systems.
The DOH also recognizes the valuable purpose of ICT for health and has drafted its
National Health Strategic Framework for 2010-2016, with the vision of ICT
supporting UHC to improve health care access, quality, efficiency, and patient's
safety and satisfaction, for reducing cost and enabling policy makers, providers,
individuals, and communities to make the best possible health decisions.
Electronic medical records
EMRs are basically comprehensive patient records that are stored and accessed from
a computer or server. Community health centers have the capacity to rapidly adapt
EMRs because they utilize a standard process nationwide. For example, the workflow
with a patient at a health center in Quezon City is basically the same as that of a
health center at Batanes.
In contrast, EMRs are more difficult to implement in hospitals because each
hospital has its own set of protocols coupled with its own system of documentation.
Even government-owned hospitals do not have a standard system of health service
provision and of maintaining patient records. This difficulty in implementing
information systems in the health sector highlights the importance of creating
standards.
Another reason EMRs are vital to community health centers is that each patient
record is usually used more frequently. For instance, a patient undergoing
treatment for tuberculosis needs to make regular visits to the health center for
TB-DOTS (Tuberculosis Directly-Observed Treatment Shortcourse). A young child is
brought to the health center regularly for child care health services, such as
immunizations, deworming, and micronutrient supplementation. Community health
centers make health care services available to families, enabling the community
health worker to observe familial predispositions to certain diseases and provide
appropriate health promotion and prevention measures.
Ideally, a person can utilize health center services from womb to tomb. This ideal
scenario is made more likely if each patient encounter is properly documented and
the patient recording system is set up with accuracy and efficiency in mind.
As stated earlier, community health nurses should be aware of health patterns and
health indicators within their catchment area. Vital statistical indicators such as
mortality and morbidity rates must come from reliable data, which can be derived
from accurate and thorough EMRs. EMR systems also allow computerized processing of
indicators, making it easier for nurses to focus on other important aspects of
health care.
One of the most widely used community-based EMR in the country is CHITS, which
began in 2004 and was funded by the International Development Research Centre
(IDRC). It was created by Dr. Herman Tolentino of the University of the
Philippines-Medical Informatics Unit (UP-MIU) and is currently being implemented at
health centers in Pasay, Navotas, Quezon City, and several other municipalities
nationwide. Training on how to optimize the EMR for community use and on-site
follow-ups of the health workers were done. This resulted in EMR features that are
customized to the needs of the health center and the community. More importantly,
involving the target end users in the development process of the EMR gave them a
sense of ownership of the program, allowing easy acceptance and utilization of
CHITS.
Telemedicine
One of the five strategic goals of the DOH National Health Strategic Framework for
2010-2016 is to capitalize on ICT. This in order to reach and provide better health
services to geographically isolated and disadvantaged areas (GIDAs), to support MDG
attainment, and to disseminate information to citizens and providers through
telemedicine and mobile health (mHealth) services.
The WHO defines telemedicine as, "the delivery of health care services, where
distance is a critical factor, by all health care professionals using information
and communications technologies for the exchange of valid information for
diagnosis, treatment and prevention of disease and injuries, research and
evaluation, and for the continuing education of health care providers, all in the
interests of advancing the health of individuals and their communities".
WHO further underscores four elements that are specific to telemedicine:
1. Its purpose is to provide clinical support.
2. It is intended to overcome geographical barriers, connecting users
who are not in the same physical location.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.
In the Philippines, the UPM-NTHC has been using telemedicine to provide health
services to remote and underserved areas of the country since 2004. It is a partner
of the DOH in the Doctors to the Barrios program. It enabled Municipal Health
Officers to teleconsult difficult cases with trained telehealth medical specialists
via SMS or e-mail. The teleconsults, which are received by a server, are then
triaged by the NTHC telehealth nurses to appropriate medical specialists.
In collaboration with the Philippine Council for Health Research and Development of
the Department of Science and Technology (DOST-PCHRD), the BuddyWorks project of
UPM-NTHC was continued from 2007 to 2010 as the National Telehealth Service Program
(NTSP).
A specific example of how telemedicine was applied in the community was the
discovery of a rare skin disease called tinea imbricata in a tribe from Kiamba,
Saranggani in Mindanao. The Municipal Health Office of Kiamba, Saranggani referred
multiple cases of strange, ring-like formations on a patient's skin. Images were
sent to the UPM-NTH telehealth nurse and were referred to a dermatology specialist
at the Philippine General Hospital, who gave the initial diagnosis of tinea
imbricata -which has only been reported in the Philippines three times since 1789.
The recommended treatment was effective. This eventually led to a medical mission
by the dermatology specialist and her fellow dermatologists in cooperation with the
local government of Kiamba to help the patients affected by the disease.
As can be seen from the example, telemedicine has the capacity to bridge the gaps
in the health referral system. It is understandable that this is not a universal
solution and may be applicable only in specific scenarios. The goal of a patient
receiving the best care as soon as possible despite an unfavorable location or
other adverse circumstances may be reached through telemedicine.
eLearning
Health education, which is essential in health promotion and maintenance, can be
facilitated by ICT.
eLearning is basically the use of electronic tools to aid in teaching. It can be
done synchronously, asynchronously, or in a combination of both. This can be in the
form of simple instructional videos and information textblasts to social network
help groups and interactive simulations. Learning can be especially useful in
correcting misconceptions about health and health care. It permits access to
reliable information about health. For example, control of communicable diseases
frequently requires community participation. With the use of Learning technology,
community health nurses can elicit community interest by showing instructional
videos on measures to control a particular disease.
eLearning can also be used to educate fellow health professionals. With eLearning,
continuing education sessions can be frequently availed of, with less time, effort
and expense involved in the process. Continuing professional education of nurses
can be undertaken by attending online and virtual seminars through teleconferences
and multiuser virtual environments.
Examples of Health projects in the community
Graphics below are the summary of Health projects, past and present, that target
community health. Note that some projects are a combination of EMRs, telemedicine,
eLearning, and other ways by which ICTs impact health.

The similarities among the projects and their implementations are noteworthy. Also,
they are scattered in different parts of the country. The working of these projects
usually does not interfere with each other, creating potential problems as
previously explained.

ROLES OF COMMUNITY HEALTH NURSES IN EHEALTH

Community health nurses' roles are significantly diversified by Health. With the
advent of Health, nurses are made available to several clients at a single time,
making health care delivery more efficient. Advances in IT may also help the nurse
in optimizing efforts towards maintaining an open line of communication with
clients, paving the way for establishing and maintaining rapport. IT literally at
the fingertips of the nurse provides greater opportunity to learn more about
clients and their conditions; eHealth, however, cannot be a replacement for actual
patient care. It is best viewed as a powerful tool for nurses-bridging gaps and
improving access especially in a resource-constrained country like the Philippines.
The following are the major roles of an Health nurse in the Philippine community
setting:
Data and records manager
As data and records managers, community health nurses monitor the trends of
diseases through the EMR, allowing for targeted interventions for health promotion,
disease prevention, curative services, or rehabilitation. Nurses also maintain the
quality of data inputs in the EMRs, making sure that information is accurate,
complete, consistent, correct, and current. Nurses also participate in regular data
audits.
Change agent
Nurses act as change agents by working closely with the community and implementing
Health with them and not for them. Change agents do not force technology on the
community, but inform and guide the community in selecting and applying appropriate
ICT tools.
Change agents also collaborate with health leaders, policy makers, stakeholders,
and other community health professionals to determine their knowledge and awareness
on Health and appropriate ICT tools. Nurses then build on the baseline Health
knowledge and help develop appropriate Health tools for the community.
Educator
Nurses provide health education to individuals and families through ICT tools (e.g.
teleconference, SMS, e-mail, and virtual/ simulated environment). They may also
participate in making Learning videos on specific diseases (e.g. diabetes mellitus,
tuberculosis), which the patients can watch during their waiting time at health
centers. Such videos may also be installed in the clients' personal phones (if
supported) and watched at a time convenient to them.
Nurses may also use scheduled text messages to patients among the catchment
population to send important health information, reminders, etc.
Telepresenter
In the event that a patient needs to be referred to a remote medical specialist
through telemedicine, nurses may function as a telepresenter. This means that the
nurse may need to present the patient's case to a remote medical specialist, noting
salient points for case assessment, evaluation, and treatment. This usually occurs
via a teleconference.
Client advocate
As client advocates, community health nurses must safeguard patient records,
ensuring that security, confidentiality, and privacy of all patient information are
being upheld. This becomes more challenging especially because with technology,
transfer of information can happen instantly.
The client must also be well informed about the benefits and challenges of EMRs,
telemedicine, and other Health tools. Nurses must ensure that personal and health
information handling through Health (i.e., collection, storage, and transmission)
is well explained. Clients must sign an informed consent, if necessary.
Nurses must also guarantee that all Health interventions are performed in a safe
and ethical manner, making sure that personnel involved in Health are competent and
have received eHealth training/certification.
Researcher
Using Health tools (e.g. EMRs), patient records can easily be retrieved and
analyzed retrospectively by community Health nurses. They are responsible for
identifying possible points for research and developing a framework, based on data
aggregated by the system.

An Health nurse researcher also pursues continuing nursing informatics education,

with the goal of developing a research framework which will be beneficial to the
community.

INTRODUCTION
School-aged children and adolescents face increasingly difficult challenges related
to health. Many of today's health challenges are different from those of the past
and include behaviors and risks linked to the majority of the leading causes of
death, such as heart disease, injuries, and cancer. The use of tobacco, alcohol,
and drugs; poor nutritional habits; inadequate physical activity; irresponsible
sexual behavior; violence; suicide; and reckless driving are examples of behaviors
that often begin during youth and increase the risk for serious health problems.
Education and health are interrelated. As early as 1950, the World Health
Organization (WHO) Expert Committee on School Health Services noted that, "to learn
effectively, children need good health". Studies have shown that nutritional
deficiencies and poor health in school-aged children are among the most common
causes of low school enrolment, absenteeism, poor school performance, and early
dropout. On the other hand, regular attendance in school is one of the essential
means of improving health. Education that provides children with both basic
academic skills and specific knowledge, skills, and attitudes related to health is
vital. This aspect of education has lifelong effects.
In the Philippines, around 1.2 million children go to preschools, 13.7 million to
elementary schools, and 6.8 million to high schools. This creates a unique
opportunity for the school nurse to make a positive impact on the nation's youth.
There are more teachers than health professionals in the country. Additionally, the
school health structure does not provide for one nurse per school. Generally, the
school nurse visits four to six schools per month, with each visit lasting for 3
days or more, depending on the type of school and school location and population.
Revisits may be done within the month for follow-up purposes. This means that the
nurse spends at least 3 days of each month in a particular school. For the rest of
the month, teachers, who also serve as school health guardians, provide primary
care as necessary, such as detection of obvious health problems and administration
of first aid. The school nurse is responsible for planning and conducting training
programs for teachers on health and nutrition.
During school visits, school nurses see students for a variety of complaints.
Increasing numbers of children are being seen in the school setting because they
lack a source of regular medical care. Through the education of students and
teachers, counseling, advocacy, and direct care across all levels of prevention,
the nurse can improve the immediate and long-term health of this population.
In 2006, an estimated 12.8 million children aged below 15 years (44% of all the
children from this age group) were living in families that did not meet basic
living requirements based on their income. Poverty is associated with decreased or
inferior health care and has been linked to serious health problems that result in
an increase in absenteeism and failure in school. The school nurse and, in the
absence of the school nurse, the well-prepared school teacher, serving as school
health guardian, can effectively manage minor complaints and illnesses, helping
these children to return to or remain in class.
There is a need for mental and physical health services for students of all ages in
an effort to improve both academic performance and the sense of well-being. This
chapter provides an overview of school health and the role of the nurse in the
provision of health services and health education. An in-depth look at the
components of a successful school health program related to the major problems of
today's youth is included in this chapter.
The evolution of school health services has brought about the development of a more
comprehensive school health program with the entire school community considered as
the client. This brought about the inclusion of services for school health
personnel.

HISTORICAL DEVELOPMENT OF SCHOOL HEALTH PROGRAMS

The definition of school health and what a school health program should be have
evolved markedly in the past 50 years. Traditionally, school health programs were
defined as covering:
1. School health services.
2. School health education.
3. A healthy school environment to include both physical and
psychosocial aspects of environment.
The interrelationships, however, among these elements as well as the manner in
which they can reinforce each other were not given emphasis, either in theory or in
practice.
In the Philippines, the first school health program required by law consisted
mostly of school health services with the passage of R.A. 124 in 1947. Entitled An
Act to Provide for Medical Inspection of Children Enrolled in Private Schools,
Colleges and Universities in the Philippines, this law stated that it was the duty
of the school heads of private schools with a total enrolment of 300 or more to
provide for a part- or full-time physician for the annual medical examination of
pupils and students.
The physicians were to render reports of their school health activities at the end
of every quarter of each school year to the Director of Health. The physicians were
placed under the direct supervision of the Bureau of Health, the forerunner of the
DOH.
With the changing roles and responsibilities of schools came a redefinition of
school health programs in the 1980s. The evolving roles of the school nurse and the
school health team in response to the needs of school children and the other
members of the school community resulted in the expansion of the school health
program to eight components. In addition to the first three components mentioned
earlier, five more components have been included, namely:
1. Health promotion for school personnel,
2. School-community projects and outreach,
3. Nutrition and food safety,
4. Physical education and recreation, and
5. Mental health, counseling, and social supports.

This new definition emphasized the need for an organized approach, implemented
through comprehensive, holistic strategies. This is the basis for "health-promoting
schools".
School nursing covers the entire scope of the eight components of school health
programs. The National Association of School Nurses (in the United States) defines
it as a specialized practice of professional nursing that advances the well-being,
academic success, and lifelong achievement of students. To that end, school nurses
facilitate positive student responses to normal development; promote health and
safety; intervene with actual and potential health problems; provide case
management services; and actively collaborate with others to build student and
family capacity for adaptation, self-management, self-advocacy, and learning.
In the Philippines, a holistic approach to strengthen health and nutrition among
school children are the concept embodied by the Redesigned Approach in School
Health Nursing (RASHN), officially adopted through the Department of Education,
Culture, and Sports (DECS) Memorandum No. 37, series 1991, RASHN is based on the
philosophy that the academic performance of the pupils and the instructional
outcomes are determined by the quality of health of the school population and the
community where they come from.
The Department of Education (DepEd) Order No. 43, s. 2011 on the subject
Strengthening the School Health and Nutrition Programs for the achievement of the
Education for All (EFA) and Millennium Development Goals (MDGs) seeks to strengthen
the School Health and Nutrition Program (SHNP) through a seamless alignment of SHN
activities with other key school programs, thus the title Integrated School Health
and Nutrition Program (ISHN). It further states that the ISHNP is designed to
maintain and improve the health of school children by preventing diseases and by
promoting health-related knowledge, skills, and practices.

SCHOOL HEALTH SERVICES

Most authorities agree that comprehensive school health programs should include the
eight components. DepEd Order No. 43, s. 2011 directs the integration of SHNP with
the annual and medium-term development plans of the region/division and with school
improvement plans, ensuring administrative and financial support. It outlines a
matrix of activities for the ISFINP designed to address FEA goals, which are:
• To expand early childhood care and education
• To improve the quality of education
• To provide learning and life skills to young people and adults
The SHNP activities are also intended to address MDG goals, specified as the
following:
• To eradicate extreme poverty and hunger
• To reduce child mortality rate
• To combat HIV/AIDS, malaria, and other diseases
• To ensure environmental sustainability
DepEd also seeks to intensify the active participation of other stakeholders, both
in the government and in the private sector, including concerned individuals in
all. activities aimed at promoting the health and nutritional status of school
children and school personnel.
Health education
Precisely because the school is an educational institution, it provides the nurse
with an environment conducive to health education. Depending on the objectives of a
specific health education activity and the catchment schools of the nurse, the
target population may be children in the preschool, primary, or secondary level.
The target population may also be the teachers and/or the school personnel. This is
in consideration of the role of teachers and school personnel as the nurse's
partners in health education, because healthy attitudes, and practices are caught
by children from adult models around them.
Health education activities are culture-sensitive and based on the identified
educational needs of the target population. Health concepts are integrated in the
curriculum from preschool to high school. [Note: The K to 12 Program consists of
Universal Kindergarten, 6 years of Primary Education, 4 years of Junior High School
and 2 years of Senior High School. Junior High School begins with Grade 7, and
Senior High School with Grade 11. The program began with the implementation of
Universal Kindergarten in 2011-2012. Grades 1 and 7 began in 2012-2013. Grade 11
will be offered for the first time in 2016-2017, and Grade 12, in 2017-2018. The
first batch will graduate in 2018. The 12-year basic education is being implemented
because it is a standard for the recognition of students and/or professionals
abroad, based on the Bologna Process for the European Union and the Washington
Accord for the United States.
Health concepts are introduced according to the developmental level of school
children. The following health education concepts are integrated in the curriculum
from Kindergarten to Senior High School:
• Nutrition;
• Personal and oral hygiene, including WASH (water, sanitation, and
hygiene);
• Prevention of soil-borne helminthiasis, mosquito-borne diseases, and
other prevalent communicable diseases like acute respiratory infections, diarrheal
disorders, and tuberculosis; and
• Use of traditional and alternative health care in the management of
common health conditions.
School health education should also include life skills education and staff
education through training and development of school personnel.
Other areas of concern for health education include:
• Oral hygiene. In addition to oral hygiene education, the Oral Health
Care Program involves the 7 o'clock Toothbrushing Habit Activity.
• Injury prevention and developing safety conscious behavior in the use
of the school playground, while engaging in sports, and the like. МАРЕН (Music,
Art, Physical Education, and Health) period is a good time for the school nurse or
teacher to talk with and counsel students about the risk of developing health
problems related to physical activity.
• Tobacco use. Smoking is a major problem in this country. Prevention
should be emphasized in young people. The Philippine results of the Global Youth
Tobacco Survey showed that 3 out of 10 students aged 12-17 years currently use some
form of tobacco. Approximately 21.7% currently smoke cigarettes; 9.7% currently use
tobacco other than cigarettes.
• Substance abuse. The use of alcohol and other drugs is associated
with problems in school, injuries, violence, and motor vehicle deaths. For this
reason, the National Drug Education Program is being implemented. This is directed
toward raising the consciousness of primary and secondary students regarding the
perils of the use of illicit drugs. It was designed to promote collaboration of
other sectors with the school system by establishing linkages among government,
private, and socio-civic organizations. Random drug testing is also carried out as
part of this program.
• • HIV/AIDS and other sexually transmitted infections. The school-based
HFV and AIDS Education and Prevention Program is an information dissemination
campaign to educate the general population on the risks of HIV/AIDS.
• Physical education
• A sedentary lifestyle is associated with obesity, hypertension, heart
disease, and diabetes. Studies show that people who are active outlive those who
are inactive and that those who are active have a better quality of life than those
who lead sedentary lives. Habits in childhood are likely to continue into
adulthood, making it imperative that children are taught the importance of being
physically active at a young age. Studies also show that children and adolescents
who are physically active have increased self-confidence and self-esteem and
decreased anxiety, stress, and depression. Regular physical activity helps build
and maintain healthy bones and muscles.
• Physical education should focus on activities that children can
continue into their adult years, such as walking, swimming, biking, and jogging.
The educational content may change as the child ages. For example, what may appeal
to a young child such as playing on the playground with friends is different from
what motivates an adolescent, such as competitive sports or weight control.

Health services
© 00:00:57
Health care provided in schools includes such preventive services as health
screening, including screening for completeness of immunization, such as measles
vaccine. A child entering Kindergarten or Grade 1 who has not completed measles
immunization should be referred to the nearest health center. School health
services also include emergency care, management of acute and chronic health
conditions, appropriate referrals, and regular deworming as part of the Integrated
Soil Transmitted Helminthiasis Prevention and Control Program.
Health screenings
One of the objectives of the School Health Nursing Program in the Philippines is to
detect early signs and symptoms of illness, disabilities, and deviations from
normal.
To achieve this objective, the school nurse carries out the following activities:
• Annual individual health assessment -examination of the eyes, ears,
nose, throat, neck, mouth, skin, extremities, posture, nutritional status, heart,
and lungs.Visual acuity test (vision screening) is done with the use of a Snellen's
chart, E-chart, or symbol chart. Ballpen click test (auditory screening) is done to
test for hearing acuity. Health examination of prospective Grade 1 entrants is
performed during summer.
• Height and weight measurement - done at the beginning and at the end
of the school year. It is accomplished for nutritional assessment and growth
monitoring using the WHO Child Growth Standards, Tables, and Charts.
• Rapid classroom inspection - inspection of the pupils in the
classroom or while they are in line formation outside the classroom. It is done to
detect illness, particularly when there is an outbreak in the community of a
condition characterized by easily observable signs and symptoms like infectious
conjunctivitis (sore eyes). It may also be carried out to assess the general state
of hygiene of the children.
Emergency care
Schools are a frequent site for student injuries that range from minor scrapes and
bruises to serious injuries, such as fractures and seizures, to severe and life-
threatening injuries, such as head injuries and severe asthma attacks. Injuries may
occur in school buildings, classrooms, physical education classes, or during
athletic
events. Emergencies can include natural events such as typhoons, floods, and
earthquakes, and man-made disasters, such as hazardous material spills, fires, and
civil
disobedience. Basic first aid equipment should be available in all schools. The
school nurse and school health guardians must be knowledgeable about standard first
aid and certified in cardiopulmonary resuscitation (CPR). Additionally, a procedure
for activating an emergency management system, including a referral system, should
be in place.
Care of the ill child
The school nurse is responsible for monitoring the health of all students. For
students with acute or chronic illnesses, administration of medications or
treatments may be necessary. The nurse is often required to assess an ill child to
determine the type of illness or health problem, identify the source of the
illness, and determine how to manage the illness (i.e., contact the parent or send
the child back to class).
Student records
Health records should be maintained for all students according to the policies of
the DepEd. Student health records should be afforded the same level of
confidentiality as that given to clients and patients in other settings (i.e.,
sharing confidential information with unauthorized persons without proper approval
is considered unethical and improper except in emergency situations)
Nutrition
School-aged children are undergoing periods of rapid growth and development and
consequently have high nutritional needs. A variety of foods must be ingested to
meet their daily requirements. Diets should include a proper balance of
carbohydrates, proteins, and fats, with sufficient intake of vitamins and minerals.
However, children and adolescents share a well-known preference for junk food.
Their diet is often high in fat and sugar and frequently consists of fast-food
items, such as hamburgers and French fries, instead of fruits and vegetables.
Skipping meals, especially breakfast, and eating unhealthy snacks contribute to
poor childhood nutrition.
Identifying nutritional problems, counseling, and making appropriate referrals are
important in the school setting.
Through the School-Based Feeding Program (SBFP), previously known as the Breakfast
Feeding Program, DepEd aims to rehabilitate at least 70% of the more than 560,000
identified severely wasted school children to normal nutritional status at the end
of 100-120 feeding days. In addition to improving the health and nutrition values
and behavior of the beneficiaries through the SBFP, DepEd also aims to increase
classroom attendance by 85-100%.
The beneficiaries of the SBFP are provided with hot meals following the developed
standardized recipes using malunggay and a 20-day cycle menu utilizing locally
produced/grown foods. By following the menu, the beneficiaries are provided
additional 300 calories per day to address nutritional deficiencies. Schools are
encouraged to develop vegetable gardens within the school grounds. Food preparation
is expected to be undertaken by the home economics/feeding teachers, homeroom
Parent-Teachers' Association on a rotation basis, or both.
Eating disorders
It is imperative that the school nurse recognizes the association between feelings
of inadequacy (e.g. low self-esteem, anger, anxiety, and depression) and unhealthy
eating practices in adolescents and young people. These self-perceptions begin
early in life; therefore, education and counseling must begin in elementary school.
Prevention should concentrate on eliminating misconceptions surrounding nutrition,
dieting, and body composition, and it should stress optimal health and personal
performance. Unfortunately, outside influences such as commercials and
advertisements make this a serious problem; adolescents and young children are
bombarded with such messages as, "You can never be too thin", and "Life will be
wonderful if you look and dress like a model".
Nurses must also be aware of eating disorders, as they frequently co-occur with
other mental disorders. Anorexia, bulimia, and binge eating have been shown to be
the three most common eating disorders. Binge eating is defined as recurrent, out-
of-control eating of large amounts of food whether a person is hungry or not.
Anorexia is a severely restricted intake of food based on an extreme fear of weight
gain. Literature has shown that anorexia is multifactorial, seen primarily in
females, and often correlated with family dysfunction or a history of sexual abuse.
Bulimia is a form of anorexia characterized by a chaotic eating pattern with
recurrent episodes of binge eating followed by purging. Health consequences of
eating disorders may include reduction of bone density, severe dehydration, tooth
decay, and potentially fatal electrolyte imbalances.
The "female athlete triad" is a syndrome consisting of eating disorders,
amenorrhea, and osteoporosis. Pressure to attain a particular body shape or weight
considered desirable in a selected sport may place the female athlete in danger of
developing this disorder. It is a complex problem with psychological and
physiological factors. It can result in menstrual irregularities, premature
osteoporosis, and decreased bone mineral density; if taken to the extreme, it can
become life threatening.
Obesity
Obesity is not considered an eating disorder, and therefore many professionals,
including nurses, overlook it. Obesity and its prevention or treatment must be of
concern to the school nurse. Statistics show that obese children and adolescents
are more likely to become obese adults.
Although many of the underlying causes of obesity are not well understood, several
contributing factors have been identified that include reduced access and
affordability of nutritious foods, decreased physical activity, and cultural and
genetic influences. Obesity is associated with the development of diabetes,
dyslipidemia, hypertension, and other disorders, such as osteoarthritis, sleep
apnea, and cholelithiasis. In addition, obesity may result in social and quality-
of-life impairments related to physical endurance, and obese children are often
labeled and ridiculed by their peers. To be successful, the treatment of obesity
must begin early and be multifaceted.
Nutritional education programs
Nutritional education is essential and must include parents, teachers, and the
child. Children need to know and understand what the food pyramid is how to make
healthy snack choices, and why balancing physical activity with food intake is
important. Obesity, dental caries, anemia, and heart disease can be reduced or
prevented with proper education and lifestyle changes. In addition, all adolescents
and school-aged children should receive counseling regarding the intake of
saturated fat.
Likewise, school officials and parents should have a consolidated effort on
screening meals served in schools and at home. Fast-food and vending machines that
are easily accessible are also recognized as a major contributing factor for poor-
quality diets of a majority of school children.
Counseling, psychological, and social services
The mental health of a child or adolescent is affected by physical, economic,
social, psychological, and environmental factors. Children, like adults, often hide
problems from themselves and from others. They may see problems as a sign of
weakness or as a lack of control. Children may also be trying to protect themselves
or someone they love and not seek help. This can have tragic results. Promotion of
mental health and reduction or removal of threats to mental health are important to
children and adolescents. Mental health is often difficult, yet essential, to
assess.
Children and teens often struggle with depression, substance abuse, conduct
disorders, self-esteem, suicide ideation, eating disorders, and under- or
overachievement.
Drugs and alcohol can enter a child's life as early as elementary school. Many
children live in single-parent households with little social or economic support.
They may not have enough to eat or a safe, warm place to sleep, yet they are
expected to come to school each day ready to learn. Services aimed at helping
children cope with these problems are often lacking or are too costly for many
families.

WARNING SIGNS OF STRESS

• Difficulty eating or sleeping
• Use of alcohol or other substances (e.g., sedatives, sleep enhancers)
• Difficulty in making decisions
• Persistent angry or hostile feelings
• Inability to concentrate
• Increased boredom
• Frequent headaches and ailments
• Inconsistent school attendance

The nurse or teacher may be the only stable adult in the child's life who will
listen without being judgmental. Therefore, one of the most important roles of the
school nurse is to act as counselor and confidante. Children may come to the school
nurse with various vague complaints, such as recurrent stomachaches, headaches, or
sexually promiscuous behavior, and the nurse must look beyond the initial complaint
to identify underlying problems.
Major depressive disorders often have their onset in adolescence and are associated
with an increased risk of suicide. Early detection and treatment may prevent
untoward consequences. The nurse and other school personnel must be on the alert
for suicide clusters that are often known to follow a successful suicide.
Adolescents often approach school nurses and other school professionals for help
before a suicide attempt. Therefore, it is important for the school nurse to be
cognizant of the warning signs associated with suicide and to recognize and refer
at-risk adolescents to appropriate mental health professionals.

TRUTHS ABOUT ADOLESCENT SUICIDES

1. Most adolescents who attempt suicide are ambivalent and torn between
wanting to die and wanting to live.
2. Any threat of suicide should be taken seriously.
3. There are usually warning signs preceding a suicide attempt, and
these may include depression, substance abuse, decreased activity, isolation, and
appetite and sleep changes.
4.
5.
Suicide is more common in adolescents than homicide.
Education concerning suicide does not lead to an increased number of attempts.
6. Females are more likely to consider or attempt suicide, and males are more
likely
7.
to complete a suicide attempt.
One suicide attempt is more likely to result in a subsequent attempt.
1. Firearms and strangulation are the predominant modalities of
completed suicides in children and adolescents.
2. Most adolescents who have attempted or completed suicide have not
been diagnosed as having a mental disorder.
3. All socioeconomic groups are affected by suicide.

Unfortunately, a large number of children are abused daily. Physical and

psychological abuse and neglect are usually a result of many interacting factors
such as poverty, social isolation, and drug and alcohol abuse. The nurse must be
alert to subtle changes in behavior or physical appearance that may point to abuse.
Physical abuse
• Has unexplained burns, bites, bruises, black eyes, or broken bones
• Shrinks at the approach of adults
• Appears frightened of parents or other relatives and cries when it is
time to go home
Sexual abuse
Has difficulty walking or sitting
Reports new onset of nightmares or bedwetting
Refuses to change into gym attire or participate in physical activities *
:
Runs away from home
Becomes pregnant or develops sexually transmitted infections (STIs)

POSSIBLE SIGNS OF ABUSE

Neglect
• Frequent absenteeism from schoolSteals food or moneyLacks adequate medical or
dental careAppears dirty or disheveled or is underweightDoes not have proper
seasonal clothing
Emotional abuse
• Exhibits changes in behavior, such as acting out or extreme passivity
Exhibits delay in either physical or emotional developmentHas attempted suicide
• Exhibits inappropriate adult or infantile behavior
OTHER COMMUNITY HEALTH SETTINGS
The school nurse may help the child learn how to solve problems, how to cope, and
how to build self-esteem. The role of the nurse often extends outside the school
campus. The family is an integral part of a child's well-being, and the nurse may
need to work closely with families to develop an appropriate health plan for a
particular child.
The Psychosocial Intervention Project is part of the effort to promote a healthy
psychosocial environment in school. This program is intended to enhance knowledge
and skills of school health personnel in providing psychosocial interventions. It
allows training of other school personnel on crisis management, especially in war-
torn and calamity-stricken areas.
Healthy school environment

The healthy school environment should consist of:

• A physical, psychological, and social environment that is
developmentally oriented and culturally appropriate, and that enables students to
achieve their potential;
• A healthy organizational culture within the school; and
• Productive interaction between the school and the community.
A problem related to this component is violence. School nurses and other school
personnel should be aware of risk factors and signs that could indicate a tendency
toward violence. Factors common in those who commit violent acts in school include
being a male, coming from a disadvantaged or poor socioeconomic background, and
having a history of abuse. Media influences that desensitize the impact of violence
are being studied more closely as another cause of increased violence among
children and adolescents. These children often have a need for instant
gratification, have easy access to guns, and may have a history of discipline
problems. Most events occurred at either the beginning or the end of the school day
or during the lunch period.
These are findings in the United States where there have been a number of shootings
and other acts of serious violence in schools in recent years. A study of violence
against children in public schools in the Philippines showed that the most common
form of violence experienced by children in all school levels is verbal abuse, that
is, being shouted at, cursed, spoken to with harsh words, ridiculed, and teased.
The study also showed that, although there are incidents of violence perpetrated by
adults on children, the more frequent victimizers are the peers of the children,
To curb violence in schools, the DepEd Order No. 40, s. 2012 on the DepEd Child
Protection Policy was issued. In the order, DepEd promotes a zero-tolerance policy
for any form of child abuse, violence, discrimination, bullying, and other forms of
child abuse
The Child Protection Policy aims to ensure that school discipline is administered
in a manner consistent with the child's human dignity. Special protection shall be
provided to children who are gravely threatened or endangered by circumstances,
which affect their normal growth and development and over which they have no
control. Circumstances that gravely threaten or endanger a child include
maltreatment by an older person and bullying or peer abuse. Special protection that
shall be provided by the school system shall take into account the primary rights
and duties of parents, legal guardians, or other individuals who exercise custody
over the child.
The plan to translate the Child Protection Policy into action includes:

• Consciousness raising; mobilization; and education of students, parents,

teachers, LGUs, and other stakeholders in addressing child abuse and bullying;
Development of a system of standard reporting of incidents of child abuse and
bullying; and
• Advocacy campaign and capability building to enable schools to:
• Apply positive and nonviolent discipline,
• Provide conflict resolution or peer mediation, including referral to
appropriate service providers, if necessary, and
• Formulate and implement guidelines for prevention and reporting of
cases of bullying.
In the Philippines, in-depth studies on this component are needed. Nurses should
initiate and participate in research that examines the complex developmental,
social, and psychological factors surrounding violence.
Health promotion for school staff
According to the National Statistical Coordination Board, schools in the
Philippines employ more than 500,000 teachers and other employees. Health promotion
programs at the work site produce beneficial results including positive effects on
blood pressure control, daily physical activity, smoking cessation, and weight
control.
Staff that participate in health promotion programs increase their health knowledge
and positively change their attitudes and behaviors relative to smoking practices,
nutrition, physical activity, stress, and emotional health. Other studies show that
health promotion programs improve morale, reduce job stress and absenteeism, and
heighten interest in teaching health-related topics to students. School nurses play
an important role in all levels of prevention through assessment, planning,
intervention, and evaluation. The school nurse can assist the faculty and staff by
giving workshops on exercise and nutrition, screening for increased blood pressure,
and establishing weight management programs.

The Department of Health and Nutrition Service offers a Teachers' Health Welfare
Enhancement Program. Through this program, school health personnel conduct health
examination and health profiling of all teachers and nonteaching personnel. Those
found at risk or manifesting signs and symptoms of illnesses are managed
accordingly.
Family and community involvement
School nurses are often asked to provide health content to families, parents, and
communities on a variety of topics, such as sexuality, STIs, HIV, communicable
diseases, and substance abuse. Health education in the community should consist of
programs that are designed to positively influence parents, staff, and others in
matters related to health. School nurses are a ready resource to the community
whenever health-related problems arise. They must step forward and volunteer their
services and expertise in a way that can positively affect their community.
Programs such as smoking cessation can include the entire community. School nurses
should be aware of the existence of these programs; they may also serve as a
consultant during implementation and as an advocate for programs to remain in
place.
Programs aimed at adolescent weight control may also need to be targeted to the
parents. Parents may not be aware of the important role they play in helping
prevent obesity in their children. School nurses can help parents develop healthy
eating habits in the home that will directly affect their families. The nurse can
also help develop physical activity programs in the community that include both the
child and the family.
Nurses should become adept at working in the public sphere by increasing their
visibility and becoming skilled in working with the media and legislators. The
media can be a useful tool in assisting school nurses with health education
advocacy.

SCHOOL NURSING PRACTICE

School nursing is a specialty unto itself. School nurses need education in specific
areas, such as growth and development, public health, mental health nursing, case
management, program management, family theory, leadership, and cultural
sensitivity, to effectively perform their roles. They must be prepared to work with
children of different ages and under highly variable circumstances. The nurse must
also keep abreast of issues affecting children and participate in research that
explores and expands the role. The school nurse's practice is relatively
independent and autonomous, even though the school nurse functions as a member of
an interdisciplinary team. For entry into school nursing, it is recommended that
nurses hold a minimum of a bachelor's degree. Some niversities are now preparing
school nurses at the master's degree level. The school nurse must be able to
identify and access professional development to maintain competency in the care of
children and adolescents.
School nurses' function in many roles including care provider, student advocate,
educator, community liaison, and case manager. Additional skills needed by school
nurses include the ability to supervise others, to practice independently, and to
delegate care.

The school setting is a perfect place to conduct research on how children adapt to
life transitions such as separation of parents, illness or death of a loved one,
illness of either themselves or a peer, domestic violence, and health-related
behaviors of the young.
Future issues affecting the school nurse
Our nation's youth are our greatest asset and hope for the future. The school
nurse's role must be constantly evolving to meet the demands of the future. Issues
that will face the school nurse of tomorrow include ethical dilemmas, use of
information and communications technology (ICT) in health care, environmental
threat brought about by climate change, threat of new and emerging infectious
diseases, and increase in antibiotic-resistant diseases. The school nurses are
required to understand and appreciate the multicultural community in which they
will practice.

OCCUPATIONAL SAFETY AND HEALTH

Article 23 of the United Nations Universal Declaration of Human Rights states,
"Everygne has the right to work, to free choice of employment, to just and
favorable conditions of work". The government, being tasked to uphold the rights of
its people, must then gather the various expertise of its members to enable itself
to promote occupational safety and health (OSH), including that of public health
nurses.
In the Philippines, the lead government agency on OSH is the Department of Labor
and Employment (DOLE). It has been given rule-making and rule-enforcement powers to
implement stipulations of the Philippine Constitution and the Philippine Labor
Code. Through its Occupational Safety and Health Center (OSHC), it produced the
National Profile on Occupational Safety and Health of the Philippines that defined
OSH as a discipline involved in, "the promotion and maintenance of the highest
degree of physical, mental and social well-being of workers in all occupations".
The union of public health nurses to the thrust of the government for OSH gave rise
to a public health nursing subspecialty called occupational health nursing. This
has been defined by the American Association of Occupational Health Nurses (AAOHN)
as the following:
The specialty practice that focuses on the promotion, prevention, and restoration
of health within the context of a safe and healthy environment. It includes the
prevention of adverse health effects from occupational and environmental hazards.
It provides for and delivers occupational and environmental health and safety
programs and services to clients.
Occupational health nursing derives its theoretical, conceptual, and factual
framework from a multidisciplinary base. Elements of this multidisciplinary base
include the following:
• Nursing science - to provide the context for health care delivery and
recognize the needs of individuals, groups, and populations within the framework of
prevention, health promotion, and illness and injury care management, including
risk assessment, risk management, and risk communication.
• Medical science - specific to treatment and management of
occupational health illness and injury, integrated with nursing health surveillance
activities.
• Occupational health sciences - including toxicology, to recognize
routes of exposure, examine relationships between chemical exposures in the
workplace and acute and latent health effects such as burns or cancer, and
understand dose-response relationships; industrial hygiene, to identify and
evaluate workplace hazards so that control mechanisms can be implemented for
exposure reduction; safety, to identify and control workplace injuries through
active safeguards and worker training and education programs about job safety; and
ergonomics, to match the job to the worker, emphasizing capabilities and minimizing
limitations.

• Epidemiology - to study health and illness trends and characteristics

of the worker population, investigate work-related illness and injury episodes, and
apply epidemiological methods to analyze and interpret risk data to determine
causal relationships and participate in epidemiological research.
• Business and economic theories, concepts, and principles - for
strategic and operational planning, for valuing quality and cost-effective
services, and for management of occupational health and safety programs.
• Social and behavioral sciences - to explore influences of various
environments (e.g. work and home, relationships, and lifestyle factors on worker
health and determine the interactions affecting worker health.
• Environmental health - to systematically examine interrelationships
between the worker and the extended environment as a basis for the development of
prevention and control strategies.
• Legal and ethical issues - to ensure compliance with regulatory
mandates and contend with ethical concerns that may arise in competitive
environments.

EVOLUTION OF OCCUPATIONAL HEALTH NURSING IN THE PHILIPPINES

Occupational health nursing in the Philippines traces its roots to Ms. Magdalena
Valenzuela of the Department of Health (DOH). She instituted the Industrial Nursing
Unit (INU) of the Philippine Nurses Association (PNA) on November 11, 1950. Ms.
Perla Gorres of the Philippine Manufacturing Company (PMC) served as the first
chairperson.
On August 19, 1964, Ms. Anita Santos of Jardine Davies was elected as first
president. She organized several continuing education programs. She also strived
for the passing of the constitution and by-laws governing the association, which
was approved on November 12, 1966. It paved way to the modification in name of the
organization to Occupational Health Nurses Association of the Philippines (OHNAP),
Inc.
On June 5-6, 1970, the first annual convention was held. In 1978, the constitution
and by-laws were amended. The latter became registered with the Securities and
Exchange Commission on September 25, 1979. As a result of the amendments, an
article in the by-laws was created to organize a Specialty Board for Certified
Occupational Health Nurses title to be conferred to its qualified affiliates.
OHNAP remains dynamically involved in the programs of DOLE, Bureau of Working
Conditions, OSHC, and DOH. Some professional organizations including The Philippine
Nurses Association & Nursing Specialty Organizations, Medical Associations
Philippine College of Occupational Medicine (PCOM), Philippine Society of
Hypertension (PSHT), Philippine Lipid & Atherosclerosis Society (PLAS) also have
active linkages with OHNAP. OHNAP is also instrumental in the "Delivery of Justice
to Disadvantaged Women"

OCCUPATIONAL HEALTH STRATEGIES: ASSESSMENT AND CONTROL OF HAZARDS IN THE WORKPLACE

The way by which the occupational health team could classify occupational health
concerns in the workplace is to identify:
1. Health hazards
2. Safety hazards
Health hazards are the elements in the work environment that can cause work-related
diseases to the worker. Safety hazards are the unsafe conditions or unsafe acts
that significantly increase the risk of a worker to be injured.
Typically, the occupational health team begins with risk anticipation and
assessment by creating a job-safety analysis. This could be done through reviews of
records, process and equipment reviews, chemical inventories, interviews, focused
group discussions, surveys, observations, and walk-through methods. In this
process, the hazards present, those who are exposed, and the degree of individual
exposures are identified. The occupational health team may categorize identified
health hazards in the workplace as follows:
1. Biological-infectious hazards: Infectious-biological agents such as
bacteria, viruses, fungi, or parasites that may be transmitted via contact with
infected clients or coworkers, and contaminated materials.
2. Chemical hazards: Various forms of chemical agents, including
medications, solutions, and gases, that interact with body tissues and cells and
are potentially toxic or irritating to body systems.
3. Enviro-mechanical hazards: Factors encountered in work environments
that cause accidents, injuries, strain, or discomfort (e.g. poor equipment or
lifting devices and slippery floors).
4. Physical hazards: Agents within work environments such as radiation,
electricity, extreme temperatures, and noise that can cause tissue trauma through
transfer of energy from these sources.
5. Psychosocial hazards: Factors and situations encountered or
associated with the job or work environment that create stress, emotional strain,
or interpersonal problems.
Having a good understanding of the nature of these hazards will allow for the
development of health promotion and prevention strategies to mitigate exposure
risk.

Typical control measures for occupational hazards can be categorized into three,
namely:
1. Administrative control refers to the development and implementation
of policies, standards, trainings, job design, and the like. For example, a
workplace where a substantial level of noise is involved may need to implement job
rotation policies to be able to assure that no worker is exposed to the threshold
limit (i.e., 85 decibels per 8-hour shift) in any given work day.
2. Engineering refers to the adoption of physical, chemical, or
technological improvements to limit the exposure of workers to the hazards of the
workplace. Noise-emitting machines can be isolated with sound-proof walls, and
dangerous machine parts can be guarded with tough materials. Toxic chemicals could
be substituted with alternatives, and their handling could be automated as well.
3. Materials provision refers to providing the workers with supplies or
supplements that can decrease their exposure or susceptibility to occupational
hazards.Personal protective equipment (PPE), immunization, and vitamin
supplementation are some examples of these. Health care and laboratory workers
could be provided with masks, eye shields, and daily doses of multivitamins to
decrease the exposure and increase the resistance to infections.
FRAMEWORK AND SCOPE OF OCCUPATIONAL HEALTH NURSING PRACTICE
As workplaces have continued to change over the past few decades, the role of the
occupational health nurse has become even more diversified and complex. Often
working as the only on-site health care professional, the occupational health nurse
collaborates with workers, employers, and other pro-fessionals to identify health
problems or needs, prioritize interventions, develop and implement programs, and
evaluate services delivered. The occupational health nurse is in a unique and
critical position to coordinate a holistic approach to the delivery of quality,
comprehensive occupational health services.
Through the changing contexts that the occupational health nurse works in, the
AAOHN's standards of occupational and environmental health nursing practice, the
amended Occupational Safety and Health Standards (OSHS) of DOLE, the code of
ethics, and continuing research guide the practice of the nurse.
AAOHN's standards of occupational and environmental health nursing practice form
the basis by which the profession describes its responsibilities and
accountabilities. For each standard, identifiable criteria are given in detail,
which can be used to evaluate practice.

In the Philippines, Rule 1965.04 of the Amended OSHS published by DOLE stipulated
the expected duties and functions to be performed by occupational health nurses as
follows:
1. Organizing and administering a health service program integrating
occupational safety in the absence of a physician; otherwise, these activities of
the nurse shall be in accordance with the physician.
2. Providing nursing care to injured or ill workers.
3. Participating in health maintenance examination. If a physician is
not available, performing work activities that are within the scope allowed by the
nursing profession, and if more extensive examinations are needed, referring the
same to a physician.
4. Participating in the maintenance of occupational health and safety
by giving suggestions in the improvement of working environment affecting the
health and well-being of the workers.
5. Maintaining a reporting and records system and, if a physician is
not available, preparing and submitting an annual medical report, using the
prescribed form to the employer as required by this standard.
The ethical framework that guides the practice of occupational health nursing is
made explicit in the AAOHN code of ethics; occupational health nurses encourage and
enable individuals to make informed decisions about health care concerns. The
occupational health nurse is a worker advocate and has the responsibility to uphold
professional standards and codes. The occupational health nurse is also responsible
to management, is usually compensated by management, and must practice within a
framework of company policies and guidelines. Ethical dilemmas arise because the
nurse is loyal to both workers and management. Issues such as screening, drug
testing, informing employees regarding hazardous exposures, and keeping the
confidentiality of health information, which is integral and central to the
practice base, often create ethical debates. As advocates for workers, occupational
health nurses foster equitable and quality health care services and safe and
healthy work environments.

AAOHN CODE OF ETHICS

• Occupational and environmental health nurses provide health, wellness, safety,
and other related services to clients with regard to human dignity and rights,
unrestricted by consideration of social or economic status, personal attributes, or
the nature of the health status.
Occupational and environmental health nurses, as licensed health care
professionals, accept obligations to society as professional and responsible
members of the community.
Occupational and environmental health nurses strive to safeguard clients' rights to
privacy by protecting confidential information and releasing information only as
required or permitted by aw.
Occupational and environmental health nurses promote collaboration with other
professionals, community agencies, and stakeholders in order to meet the health,
wellness, safety, and other related needs of the client.
Occupational and environmental health nurses maintain individual competence in
nursing practice,
based on scientific knowledge, and recognize and accept responsibility for
individual judgments and actions, while complying with appropriate laws and
regulations.

Research is an integral component of occupational and environmental health nursing

practice because it provides the basis for scientific discovery that guides and
improves practice. In 1989, research priorities in occupational health nursing were
first identified and published (Rogers, 1989). They are now being updated
periodically to serve as the scientific basis to continue to build the body of
knowledge in occupational and environmental health nursing for practice improvement
and expansion.

RESEARCH PRIORITIES IN OCCUPATIONAL NURSING

1. Effectiveness of primary health care delivery at the worksite.
2
3.
Effectiveness of health promotion nursing intervention strategies.
Strategies that minimize work-related adverse health outcomes (e.g., respiratory
disease).
4
Health effects resulting from chemical exposure in the workplace.
1. Occupational hazards of health care workers (e.g., latex allergy,
blood-borne pathogens).
2. Factors that influence worker rehabilitation and return to work.
3. Effectiveness of ergonomic strategies to reduce worker injury and
illness.
20 〇）
The nature and effects of stress and workplace stressors on worker health.
Health effects resulting from the interaction between aging and workplace hazards.
1. Evaluation of critical pathways to effectively improve worker's
health and safety and to enhance maximum recovery and safe return to work.
2. Evaluation of intervention strategies to improve worker health and
safety.
3. Strategies for increasing compliance with or motivating workers to
use personal protective equipment.
4. Emergency/pandemic preparedness in the workplace.
5. Impact of occupational health nursing interventions on worker's
compensation claims.

LEVELS OF PREVENTIVE CARE AND OCCUPATIONAL HEALTH NURSING

Like the practice of all community health professionals, the occupational health
nurse's practice is based on the concept of prevention. Promotion, protection,
maintenance, and restoration of worker's health are priority goals set forth in the
definition of occupational health nursing.
As occupational health nurses usually practice autonomously in their role as health
care providers, the occupational health nurse's activities in primary, secondary,
and tertiary prevention strategies are expected to assume an even more important
role in the prevention and treatment of illness, injury, and chronic disease in the
future.
For example, a study by Rogers and Livsey examined the scope of independent and
interdependent practice by occupational health nurses related to these activities
and found that 71% of occupational health nurses had overall responsibility for
program management, and the majority performed surveillance, screening, and
prevention functions as independent practice. Physician supervision for any of
these activities ranged from only 0% to 8% in reporting. The results of this study
validate the independent functioning in scope of occupational health nursing
practice related to surveillance, screening, and prevention activities while
recognizing the contributions all providers make to a healthy workforce.
Primary prevention
In the area of primary prevention, the occupational health nurse is involved in
both health promotion and disease prevention. O'Donnell describes health promotion
as the following:
The art and science of helping people discover the synergies between their core
passions and optimal health, enhancing their motivation to strive for optimal
health, and supporting them in changing lifestyle to move toward a state of optimal
health. Optimal health is a dynamic balance of physical, emotional, social,
spiritual and intellectual health. Lifestyle change can be facilitated through a
combination of learning experiences that enhance awareness, increase motivation,
and build skills and most importantly, through creating opportunities that open
access to environments that make positive health practices the easiest choice.
Disease prevention begins with recognition of a health risk, a disease, or an
environmental hazard and is followed by measures to protect as many people as
possible from harmful consequences of that risk.
The occupational health nurse comes in contact with numerous employees daily for
many reasons (e.g. assessment and treatment of episodic illness or injury and
health surveillance); therefore, this is an important method of promoting health.
The phrase "seize the moment" aptly describes the opportunity that exists with
every employee encounter.

Occupational health nurses plan, develop, implement and evaluate aggregate-focused

intervention strategies. The occupational health nurse plans and implements
programs such as weight and cholesterol reduction, acquired immunodeficiency
syndrome (AIDS) awareness, ergonomics training, and smoking cessation. Performing
"walk-through" surveys in the workplace on a regular basis, recognizing potential
and existing hazards, and maintaining communications with safety and industrial
hygiene resources to prevent illness and injury from occurring will continue to be
the critical jobs of the occupational health nurse.
For overall health promotion, the nurse may plan, implement, and evaluate a health
fair, which is a multifaceted health promotion strategy that usually includes a
number of community health resources to provide expertise on a wide range of health
issues and community services. As part of an overall health and wellness strategy,
the occupational health nurse may negotiate with the employer for an on-site
fitness center or area with fitness equipment; if cost or space is prohibitive,
then the employer may choose to partially subsidize membership at a local fitness
center.
Types of nonoccupational programs included in the area of primary prevention are
cardiovascular health, cancer awareness, personal safety, immunization, prenatal
and postpartum health, accident prevention, retirement health, stress management,
and relaxation techniques. Occupational health programs could include topics such
as emergency response, first aid and cardiopulmonary resuscitation (CPR) training,
right-to-know training, immunization programs for international business travelers,
prevention of back injury through knowledge of proper lifting techniques,
ergonomics, and other programs targeted to the specific hazards identified in the
workplace.
Women's health and safety issues such as maternal-child health, reproductive
health, breast cancer education and early detection, stress management, and work-
home balance issues will achieve heightened significance as more women enter the
workforce. Thirty percent of women currently in the workforce are between ages 16
and 44 years, and each year, approximately 1 million infants are born to these
women. Interest in workplace safety and the relationship to reproductive outcomes
continues to grow as women of childbearing age enter the workplace in greater
proportions than ever before.
The occupational health nurse can play a key role in the development and delivery
of prenatal, postpartum, and childhood programs in the workplace. Of primary
importance will be the ability to serve as a change agent to initiate needed
programs in the work environment. Employers must be educated regarding strategies
not only to reduce health care costs for women and infants but also to improve the
work environment for mothers. Women who believe their employers are interested in
the well-being of themselves and their families are more apt to be productive and
satisfied employees. The occupational health nurse can play a critical role in the
shaping of supportive policies and practices to accommodate the needs of families,
including flexible working hours, parental leave, and on-site child care.
The occupational health nurse may face challenges in developing programs that are
culturally and linguistically appropriate. The occupational health nurse may be in
an advocacy role to negotiate with the employer for changes in the work environment
that will reduce or eliminate existing or potential occupational exposure to risk
factors.
00:00:29
Secondary prevention
Secondary prevention strategies are aimed at early diagnosis, early treatment
interventions, and attempts to limit disability. The focus at this level of
prevention is on identification of health needs, health problems, and employees at
risk.
As with primary prevention, the occupational health nurse uses a number of
different secondary prevention strategies. By providing direct care for episodic
illness and injury, the occupational health nurse is afforded the opportunity to
conduct assessments and provide treatment and referrals for a variety of physical
and psychological conditions. The occupational health nurse can offer health
screenings, which are designed for early detection of disease, at the worksite with
relative ease and at minimal cost. Screenings may focus on vision, cancer,
cholesterol, hypertension, diabetes, tuberculosis, and pulmonary function. Other
types of screening such as mammography may be contracted with a partner who uses
mobile equipment.
Secondary prevention efforts provided by the occupational health nurse include
preplacement, periodic, and job transfer evaluations to ensure that the worker is
being placed or is continuing to work in a job that is safe for that worker. The
preplacement evaluation is performed before the worker begins employment in a new
company or is placed in a different job. The evaluation is a baseline examination
that consists of a medical history, an occupational health history, and a physical
assessment that should target the type of work that the employee will be
performing. For example, if the employee is going to be lifting materials in a
warehouse, special attention should be given to any history of musculoskeletal
problems. Strength tests and range of motion examinations should be performed for
all muscle groups.
The preplacement examination may also include medical tests to determine specific
organ functions that may be affected by exposure to existing agents in the
employee's workplace. For example, if the employee is working with a chemical that
is a known liver toxin, baseline liver function tests may be appropriate to
determine the current health status of the employee's liver and its ability to
handle this specific chemical exposure.
Periodic medical assessments for individuals exposed to substances or irritants
such as lead, asbestos, noise, or various chemicals are done at regular intervals
(e.g. annual and biannual) based on specific protocols. Examination of individuals
transferring to other jobs is critical in order to find the changes in health that
may have occurred while the employee was working in a specific area or with a
specific process.

Activities must continue to focus on prevention and early detection by increasing

awareness of the incidence of commonly occurring health conditions such as breast
cancer and providing accessible and affordable screening programs. The occupational
health nurse is in an excellent position to play a key role in reducing morbidity
and mortality associated with these health concerns. Increasingly, the occupational
health nurse will be expected to document the return on investment for these and
other related activities in the workplace.
Tertiary prevention
On a tertiary level, the occupational health nurse plays a key role in the
rehabilitation and restoration of the worker to an optimal level of functioning
based on the limitations imposed by the disability or illness. Strategies include
case management, negotiation of workplace accommodations, and counseling and
support for workers who will continue to be affected by chronic disease.
Knowledge of the workplace, ability to negotiate with the employer for appropriate
accommodations, early intervention, and comprehensive case management skills have
been and will continue to be essential to the disabled employee's successful return
to work. The process of returning an individual to work begins with the onset of
injury or illness. Regardless of whether this involves an occupational or a
nonoccupational condition, the occupational health nurse is the center of case
management.
The nurse works closely with the primary care provider to monitor the progress of
the ill or injured worker and to identify and eliminate potential barriers in the
return-to-work process. The nurse has a comprehensive understanding of the
workplace and of the physical requirements necessary for the employee to work. The
physical demands analysis is a useful tool in objectively assessing the physical
demands of any job. Once the assessment is completed, the occupational health nurse
can relay this information to community health professionals caring for the
employee.
For workers needing special accommodations, the occupational health nurse can
negotiate and facilitate the ones that are appropriate to the employee's health
limitations. The nurse is often the driving force behind the employer's duty of
creating a transitional duty pool. The goal of this program is to provide temporary
work that is less physically demanding in nature than the employee's regular work.
This facilitates the employee's return to the workplace earlier than be required to
wait until full strength is regained.
The occupational health nurse can monitor and support the health of employees
returning to work who continue to experience adverse health effects of chronic
disease. For example, the employee who is returning to work after sustaining a
myocardial infarction may have blood pressure monitored on a routine basis.
Counseling regarding adjustment to normal work life and support for behavior
modification (e.g. smoking cessation) also may be provided.

Moreover, because older workers are more prone to chronic disease, the occupational
health nurse can implement and monitor treatment protocols and assist workers to
live and work at their optimum comfort level while managing their disease.
Responsibilities for the care of elderly parents or significant others will
influence the balance of work and home for older workers. The occupational health
nurse's role as counselor, referral resource for workers, and consultant to
management can influence future beneficial changes.
Although the occupational health nurse is often independent, and most of the time
is the only health care provider in an organization, he or she usually works with
other occupational health and safety specialists who may or may not be employed by
the company. They are usually present on a consultation or visiting scheme. Some of
these experts are from different professions:
• Toxicologist - studies and identifies the toxic properties of agents
used in work which the workers might be exposed to.
• Industrial hygienist - identifies, evaluates, and controls toxic
exposures and hazards in the work environment.
• Safety specialist - prevents occupational injuries and evaluates
safety practices and protocols in the workplace.
• Ergonomist - design specialist who helps promote healthy interface of
humans and their tools.
 • Epidemiologist - conducts research studies on the patterns of disease
and history of occupational diseases and injuries in the workforce.

SKILLS AND COMPETENCIES OF THE OCCUPATIONAL HEALTH NURSE

Although clinical and emergency care remains an important tenet of occupational
health nursing, the current and future practice must focus on a proactive approach
with the goal of preventing illness and injury and promoting health. The
occupational health nurse must then possess competencies necessary to recognize and
evaluate potential and existing health hazards in the workplace. Management and
budgeting skills and knowledge of legal and regulatory requirements, toxicology,
ergonomics, epidemiology, environmental health, safety, counseling, and health
promotion and education are essential to meet the present and future demands of the
occupational health nursing practice.
Competencies in occupational and environmental health nursing have been delineated
in nine categories by AAOHN. Each competency delineates comprehensive performance
criteria at the competent, proficient, and expert levels. Each level is described,
followed by an example of occupational health nursing practice at that level.

Competency categories in occupational and environmental health nursing

1. Clinical and primary care
2. Case management
3. Workforce, workplace, and environmental issues
4. Regulatory and legislative
5. Management
6. Health promotion and disease prevention
7. Occupational and environmental health and safety education and
training
8. Research9. Professionalism

Competent
At the "competent" level of practice, nurses gain confidence and their perception
of the role is one of mastery and an ability to cope with specific situations.
There is less of a need to rely on the judgments of peers and other professionals.
Work habits tend to emphasize consistency rather than routinely tailoring care to
encompass individual differences.
Occupational and environmental health nursing example: The competent nurse is an
occupational and environmental health nurse with sufficient experience to recognize
a range of practice issues and function comfortably in roles such as clinician,
occupational health services coordinator, and case manager. The competent nurse
follows company procedures and relies on assessment checklists and clinical
protocols to provide treatment.
Proficient
The "proficient" nurse has an increased ability to perceive client situations as a
whole on the basis of past experiences, focusing on the relevant aspects of the
situation.
The nurse is able to predict the events to expect in a particular situation and can
recognize that protocols sometimes must be altered to meet the needs of the client.
Occupational and environmental health nursing example: A proficient occupational
and environmental health nurse is able to quickly obtain the information needed for
accurate assessment and move rapidly to the critical aspects of the problem.
Structured goals are replaced by priority setting in response to the situation.
This nurse usually possesses sophisticated clinical or managerial skills in the
occupational health setting.
Expert
The "expert" nurse has extensive experience and a broad knowledge base and is able
to grasp a situation quickly and initiate appropriate action. The nurse has a sense
of salience grounded in practice, guiding actions and priorities.
Occupational and environmental health nursing example: Occupational and
environmental health nurses at the expert level are capable of providing leadership
in developing occupational and environmental health policy within an organization,
functioning in upper executive or management roles, serving as consultants to
business and government, and designing and conducting significant research in the
field.

Examples of skills and competencies for occupational health nursing

As described, numerous skills and competencies are necessary for occupational
health nursing practice. Examples of some of these are outlined here, according to
the nine defined areas of competence.
Clinical and primary care
• Applying the nursing process in the delivery of care
• Providing first aid and primary care according to treatment protocols
• Conducting a physical assessment
• Taking an occupational and environmental health history
• Diagnosing and treating
• Being knowledgeable about immunization protocols
• Identifying employees' emotional needs and providing support and
counseling
• Using a multidisciplinary problem-solving approach to occupational
health illness and injury
• Maintaining records
• Clinical testing and monitoring
• Responding to medical emergencies
• Being knowledgeable about trends in health-related issues
Case management
• Identifying the need for case management services
• Conducting case management assessments using a multidisciplinary
framework
• Developing case management care plans
• Evaluating resources and vendors for case management
• Implementing early return-to-work programs
• Monitoring and evaluating outcomes

• Developing policies and programs for case management

• Analyzing trends for case management services
• Designing disability management systems
• Conducting research based on case management outcomes
Workforce, workplace, and environmental issues
• Having knowledge of worksite operations, manufacturing processes, and
job tasks
• Identifying and monitoring potential and existing workplace exposures
• Influencing appropriate and targeted recommendations for control of
workplace hazards
• Having knowledge of toxicological, epidemiological, and ergonomic
principles
• Understanding appropriate engineering and administrative controls and
PPE specific to preventing workplace health hazard exposures
• Understanding roles and collaboration with other cross-functional
groups as an integral part of a core multidisciplinary team
• Performing risk assessments
• Managing health surveillance programs
Legal and ethical responsibilities
• Being knowledgeable of state nursing practice acts and ability to
practice occupational health nursing within state guidelines
• Being knowledgeable of federal, state, and municipal regulations
pertaining to occupational and environmental health
• Being knowledgeable of the associated guidelines, and other relevant
occupational and environmental health laws
• Being knowledgeable of all aspects of medical record-keeping
practices in compliance with nursing practice, state law, and standards of practice
• Being knowledgeable of current legal trends related to negligence and
malpractice cases in professional nursing and in the occupational health setting
• Being knowledgeable of confidentiality parameters
• Influencing regulatory and legal processes related to occupational
and environmental health
Management and administration
• Managing budgets
•
• Hiring staff and management of staff performance
• Fostering professional development plans
• Developing program goals and objectives
• Developing business plans through knowledge of internal and external
resources
• Providing comprehensive on-site services and programs
• Knowing needs of business and employees
• Writing reports
• Performing audits and quality assurance
• Handling workers' compensation and disability
• Performing cost-benefit analyses, cost-effectiveness analyses, and
outcomes monitoring
• Allocating appropriate staff resources
• Providing leadership in health-related issues
• Negotiating
• Facilitating work accommodations and return-to-work processes
• Coordinating medical response activities and site disaster planning
• Being a resource expert on health issues for employees and management
• Participating in strategic operations planning
Health promotion and disease prevention
• Conducting needs assessments
• Recognizing cultural differences and their relationship with health
issues
• Using effective communication styles to match diverse employee and
management audiences
• Making effective presentations
• Planning, developing, implementing, and evaluating health programs
designed to meet the needs of specific employee groups or organizations
• Evaluating health promotion outcomes
• Applying adult learning theory and principles to health education
programs
• Integrating all levels of prevention into company culture

Occupational and environmental health and safety education

• Creating effective professional and technical support networks both
functionally and cross-functionally
• Developing and implementing training programs for workers and
professionals
Research
• Identifying researchable problems
• Systematically collecting, analyzing, and interpreting data from
different sources
• Recognizing trends in health outcomes by department, work area, or
work process
• Planning, developing, and conducting research
• Developing and testing models and theories relative to occupational
and environmental health nursing practice
Professionalism
• Engaging in a lifelong learning plan
• Maintaining currency in practice
 • Acting as a professional role model for students and colleagues
• Advancing the specialty through knowledge and science

IMPACT OF LEGISLATION ON OCCUPATIONAL HEALTH

Being a staunch advocate in the promotion of occupational health and safety, DOLE
has consistently implemented and enforced policies and practices to meet its goals.
It possesses legislative and rule-making powers with regard to the following laws
and standards:
• Presidential Decree PD) 442 Philippine Labor Code on prevention and
compensation.
• The Administrative Code on Enforcement of Safety and Health Standards
• The Occupational Safety and Health Standards (OSHS)
• Executive Order 307 creating the Occupational Safety and Health
Center (OSHC) under the Employees Compensation Commission
• PD 626 Employees Compensation and State Insurance Fund
• Hazard-specific laws regarding anti-sexual harassment
• R.A. 9165 Comprehensive Drugs Act of 2002
• R.A. 8504 National HIV/AIDS Law of 1998
• Laws and regulations under jurisdiction of government organizations
other than DOLE
• DOH: Sanitation Code
• Department of Agriculture (DA): Fertilizer and Pesticides Act
• Department of Environment and Natural Resources (DENR): R.A. 6969,
Ratification of Stockholm Convention, Chemical Control
• R.A. 9185 Comprehensive Dangerous Drugs Act of 2002
• R.A. 6541 National Building Code of the Philippines
• R.A. 6969 Toxic Substances Act
• R.A. 9231 Special Protection of Children against Child Abuse,
Exploitation and Discrimination Act
P.D. 442: The Philippine Labor Code
In one of its objectives, The Philippine Labor code, P.D. 442 aims to protect every
citizen desiring to work locally or overseas by securing the best possible terms
and conditions of employment. Under Article 6 of the same code, all rights and
benefits granted to workers shall, except as may otherwise be provided, apply alike
to all workers, whether agricultural or nonagricultural. This also includes the
fundamental right to health and safety in the workplace. The following are relevant
to the practice of occupational health nurses.

Working conditions and rest periods

7
As hours of work and compensation correspondingly affect a worker's health, well-
defined parameters have been set. It is clearly defined in Article 83 that the
normal hours of work of any employee shall not exceed 8 hours a day. In the case of
health personnel in cities and municipalities with a population of at least one
million (1,000,000) or in hospitals and clinics with a bed capacity of at least
100, they shall hold regular office hours for 8 hours a day, for 5 days a week,
exclusive of time for meals, except when the demands of the service require work
for 6 days or 48 hours, in which case, they shall be entitled to an additional
compensation of at least 30% of their regular wage for work on the sixth day.
Hours of work, mentioned under Article 84, shall include (a) all time during which
an employee is required to be on duty or to be at a prescribed workplace; and (b)
all time during which an employee is suffered or permitted to work. This includes
rest periods of short duration during working hours. The employer, as stated in
Article 85, shall also provide regular meal periods of no less than 60 minutes.
Medical, dental, and occupational safety
All employers are responsible for the safety of their workers. Necessary health
support must be made available and provided to the workers accordingly. This is to
ensure prompt recognition and response at all times.
Article 156 requires that every employer shall keep in the establishment such
first-aid medicines and equipment as the nature and conditions of work may require,
in accordance with such regulations as DOLE shall prescribe. Training of a
sufficient number of employees in first-aid treatment is also the responsibility of
the employer.
It shall be the duty of every employer, according to Article 157, to furnish
employees in any locality with free medical and dental attendance and facilities
consisting of:
• The services of a full-time registered nurse when the number of
employees exceeds 50 but not more than 200 except when the employer does not
maintain hazardous workplaces, in which case, the services of a graduate first-
aider shall be provided for the protection of workers, where no registered nurse is
available.
• The services of a full-time registered nurse, a part-time physician
and dentist, and an emergency clinic when the number of employees exceed 200 but
not more than 300.
• The services of a full-time physician, dentist, and full-time
registered nurse as well as a dental clinic and an in infirmary or emergency
hospital with one bed capacity for every 100 employees when the number of employees
exceeds 300.
• In cases of hazardous workplaces, no employer shall engage the services
of a physician or a dentist who cannot stay in the premises of the establishment
for at least 2 hours, in the case of those engaged on part-time basis, and not less
than 8 hours, in the case of those employed on full-time basis. Where the
undertaking is nonhazardous in nature, the physician and dentist may be engaged on
retainer basis, subject to such regulations as the Secretary of Labor and
Employment may prescribe to ensure immediate availability of medical and dental
treatment and attendance in case of emergency.
• If a hospital or dental clinic is accessible from the employer's
establishment, the requirement for an emergency hospital or dental clinic shall not
be applicable, and it is mentioned in Article 158. However, the employer should
also made arrangement for the reservation of the necessary beds and dental
facilities for the use of employees.
• Article 159 requires physicians engaged by an employer to also
implement a comprehensive occupational health program for the benefits of the
employees. Pursuant to Article 160, physicians, dentists, and nurses employed by
employers shall have the necessary training in industrial medicine and occupational
safety and health. The Secretary of Labor and Employment, in consultation with
industrial, medical, and occupational safety and health associations, shall
establish the qualifications, criteria, and conditions of employment of such health
personnel. It shall be the duty of any employer, according to Article 161, to
provide all the necessary assistance to ensure the adequate and immediate medical
and dental attendance and treatment to an injured or sick employee in case of an
emergency.
• Safety and health standards, research, training programs,
administration of safety health, and laws are carefully looked into by DOLE to
ensure occupational health and safety.
• Compensation
• According to Article 86 of this code, a night shift differential of not
less than 10% of a worker's regular wage must be paid for every hour of work done
between 10 o'clock in the evening and 6 o'clock in the morning. Overtime work, on
the other hand, has a different rate. Article 87 requires employers to give an
additional of at least 25% percent of a worker's regular wage for every hour worked
beyond the regular 8 hours. Furthermore, if work greater than 8 hours has been
performed during a holiday or rest day, a worker must be paid an additional
compensation equivalent to the rate of the first 8 hours on a holiday or rest day
plus at least 30% of regular wage. However, Article 88 emphasizes that undertime
may not be offset by an overtime on any other day.

It may also be possible that an employer may require any employee to perform
emergency overtime work, as termed in Article 89. The conditions remain limited to
the following:
• When the country is at war or local emergency has been declared by
the National Assembly or the Chief Executive.
• When it is necessary to prevent loss of life or property in case of
imminent danger to public safety due to an actual or impending emergency in the
locality caused by serious accidents, fire, flood, typhoon. earthquake, epidemic,
or other disaster or calamity.
• When there is urgent work to be performed on machines,
installations, or equipment, in order to avoid serious loss or damage to the
employer or some other cause of similar nature.
• When the work is necessary to prevent loss or damage to perishable
goods.
• Where the completion or continuation of the work started before the
eighth hour is necessary to prevent serious obstruction or prejudice to the
business or operations of the employer.
Employees are entitled to a weekly rest day as well. According to Article 91, it
must not be less than 24 consecutive hours after every 6 consecutive normal work
days.
It is the employer who determines and schedules the weekly rest day of the
employees. An exception, however, is that the employer shall respect the preference
of employees as to their weekly rest day when such preference is based on religious
grounds. Still, an employer may require work on a rest day, in accordance with
Article 92, if any of the following happens:
• In case of actual or impending emergencies caused by serious
accident, fire, flood, typhoon, earthquake, epidemic or other disaster or calamity
to prevent loss of life and property, or imminent danger to public safety.
• In cases of urgent work to be performed on the machinery, equipment,
or installation, to avoid serious loss which the employer would otherwise suffer.
• In the event of abnormal pressure of work due to special
circumstances, where the employer cannot ordinarily be expected to resort to other
measures.
• To prevent loss or damage to perishable goods.
• Where the nature of the work requires continuous operations, and the
stoppage of work may result in irreparable injury or loss to the employer.
• Under other circumstances analogous or similar to the foregoing as
determined by the Secretary of Labor and Employment.
If work, on the other hand, is made or permitted to be done on a scheduled rest day
or holiday work, Article 93 mandates that a worker must be paid an additional
compensation of at least 30% of his or her regular wage. An employee shall be
entitled to such additional compensation for work performed on Sunday only when it
has been established as a rest day. If the employee has no regular workdays and no
regular rest days, an additional compensation of at least 30% of the regular wage
must be given for work performed on Sundays and holidays. During special holidays,
an additional 30% of the regular wage must be given. And in the event that the
holiday work falls on the scheduled rest day, the worker is entitled to an
additional compensation of at least 50% of the regular wage.
Working conditions for special groups of employees
Women, especially pregnant women, and minors alike are vulnerable members of the
population. General knowledge regarding specific work matters may help occupational
health workers uphold and protect their health.
As declared in Article 133 of this code, for a pregnant woman employed, who
rendered an aggregate service of at least 6 months for the last 12 months, the
employer shall grant her leave of at least 2 weeks prior to the expected date of
delivery and another 4 weeks after normal delivery or abortion. She must receive
her full pay based on her regular or average weekly wages. When she applies for the
maternity leave, she may be required by the employer to produce a medical
certificate stating that the delivery will probably take place within two weeks.
The maternity leave shall be extended without pay on account of illness medically
certified to arise out of the pregnancy, delivery, abortion, or miscarriage, which
renders the woman unfit for work, unless she has earned unused leave credits from
which such extended leave may be charged. Also, the employer shall only pay the
maternity leave for the first four deliveries by the woman employee.
According to Article 134, establishments that are required by law to maintain a
clinic or infirmary must provide free family planning services. The services shall
include, but not be limited to, the application or use of contraceptive pills and
intrauterine devices. DOLE, in coordination with other agencies of the government
engaged in the promotion of family planning, shall develop and prescribe incentive
bonus schemes to encourage family planning among female workers in any
establishment or enterprise.
No child below 15 years of age shall be employed, except when the child works under
the sole responsibility of parents or guardian, and employment does not in any way
interfere with the schooling. Any person between 15 and 18 years of age may be
employed for such number of hours and such periods of day as determined by the
Secretary of Labor and Employment in appropriate regulations. A person below 18
years of age shall in no case be allowed to undertake employment that is hazardous
or deleterious in nature as determined by the Secretary of Labor and Employment.

TRENDS AND ISSUES CONCERNING OCCUPATIONAL HEALTH

Occupational accidents, injuries, and diseases have long been causes of concern at
all levels due to the human, social, and economic costs they entail. To prevent
control, reduce, or eliminate these hazards and risks, measures and strategies have
been developed and are continuously applied to be at pace with the changing
technology and economy. Still, occupational accidents and diseases remain common,
and the burden they come with continues to be significant.
The International Labour Office (ILO), a global lead agency on occupational safety
and health, estimated that 2.2 million work-related deaths occur annually. The
number shows an increase of 10% over the past 5 years. The overall annual rate of
occupational accidents, fatal and nonfatal, is estimated at 270 million. On the
other hand, nonfatal work-related diseases are approximated to reach 160 million
yearly, gived an estimated global workforce of 2.8 billion. Exposure of workers to
hazardous substances, processes, and working conditions tends to increase the risk
of workers to develop work-related diseases such as cancers, cardiovascular
diseases, nervous disorders, renal and chronic respiratory diseases,
pneumoconiosis, and asthma. The highest proportions of these occupational
fatalities are secondary to work-related cancers, circulatory and cerebrovascular
diseases, some communicable diseases, and accidental occupational injuries.
According to ILO, there are significant variations in occupational safety and
health performance among countries, economic sectors, and sizes of enterprise. It
is notable that recent data from the ILO and the World Health Organization (WHO)
indicate that overall occupational accident and disease are slowly declining in
most industrialized countries, but they are level or increasing in developing and
industrializing countries. Worldwide, the highest rates of occupational deaths
occur in agriculture, forestry, mining, and construction, as reflected in
statistics. Certain occupations and sectors, such as meat packing and mining, have
high rates of work-related diseases, including fatal occupational diseases.
Furthermore, small workplaces (those with fewer than 50 employees) have worse
safety records than large ones (those with more than 200 employees). The rate of
fatal and serious injuries in small workplaces is double that of the large ones.
It is also found that concerns of some groups are commonly overlooked, thus,
placing them at higher risk:
• The gender division of labor poses an impact on women's safety and health in the
workplace. Usually, safety standards are based on the model of a male worker, since
86% of health and safety inspectors are male. Tasks and equipment are designed for
male body size and shape, which can lead to discrimination in certain areas.
• Some countries do not include home-based workers under safety and
health legislation.
• Part-time workers may also suffer from not being covered by safety
and health provisions.
• Many economically active migrants have been exposed to working
conditions that are abusive and exploitative. Language barriers, exposure to new
technology, family disruption, poor access to health care, stress, and violence are
some of the specific problems they face that can make them particularly vulnerable
to safety and health risks at the workplace.
• Workers in the informal economy are much more likely to be exposed to
poor working environments, low safety and health standards, and environmental
hazards, and to suffer poor health or injury as a result than formal workers. This
is because informal workers have little or no knowledge of the risks they face and
how to avoid them.
• Many children are involved in hazardous work.
• The ageing of the global workforce raises many concerns, including
some relating to occupational safety and health.
• The accident rate of contract workers is, on average, twice that of
permanent workers. This is seemingly due to the belief of many employers that
subcontracting certain tasks can subcontract their safety responsibilities.
• Drivers are particularly at risk. Road accidents usually involve
people in the course of their work, but the deaths are treated as road traffic
accidents rather than work-related fatalities.
In the Philippines, the majority of workers are young males working in smaller
places in agriculture or in the services sector. In 2006, a total employment of
33.0 million workers was distributed among agriculture, fisheries, and forestry
(11.8 million); industry (4.9 million); and services (15.7 million). Employed male
and female workers account for 20.0 and 12.4 million, respectively. A total of 22.6
million employed workers are between ages 15 and 44, while 9.8 million workers are
between ages 45 and 65.
In the supposed total employment of 32.4 million workers in 2006, only about 2.2
million workers, or less than 10% of total employment, in medium and large
enterprises received effective OSH protection and services. Better OSH assistances
lead to increased efficiency and productivity gains in both medium and large
corporations, such as partners and beneficiaries of the Zero Accident Program and
the awardees of the Gawad Kaligtasan Kalusugan.
About 90% of the Philippine workforce does not experience favorable working
conditions. According to studies by OSHC in 2006, many risks and hazards are
present in microfirms and the informal sector in metal and woodworking, garment and
footwear, small-scale mining, and fishing. These include exposure to chemicals and
substandard equipment and tools, even the unhygienic working environment itself.

Although there are no definite answers as to why OSH protection remains limited to
a relatively small labor force in the formal sector, there are some reasons worth
mentioning:
• It has been long envisioned that informal sectors would soon
disappear with rapid growth and development, but these hopes are yet to be
fulfilled. More than that of not being able to convert informal to formal sectors,
the number of the former is even growing everywhere.
• Social concerns have been overlooked during the emergence of
globalization.
• The gap between the protected and the unprotected has been widening.
Formal sector workers are better protected and served through legislation and
enforcement, company clinics, safety and health committees, Medicare, PPE,
compensation, or rehabilitation.
• Instead of the employers and workers in the informal sector rallying
for effective OSH legislation, enforcement, and promotional drives, they are more
preoccupied with making ends meet. It leaves them unaware about OSH hazards and
risks.
Within the context of these evolving organizational trends, key characteristics
include a focus on a shared vision, strategy, and long-term objectives within an
environment composed of individuals working in teams. In contrast to the past,
occupational health nurses have opportunities to work on cross-functional teams to
shape decisions in areas such as benefits, research, safety, and legal matters.
Particularly, occupational health nurses have opportunities to positively affect
the transformation of the health care delivery system, establish policies within
the managed care environment and within corporations, and assume leadership
positions on legislative staff and in governmental agencies.
Corporations have become driving forces in developing alternative approaches to
health care. Rapidly increasing health care costs have spawned a number of
alternative approaches to providing health care, such as preferred provider
organizations.
It is important that the occupational health nurse remains informed about the
various health care options available to the workforce as rapid changes occur
regarding corporate benefits. This is of particular importance when considering the
referral of an employee to a health resource. Participation in one of the managed
care plans requires that treatment takes place according to the organization's
guidelines and within its health service delivery system. Managed care plans have
nearly replaced traditional indemnity plans. Access to care is closely managed and
often limited. As this trend continues, the role of the occupational health nurse
will take on an added importance. The nurse must be prepared to accept increasing
responsibilities as a primary care provider, as well as tertiary care coordinator
or a case manager.
As businesses seek ways to maximize the value of money spent on health care
services, occupational health nurses and other health professionals face both an
opportunity and a threat. The opportunity comes from being able to demonstrate that
cost-effective, quality health programs do improve the health of employees and
their dependents, positively influencing their company's attempts to control rising
health care costs. The threat is that if health professionals cannot prove cost-
effectiveness and value to companies, their functions may be eliminated or replaced
by contract services.
Ethical insights: Confidentiality of employee health information
Occupational health nurses sometimes experience ethical dilemmas because of dual
responsibility to both their employer and employees. In dealing with health
information, the employee has a right to privacy and should "be protected from
unauthorized and inappropriate disclosure of personal information". Exceptions can,
and in some situations must be made. These include:
1. Life-threatening emergencies.
2. Authorization by the employee to release information to others (e.g.
insurance company, health care provider).
3. Workers' compensation information.
4. Compliance with government laws and regulations.
The AAOHN identifies three "levels of confidentiality" of health information. Level
I relates to information required by law (e.g. data on occupational illness and
injuries, exposure data, and information derived from special examinations [i.e.,
tests given to food handlers]). Level Il covers information that will assist in
management of human resources (e.g. information obtained from job placement and
other health examinations to determine "workability status" of the employee).
Finally, Level Ill focuses on "personal health information". This includes non-job-
related health problems or health counseling.
Disclosure of Levels I and Il information to management should be allowed only on a
need-to-know basis, generally with reference to workability status and regulatory
compliance. Disclosure of Level III information to management and regulatory
agencies should only be allowed as required by law. Finally, disclosure of Level
Ill information to health insurance providers should be made only with appropriate
written authorization of the employee.
Meeting the needs of employees in smaller businesses is another important practice
priority. The integration of occupational health and safety principles into the
curricula of schools of nursing, engineering, and management is critical. Community
health nurses may assume occupational health nursing roles; therefore, community
health nurses must be knowledgeable about the specialty area of occupational health
nursing. Municipalities, smaller companies, visiting nurse associations, and home
care agencies may provide opportunities for community health nurses to be involved
in screening programs, health education activities, workplace hazard evaluations,
and other occupational health-related activities.

The occupational health nurse's strengths are embedded in assessing, planning,

implementing, and evaluating health programs for populations, care plans for
individuals, and health education activities for worker aggregates. Often, a lack
of understanding or misconceptions about the role of the occupational health nurse
have fostered the invisibility of the nurse, both within the nursing profession
itself and within the business environment, thereby exacerbating the difficulties
faced in being the sole guardian of health for workers in many companies.
Empowered, well-trained, educated occupational and environmental health nurses can
help bring about crucial changes in the areas of primary, secondary, and tertiary
prevention in occupational health.
In response to societal changes and historical events, the practice of occupational
health nursing has changed dramatically, demanding a sophisticated knowledge base
and problem-solving skills that are empirically grounded and multidisciplinary in
nature. The roles and responsibilities of the occupational health nurse must be
clearly articulated to lay people, managers, workers, union representatives, and
colleagues in occupational health, nursing, and medicine to ensure that
occupational health nursing can continue to positively affect workers' health,
contribute to decreasing health care costs, and foster reduction in health risks.
Occupational health nurses must seize opportunities in areas such as program
planning, research, and policy making during this era fraught with a health care
system in crisis. Issues to be addressed and managed include nursing shortages in
many areas of the country, dramatic changes in the business environment, employees'
increasing awareness of workplace hazards, and the ever-increasing need to
demonstrate the cost-effectiveness of occupational health nursing care and
services.
Case study: Application of the nursing process
Leslie Johnston, a 23-year-old woman, was transferred by her employer into a job
that required her to work with chemicals used in photolithography. Leslie became
concerned when she noticed that the label on one of the pieces of equipment warned
of possible adverse effects on reproduction. Because of her concern and related
issues, she went to the on-site health clinic to talk with Peter Mitchell, the
occupational health nurse.
Peter invited Leslie into his office to ask her questions and do a brief health
history. Leslie reported that her health had been "excellent" until recently, but
that she had not felt well since transferring to her new position. She explained
that she was newly married and thought she may be pregnant, but this was
unconfirmed. She questioned whether her vague physical complaints (fatigue,
headaches, occasional queasiness) might be related to working with chemicals, a
pregnancy, or another reason.
Peter reassured Leslie that he had been employed at the company for 8 years, and he
was aware that there were no restrictions in Leslie's work area for pregnant women.
He pulled up her health file from his computerized database and gave her a set of
health history forms to complete. He also had her read and sign several forms
related to confidentiality and assured her that none of her health information
would be shared with their employer without her consent.

Assessment
To obtain needed information, Peter:
• Completed general health and occupational health histories.
• Performed a modified physical assessment and discussed the symptoms
that Leslie was experiencing.
• Referred Leslie to her personal health care provider for further
evaluation and to obtain a pregnancy test. (Note that some on-site clinics can be
equipped for basic procedures such as this. If this is not a service provided by
the occupational health nurse, referral must be made to the employee's health care
provider. If the employee does not have one, referral must be made to an
appropriate community health resource.) Peter encouraged Leslie to inform her
supervisor and himself should the pregnancy test be positive so they could adapt
her assignments to her condition.
• Assessed Leslie's work area with an industrial hygienist to determine
whether there might be problems such as leaking equipment or problems with
ventilation.
• Reviewed the most current industrial hygiene data appropriate to the
area.
Diagnosis
Individual:
• At risk for chemical exposure
• Vague physical complaints of unknown etiology
• Possible pregnancy
• At risk for possible adverse pregnancy outcomesStress related to
concern regarding possible exposure to harmful chemicals
Community (Workplace):
• Potential for exposure of employees to unsafe chemicals and/or working conditions
Planning

Peter developed a plan of care based on Leslie's health history and concerns.
Together they set the following goals:
Individual:
Short-term goals
• Determine pregnancy status.
• Determine potential exposure levels and review side effects of
chemicals.
• Determine reason for her vague physical complaints.
• Reduce stress experiences.
Long-term goals
• Ensure that the work environment is safe for future pregnancies (if
Leslie is not pregnant at present).
• Collaborate with Leslie and her supervisor on possible work
restrictions.
Community (Workplace):
Short-term goals
• Company personnel (e.g. the occupational health nurse, the industrial
hygienist, and all others who are directly affected) will be knowledgeable in the
safe handling of all hazardous chemicals.
• All company policies will be followed regarding safety and exposure.
Long-term goals
• Policies on handling of chemicals and related information will be
reviewed periodically as required by law.
• All employees who work with and around potentially hazardous
chemicals will undergo periodic instruction and checkoff related to proper
procedures.
• Work areas will be monitored per policy for compliance with safe
practices.

There will be no incidents involving worker exposure to chemicals.

Intervention
Individual:
Peter conducted a brief physical examination and did not identify any obvious
physical abnormalities. Because Leslie's chief complaints were fatigue, occasional
headaches, and queasiness, he encouraged her to make an appointment with her
primary care provider or gynecologist for a more extensive workup and to assess for
pregnancy.
With her permission, he called the industrial hygienist to counsel with Leslie
regarding the policies of the company and to explain what chemicals might
potentially be hazardous and to review procedures and restrictions. The hygienist
also stated that he would send a team to Leslie's work area to take air samples,
check lighting, and perform other tests to ensure there were no problems.
Community (Workplace):
The assigned industrial hygiene team sampled the environment for chemical exposure
per established procedure. They also set up a plan to add the area to more frequent
observation pending the results of the tests. The hygienist assured Peter and
Leslie that he would communicate any work restrictions or changes to the personnel
department and Leslie's supervisor if needed.
Evaluation
Individual:
Following the meeting with Peter and the industrial hygienist, Leslie stated that
she felt reassured. She agreed to make an appointment as soon as possible with her
doctor for an evaluation and pregnancy test. She also agreed to inform Peter and
her direct supervisor if she learned that she was pregnant.
Community (Workplace):

The industrial hygienist and his assistants performed several tests in close
proximity to Leslie's work station and found no abnormal readings and all equipment
was in good working order. As per agency policy and following OHSA regulations,
they charted all findings and submitted reports.
Levels of prevention
Primary
• Teach about chemicals, exposures, etc.
• Instruct on chemical exposure prevention.
• Provide PPE.
Secondary
• Assess employee for signs and symptoms.
• Assess work environment for exposure.
• Refer for evaluation of possible health problems as needed.
Tertiary
• Provide reproductive counseling.