Notes

Community Health Nursing I

Health
Considered as the goal of public health in general and community health nursing in particular.
Defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 1995).

Global Health Situation
Age structure of death: in 1995, only 21% of all deaths were among the under 5s. 7% among those 5-19, 29% among those 20-64 and 43% among the over 65s.
By 2025, 8% of all deaths will be under 5s. 3% among 5-19 years old, among 20-64 years old and 63% among the over 65s.

Determinants of the Global Health Situation: (Look for):

Population
Life Expectancy :
Female – 70 years old
Male – 64 years old

Age structure of death :
in 1995, only 21% of all deaths were among the under 5s. 7% among those 5-19, 29% among those 20-64 and 43% among the over 65s.
By 2025, 8% of all deaths will be under 5s. 3% among 5-19 years old, among 20-64 years old and 63% among the over 65s.

Leading cause of global death:
- Infectious and parasitic diseases
- Circulatory diseases
- Cancer
- Respiratory diseases
- COPD
- Perinatal conditions

The Philippine Public Healthcare Scenario
The national budget allocation for health care is relatively small.
Local government units augment the national budget to an undetermined extent.
This scenario requires strategies that will allow maximization of limited resources:
Health promotion
Disease prevention
In the past 20 years some infectious degenerative diseases are on the rise.
Many Filipinos are still living in remote and hard to reach areas where it is difficult to deliver the health services they need.
The scarcity of doctors, nurses and midwives.

Leading Causes of Morbidity:
Communicable diseases
Heart problems
Hypertension
Accidents
Malignant neoplasms
Leading Causes of Mortality:
Diseases of the heart and vascular system
Pneumonia
PTB
Diarrheal diseases












Different definitions of Public Health:

Public Health (Dr. CE Winslow)
“Science and art of preventing disease, prolonging life, promoting health and efficiency through the following:
Organized community effort of sanitation of the environment
Control of communicable diseases
The education of individuals in personal hygiene
The organization of medical and nursing services for the early diagnosis and preventive treatment of disease; and
The development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health.

* Organizing these benefits as to enable
every citizen to realize his birthright of
health and longevity.

Public Health (WHO)
- Art of applying science in the context of politics so as to reduce inequalities in health ensuring the best health for the greatest number.

Core business:
Disease prevention
Injury prevention
Health protection
Health public policy
Promotion of health and equitable health gain


Public Health Nursing (WHO)
Special field of nursing combines the skills of nursing, public health and some phases of social assistance and functions as part of the total public health program for the promotion of health, the improvement of the conditions in social and physical environment, rehabilitation of illness and disability.



Community Health Nursing (Ruth Freeman)
“A service rendered by a professional nurse with communities, groups, families, individuals at home, in health centers, in clinics, in school, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation.”

Community Health Nursing (Clark)
“A synthesis of nursing knowledge and practice and the science and practice of public health, implemented via a systematic use of the nursing process and other processes to promote health and prevent illness in population groups.”

Community Health Nursing (Maglaya)

NURSING PROCESS IN THE
DIFFERENT LEVELS OF
CLIENTELE-INDIVIDUALS,
FAMILIES, POPULATION
GROUPS AND COMMUNITIES,
CONCERNED WITH THE
PROMOTION OF HEALTH,
PREVENTION OF DISEASE AND
DISABILITY AND
REHABILITATION.”

The goal of Community Health Nursing (Nisce)
To raise the level of citizenry by helping communities and families to cope with the discontinuities, in a way as to maximize their potential for high level of wellness.

The goal of Community Health Nursing (Jacobson)
A learned practice of discipline with the ultimate goal of contributing as individuals and in collaboration with others to the promotion of client’s optimum level of functioning.

Community Health Nursing (Dr. Ruth Freeman)
A service rendered by professional nurse to the different places on where to practice CHN, such as; health centers, clinics, school & workplace for the promotion of health.

HALLMARK OF CHN AS
POPULATION OR
AGGREGATE FOCUSED:

POPULATIONS
Caseloads
Clinics
Districts
Census Tracts
Cities


AGGREGATE
Family At Risks

Four Important Components of CHN
Health Care Delivery System
budget allocation
Clients
Individual
Family
Group
Community
Health – basic community right; goal of Public Health and CHN in particular
Factors affecting health of an individual
Economic
Political
Sociocultural
Environmental Factors

Public/CHN is a Synthesis of Public and Nursing Practice

Goals of professional practice 🡪 Promotion of health and prevention of disease

CHN Practice
Comprehensive
General
Health
Continual & Not episodic

4 different Levels of Clientele
Individual
Family
Population group
Community

Basic Concepts and Principles of CHN
The community is the patient in CHN.
The family is the basic unit of care, hence, the CHN consider the health needs of all members of the family in providing nursing services.
Client is considered as an active partner, not just passive recipient of care.
The goal in improving community health is realized through multi-sectoral efforts.

Standards of Public Health Nursing in the Philippines

Assessment
Collects comprehensive data pertinent to the health status of populations
Population diagnosis and priorities
Analyzes the assessment data to determine the population diagnoses and priorities
Outcomes and identification
Identifies expected outcomes for a plan that is based population diagnoses and priorities
Planning
Planning
Develops a plan that reflects
best practices by identifying
strategies, action plans, and
alternatives to attain
expected outcomes.


Implementation
Implements the identified plan
by partnering with others


Coordination
Coordinates programs,
services and other activities to
implement the identified plan


Health Education and Health Promotion
Employs multiple strategies
to promote health, prevent
disease and ensure a safe
environment for populations


Consultation
Provides consultation to
various community groups and
officials to facilitate the
implementation of programs
and services


Regulatory Activities
Identifies, interprets and
implements public health laws,


Evaluation
Evaluates the health status
of the population.


Roles and Responsibilities of a Community Health Nurse

Clinician
Focus on the health of the population or individuals on the larger context of the community.

Provides nursing care to the sick and disabled in order to reduce disease, discomfort, disability and premature death, among others.
Advocate
Speaks or acts for those who cannot speak/act for themselves.

Advocates for self-care and self-determination.

Collaborator
Brings together strengths and weaknesses of people involved toward a common goal.

Works with people in the community toward a common goal and relies on joint or shared decision-making.

Consultant
Catalyst to bring change, helping people understands processes and actions, and assisting them in making decisions.

Counselor
Listens and provides feedback and information, strengthens and guides people’s own decision making skills and explores feelings and attitudes for people understand themselves and their decisions.

Educator
Acts as health educator which is one of her most important roles as Community Health Nurse.
Provides knowledge, skills and attitudes needed by the community members for self-efficacy in making decisions and empowerment.
Enables clients to make informed decisions, identifies populations at risk, and explores learning strategies.

HISTORY OF PUBLIC HEALTH NURSING IN THE PHILIPPINES
1577: Friar Juan Clemetene opened a medical dispensary in Intramuros for the indigent.
1690: Dominican Father Juan De Pergero worked towards installing a water system in San Juan Del Monte (Now San Juan City, Metro Manila) and Manila.
1805: Dr. Francisco De Balmis introduced smallpox vaccination.
1876: The first Medicos Titulares were appointed and worked as provincial health officers.
1888: The University of Santo Tomas opens a two-year, CIRUJANOS MINISTRANTES course to produce male nurses and sanitary inspectors.
1901: The board of health of the Philippines islands was created through ACT 157, which eventually evolved into the Department of Health (DOH).
1912: The Fajardo Act Law created sanitary divisions made up one to four municipalities.
1905: Association De Feminista Filipina founded La Gota De Leche, the first center dedicated to the service of mothers and babies.
1947: The DOH was reorganized into bureaus and the administration of city health departments was placed at bureau level. 1954: The congress passed R.A. 1082 or the rural health unit act which provided an RHU in every municipality.
1957: R.A. 1891 was enacted to have a more equitable distribution of health personnel.
1958: Regional health officers were created as a result of decentralization efforts, thus creating the position: regional health officer.
1970: The Philippine health care delivery system was restructured, paving the way for the healthcare system that exists to this day where health services are classified into primary, secondary and tertiary levels.
1991: R.A. 7160 or the local government code mandates the devolution of basic services, including health services, to local government units and the establishment of a local health board in every province and city or municipality.
1999: Health sector reform agenda was launched to direct government efforts towards comprehensive reforms.
2005: Formula one (F1) for health was launched to provide an implementation framework to the reform agenda. 2010: Universal health care was launched to provide the necessary revisions to the F1 framework.
The Health Care Delivery System - totality of all policies, facilities, equipments, products that addresses the needs of people.
A nation’s health care delivery system has a tremendous impact not only the health of its people but also on their total development including their socioeconomic status. Anderson and Mcfarlene (2011) emphasized the role of the following factors in shaping 21st century health that further influence health care delivery system:
1. Health care “reforms”
2. Demographics
3. Globalization
4. Poverty and growing disparities
5. Social disintegration

World Health Organization (WHO) as this specialized agency of the United Nations (UN) provides global leadership on health matters.
In the Philippines, health services are provided by the government and the private sector – for profit as well as nonprofit, with the latter frequently referred to as nongovernmental organizations or NGO’s.
In the national level, director is set by department of health (DOH) by virtue of mandate of the Local Government Code (R.A.7160) LGU’s should have operating mechanism to meet the priority needs and service requirements of their communities. Basic Health Services are regarded as priority services for which LGU’s are primary responsible.
A Health System consists of all organizations, peoples, and actions whose primary intent is to promote, restore, or maintain health. A health system has six building blocks or components:
1. Service delivery
2. Health workforce
3. Information
4. Medical products, vaccines, and technologies
5. Financing
6. Leadership and governance or Stewardship.

The World Health Organization
The WHO constitution came into force on April 7, 1948. Since then April 7 has been celebrated each year as World Health Day. The WHO constitution states that its objective is the attainment of all peoples of the highest possible level of health. To attain its objective, WHO carries out the following core functions:
• Providing leadership on matters critical to health and engaging partnerships where joint action is needed. WHO has 193 members of countries and 2 associate members. WHO and its members work with UN agencies, NGO’s and the private sector. The WHO country focus is directed toward providing technical collaboration with member states with accordance with each country’s needs and capacities.
• Shaping the research agenda and stimulating the generation, translation, and disseminating valuable knowledge. The WHO strategy on research for health has 5 goals:
1. Capacity- in reference to capacity-building to strengthen the national health research system
2. Priorities – to focus research on priority health need particularly in low and middle income countries
3. Standards - to promote good research practice and enable the greater sharing of research evidence, tools, and materials
4. Translation - to ensure that quality evidence is turned into products and policy
5. Organization – to strengthen the research culture within WHO and improve the management and coordination of WHO research activities.
• Setting norms and standards and promoting and monitoring their implementation. WHO develops norms and standards for various health and health –related issues, such as pharmaceutical products including vaccines and other biological products used in immunization, practices in maternal and child care, and environmental conditions.
• Articulating ethical and evidence-based policy options. Through its Department of Ethics and Social Determinants, WHO is evolved in various issues on health ethics. In collaboration with other governmental and nongovernmental organizations, WHO has worked on bioethical concerns such as those related to human organ and tissue transplantation, reproductive technology and public health response to threats of infectious diseases like AIDS, influenza, and tuberculosis.
• Providing technical support, catalyzing change, and building sustainable institutional capacity. WHO offers technical support training to its member countries in the fields of maternal and child health, control of diseases, and environmental health services. WHO is involved in monitoring the health situation and assessing health trends. WHO has developed guidance and tools and measurement, monitoring and evaluation.
The Millennium Development Goals
On September 6 to 8, 2000, world leaders on UN General Assembly participate in Millennium Summit. The result of the summit was a resolution entitled United Nations Millennium Declaration. In this declaration, the world leaders recognized their collective responsibility to uphold the principles of human dignity, equality and equity at the global level.
The declaration expressed the commitment of the 191 member states, including the Philippines, to reduce extreme poverty and achieve seven other targets - now called the Millennium Development Goals (MDG’s) by the year 2015.
The following are the eight MDG’s and the targets corresponding to health-related MDG’s 4,5, and 6:
1. Eradicate extreme poverty and hunger.
2. Achieve universal primary education.
3. Promote gender equality and empower women.
4. Reduce child mortality. Target: reduce by 2/3, between 1990 and 2015, the under-five mortality rate.
5. Improve maternal health.
Target: a. Reduce by three quarters the maternal mortality ratio b. Achieve universal access to reproductive health
6. Combat HIV/AIDS, malaria and other diseases. Targets: a. Have halted by 2015 and begun to reverse the spread of HIV/AIDS b. Achieve by 2010, universal access to treatment for all those who need it c. Have halted by 2015, and begun to reverse the incidence of malaria and other major diseases.
7. Ensure environmental sustainability
8. Develop a global partnership for development
The Philippine Health Care Delivery System
The DOH serves as the main governing body of health services in the country. The DOH provides guidance and technical assistance to LGUs through the center for health development in each of the 17 regions.
* Provincial governments are responsible for administration of provincial and district hospitals.
* Municipal and city governments are in charge of primary care through rural health units (RHUs) or health centers.
*Satellite outposts known as barangay health stations (BHSs) provide health services in the periphery of the municipality or city.
The private sector is composed of for-profit and nonprofit agencies this sector provides all levels of services and accounts for a large segment of health service providers in the country. About 30% of Filipinos utilize private health facilities. Estimated 60% of national health expenditure goes to the private sector which employs more than 70% of the health professionals in the Philippines.
Financing of health services is provided by three major groups:
The government (national and local),
private sources
and social health insurance.
The National Insurance Act of 1995 (R.A. 7875) created by the Philippine Health Insurance Corporation (PhilHealth). It is tax-exempt government corporation attached to the DOH for policy coordination and guidance, and aims for universal health coverage of all Filipino citizens.
The Department of Health
The DOH is the national agency mandated to lead the health sector towards assuring quality health care for all Filipinos.
DOH Vision: is to be a global leader for attaining better health outcomes, competitive and responsive health care system, and equitable health financing.
(NEW) DOH VISION - Filipinos are among the healthiest people in SouthEast Asia by 2022 and Asia by 2040.
DOH Mission: to guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health.
(NEW) DOH MISSION - To lead the country in the development of a productive, resilient, equitable and people-centered health system.
In the pursuit of its vision and execution of its mission, the following has the major roles:
1. Leader in health
2. Enabler and capacity builder
3. Administrator of specific services
The DOH core values reflect adherence to the highest standards of work namely:
1. Integrity
2. Excellence
3. Compassion and respect for human dignity
4. Commitment
5. Professionalism
6. Teamwork
7. Stewardship
The DOH carries out its work through the various central bureaus and services in the central office, Center for Health Development (CHD) in every region, DOH- attached agencies, and DOH-retained hospitals.
Levels of Health Care Delivery
The DOH issued administrative order 2012-0012 (Rules and Regulations Governing the new Classification of Hospitals and Other Health Facilities in the Philippines) that provides for a new classification scheme of health facilities.
Hospitals Other Health Facilities General
• Level 1
• Level 2
• Level 3 (teaching/ training A. Primary Care Facility B. Custodial facility C. Diagnostic/ Therapeutic facility Specialty D. Specialized outpatient facility

DOH administrative Order 2012-0012 classifies other health facilities as follows:
Category A. Primary Health Care Facility – a first contact health care facility that offers basic service including emergency services and provision for normal deliveries.
1. Without in-patient beds like health centers, out-patient clinics, and dental clinics. 2. With in-patient beds – a short-stay facility where the patient spends on the average of one to two days before discharge. Ex: Infirmaries and birthing (Lying-in) facilities.
Category B. Custodial Care Facility – a health facility that provides long-term care, including basic services like food and shelter, to patients with chronic conditions requiring ongoing health and nursing care due to impairment and a reduced degree of independence in activities of daily living, and patients in need of rehabilitation.
Ex: Custodial health care facilities, substance/drug abuse treatment and rehabilitation centers, sanitaria, leprosaria, and nursing homes.
Category C. Diagnostic/Therapeutic Facility - a facility for the examination of the human body, specimens from the human body for the diagnosis, sometimes treatment of disease or water for drinking analysis. The test covers the preanalytical, analytical and post analytical phases of examination.
Ex; laboratories
Category D. Specialized outpatient facility – a facility that performs highly specialized procedures on an outpatient basis.
Ex: Dialysis clinic, ambulatory surgical clinic, cancer chemotherapeutic center/clinic, cancer radiation facility, and physical medicine and rehabilitation center/clinic.

The Rural Health Unit
The RHU, commonly known as health center, is a primary level health facility in the municipality. The focus of RHU is preventive and promotive health services and the supervision of BHSs under its jurisdiction. The recommended ratio of RHU to catchment population is 1 RHU: 20,000 populations.
The BHS is the first contact health care facility that offers basic services at the barangay level. It is a satellite station of the RHU. It is manned by Volunteer Barangay Health Workers (BHW’s) under the supervision of Rural Health Midwife (RHM).
The Rural Health Unit Personnel
The Municipal Health Officer (MHO) or Rural Health Physician heads the health services at the municipal level and carries out the following roles and functions:
1. Administrator of the RHU a. Prepares the municipal health plan and budget b. Monitors the implementation of basic health services c. Management of the RHU staff
2. Community physician a. Conducts epidemiological studies b. Formulates health education campaigns on disease prevention c. Prepares and implements control measures or rehabilitation plan
3. Medico-legal officer of the municipality.
The revised implementing rules and regulations (IRRSs) of R.A. 7305 or the Magna Carta of Public Health Workers stipulate that there be one rural health physician to a population of 20,000.
Local Health Boards
• R.A 7160 or Local Government Code was enacted to bring about genuine and meaningful local autonomy.
• This will enable local governments to attain their fullest development as self-reliant communities and make them more effective partners in the attainment of national goals.
• Devolution refers to the act by which the national government confers power and authority upon the various LGU’s to perform specific functions and responsibilities.
• R.A 7160 provided for the creation of the Provincial Health Board and the City/Municipal Health boards, or Local Health Boards.
The functions of local health boards are as follows:
1. Proposing to the Sanggunian annual budgetary allocations for the operation and maintenance of health facilities and services within the province/city/municipality;
2. Serving as an advisory committee to the Sanggunian on health matters; and
3. Creating committees that shall advise local health agencies on various matters related to health service operations.

The Health Referral System
• A referral is a set of activities undertaken by a health care provider or facility in response to its inability to provide the necessary health intervention to satisfy a patient’s need.
• A functional referral system is one that ensures the continuity and complementation of health and medical services
• It usually involves movement of a patient from the health center of first contact and the hospital at first referral level.
• When hospital intervention has been completed, the patient is referred back to the health center. This accounts for the term two-way referral system.
• Referrals may be internal or external
• Internal referrals – occur within the health facility; may be made to request for an opinion or suggestion, comanagement, or further management or specialty care.
• External referral – is a movement of a patient from one health facility to another. It may be vertical, where the patient referral may be from a lower to a higher level of health facility or the other way round.

The Inter-Local Health Zone
• The referral system functioning within the context of the Inter-Local Health Zone (ILHZ) provides a means for consolidating health care efforts.
• The ILHZ is based on the concept of the District Health System, a generic term used by WHO to describe an integrated health management and delivery system based on a defined administrative a geographical area.
• An ILHZ has a defined catchment population within a defined geographical area, it has a central or core referral hospital and a number of primary level facilities such as RHUs and BHSs.
The ILHZ has the following components: • People. Although WHO has described the ideal population size of a health district between 100,000 and 500,000, the number of people may vary from zone to zone, especially when taking into consideration the number of LGUs that will decide to cooperate and cluster. • Boundaries. Clear boundaries between ILHZs establish accountability and responsibility of health service providers. • Health facilities. RHUs, BHSs, and other health facilities that decide to work together as an integrated health system and a district or provincial hospital, serving as the central referral hospital. • Health workers. To deliver comprehensive services, the ILHZ health workers include personnel of the DOH, district or provincial hospitals, RHUs, BHSs, private clinics, volunteer health workers from NGOs, and community based organizations.
Health Sector Reform: Universal Health Care
• Also called the Aquino Health Agenda, is the latest in a series of continuing efforts of the government to bring about health sector reforms.
• UHC was built upon strategies of two previous platforms of reform: the initial Health Sector Reform Agenda and FOURmula One for health.


Goals and Objectives
1. Better health outcomes
2. Sustained health financing, and
3. A responsive health system by ensuring that all Filipinos, especially the disadvantaged group, have equitable access to affordable health care.

Strategic thrusts
The attainment of the goal of UHC is through the pursuit of three strategic thrusts:
A. Financial risk protection through expansion in NHIP enrollment and benefit delivery
B. Improved access to quality hospitals and health care facilities
C. Attainment of the health-related MDGs
To achieve the three strategic thrusts, six strategic instruments shall be optimized:
1. Health financing - instrument to increase resources for health that will be effectively allocated and utilized to improve the financial protection of the poor and the vulnerable sectors.
2. Service delivery – instrument to transform the health service delivery structure to address variations in health service utilization and health outcomes across socioeconomic variables.
3. Policy, standards, and regulation – instrument to ensure equitable access to health services, essential medicines, and technologies of assured quality, availability and safety.
4. Governance for health – instrument to establish the mechanisms for efficiency, transparency, and accountability, and prevent opportunities for fraud.
5. Human resources for health – instrument to ensure that all Filipinos have access to professional health care providers the appropriate level of care.
6. Health information – instrument to establish a modern information system that shall: a. Provide evidence for policy and program development; b. Support for immediate and efficient provision of health care and management of province-wide health systems.
Public Health programs
1. Reproductive and maternal health: prepregnancy services and care during pregnancy, delivery, and postpartum period
2. Expanded Garantisadong Pambata (child health): advocacy for exclusive breastfeeding in the first 6 months of life, newborn screening program, immunization, nutrition services, and integrated management of childhood illness.
3. Control of communicable disease such as tuberculosis, mosquito-borne diseases, rabies, schistosomiasis, and sexually transmitted infections
4. Control of noncommunicable or lifestyle diseases
5. Environmental health