Community Health Nursing

Basic Concepts and Principles

Robitani A. Torres, MD, RN, MAN

Lecturer/Clinical Instructor
Community Health Nursing

 A field of nursing that is a synthesis of nursing

practice with public health using primary
health care as the tool in the delivery of
health services
 With the ultimate goal of contributing as
individuals and in collaboration with others to
the promotion of client’s optimum level of
functioning thru teaching and delivery of care
Community Health Nursing

 A service rendered by a professional nurse to

individuals, families, communities and
population groups in health centers, clinics,
schools, and the workplace in order to
promote health, prevent illness, provide care
for the sick at their respective homes, provide
effective rehabilitation (Freeman, 1970)
Philosophy of CHN

 The philosophy of CHN is based on the worth

and dignity of men.
 The philosophy of care is based on the belief
that care directed to the individual, the
family, the population group, and the
community contributes to the healthcare of
the population as a whole.
Goal of CHN

 To assists the individual, family, population

group, and community in attaining their
highest level of holistic health which is
attained through multidisciplinary effort and
to promote reciprocally supportive
relationship between people and their
physical and social environment.
CHN – Concepts and Principles

 Family
▪ Is the primary unit of care where primary prevention is
given priority.
▪ The individual client is a member of the family.
▪ The family may be a part of a population group which in
turn is a part of the bigger group which is the
community.
▪ Community is the client of CHN
CHN – Concepts and Principles

 Partnership
▪ The CHN works with, not for, the individual patient,
family, group or community as active partners and not
as passive recipients of care.
CHN – Concepts and Principles

 Change
▪ The practice of CHN is affected by changes in society in
general, and by developments in the health field in
particular.
CHN – Concepts and Principles

 Healthcare Delivery System

▪ CHN is part of a community health system and of a
larger human services system.
▪ The CHN interacts, collaborates, and coordinates using
the mulitdisciplinary approach with teamwork as the
driving force in the efficient, effective, and equitable
delivery and utilization of the services
Salient Features of CHN

 Population or Aggregate-Focused
 Hallmark of Community Health Nursing
 Whole Community is the client
 Population based assessment
 Services delivered to individual clients and
families must be viewed and evaluated in terms of
their effects and impact on total community
health.
Salient Features of CHN

 Greatest Good for Greatest Number

▪ CHN first looks at the health needs and problems of the
community rather than focusing solely on the needs of
individuals or families.
▪ When a particular situation is sseen as a risk or hazard to
the health of the whole community or can afflict a
greater number of individuals – then that is seen as a
community health problem which needs community-
wide interventions.
Salient Features of CHN

 Utilizes the Nursing Process

▪ Using a problem solving scientific method
▪ Facilitates the delivery of planned, systematic,
effective, and efficient care to clients.
Salient Features of CHN

 Promotive – Preventive by Nature

▪ The priority of CHN is on the promotive and preventive
aspects of care rather than the curative
Salient Features of CHN

 Uses a Variety of Instruments

▪ CHN makes use of tools for measuring and analyzing
community health problems like public statistics or vital
statistics.
▪ Community map is also a very helpful tool.
▪ Interview, schedule, survey forms, and questionnaires
may also be used.
Salient Features of CHN

 Requires Management Skills

▪ CHN applies principles of management especially during
the organization of the nursing service in the local health
agency and in activities that require the effective
management of a certain program or health service.
Recipients of Care by CHN

 The Individual
▪ A specific person or client in various stages of health or
illness who is given the appropriate nursing intervention
by the CHN and other members of the health team as
the condition warrants
Recipients of Care by CHN
 The family
▪ A group of people affiliated by consanguinity, affinity, or co-residence.
▪ The basic unit of society.
▪ Types of Families:
1. Nuclear – consisting only of husband and wife and their children but maintains
relatively close ties with their relatives
2. Conjugal – similar to nuclear family except that it is relatively independent from the
relatives or parents and of other families.
3. Extended – “consanguinal family” – where a family is composed of several families of
the same blood (nuclear family plus parents of either or both husband and wife, other
relatives)
4. Single-parent – families headed by single spouse, either single parent, widow, or
widower
5. Blended – “step family” characterized by mixed parents, with one or both parents
remarried bringing their respective children of the former family into the new family.
6. Traditional – middle-class family with a father who is the family breadwinner and a
mother who is the typical housewife.
Recipients of Care by CHN

3. Population Group
▪ Vulnerable groups or those at risk of developing
certain health or health related problems.
▪ They share common characteristics, developmental
stage or common exposure to particular
environmental factors, thus resulting to common
health problems.
▪ Common defining characteristics, traits, needs:
▪ Age, sex, illness, or disease, socio-economic status, lifestyle, or
habits which are unhealthy
Recipients of Care by CHN

4. The Community
▪ A group of people sharing common geographic boundaries and/or
common values and intersts
▪ The group which functions within socio-cultural context and
varying physical environment and the people’s way of behaving and
coping differ from one group to another
▪ Classifications:
1. Rural – open lands, often agricultural, more spacious, less
densely populated
2. Urban – city or cities, non agricultural, densely populated,
marked by industrial products and technology, central business
districts
3. Suburban / Rurban or the Capitals – usually the administrative
capital of a province char. By a mix of agri and industry
Health

 A state of complete physical, mental, and

social well-being and not merely the absence
of disease or infirmity (WHO, 1995)

 The goal of public health in general and of

community health nursing in particular.
Determinants of Health (Factors in the
Eco-system affecting OLOF)

1. Political Factors
2. Behavioral Factors
3. Heredity/Biologic factors
4. Health Care Delivery System
5. Environmental influences
6. Socio-economic influences
Political Factors

 Politics have power and authority to regulate

the environment and social climate.
 Ex. Laws or legislative acts are often related
to promoting safety and people
empowerment
Behavioral Factors

 Certain habits, liefstyles, health care, and

child-rearing practices are determined by
culture and ethnic heritage.
 Ex. Culture, habits, customs
Heredity factors

 Factors related to a person’s physiological

make-up – his/her genetic endowment or
inheritance, inherent mentality or
temperament
Health Care Delivery System

 Provision of health services that are

community-based, accessible, acceptable,
affordable, sustainable.
Environmental Influence

 Everything external to the body and consists

of physical, psychological, social, and cultural
dimensions or aspects.
 water, land, air quality, climate, weather,
housing condition, sanitation, noise level
 Ex. Poor sanitation, smoking, poor garbage
collection, utilization of pesticides, water
wastes
Socio-economic influences

 Ex. Unemployment, lack of education, lack of

descent housing
Roles and Functions of the Public
Health/Community Health Nurse

CHN as Provider of
CHN as Researcher Nursing Care
CHN as
Manager

CHN as Client
Advocate

CHN as Coordinator
CHN as COMMUNITY of Services
Change Agent

CHN as CHN as Community

Role Model Organizer

CHN as Trainer and CHN as Health

Health Educator Monitor
CHN as Provider of Nursing Care

 Provides direct nursing care to the sick or

disabled in the home, clinic, school, or
workplace
 Develops the family’s capability to take care
of the sick, disabled, or dependent member
CHN as Manager/Supervisor

 Formulates individual, family, group, and

community centered plan.
 Interprets and implements programs,
policies, memoranda, and circulars
 Organizes workforce, resources, equipment,
and supplies at the local level
CHN as Community Organizer

 Motivates and enhances community

participation in terms of planning,
organizing, implementing, and evaluating
health services.
 Initiates and participates in community
development activities
CHN as Coordinator of Services

 Coordinates with individuals, families, and

groups for health related services provided by
various members of the health team.
 Coordinates nursing program with other
health programs like environmental
sanitation, health education, dental health,
and mental health
CHN as Trainer / Health Educator

 Identifies and interprets training needs of the

RHMs, BHWs, and hilots.
 Conducts training for midwives and BHWs on
health promotion and disease prevention.
 Acts as resource speaker on health and health
related services.
CHN as Health Monitor

 Detects deviation from health

practices/behavior of clients through
contacts/visits with them.
CHN as Change Agent

 Motivates changes in health behavior

lifestyles of individuals, families, group, and
communities in order to promote and
maintain health.
CHN as Client/Patient Advocate

 The CHN protects the the interest and

welfare of the client when the latter’s health,
safety, or welfare is threatened by others.
CHN as Researcher

 Participates in the conduct of survey studies

and researches on nursing and health related
subjects.
 Coordinates with government and non-
government organizations in the
implementation of studies/research
CHN as Role Model

 Provides good example of healthful living to

the members of the community.
Historical Background of
Community Health / Public
Health Nursing Practice in the
Philippines
Pre-Spanish and Spanish Periods
(before 1898)
 Traditonal health care practices – use of herbs
and rituals for healing
1898

 The history of Public Health Nursing in the

Philippines is embedded in the history of
Department of Health which was first
established as the Department of Public
Works, Education and Hygiene
1901

 Act No. 157of the Philippine Commission

Created the Board of Health of the Philippine
Board of Health for Manila

 Act No. 309

created the provincial and municipal Boards
of Health
1905

 Act No. 1407 (Reorganization Act)

Abolished the Board of Health and was
replaced by the Bureau of Health under the
Department of Interior.
1912

 The Fajardo Act (Act of 2156) created

Sanitary Divisions.
 The President of the Division (forerunners of
the present Municipal Health Officers) took
charge of 2 or 3 municipalities. Where there
were no physicians available, male nurses
were assigned to perform duties of the
President, Sanitary Division.
1912

 The Philippine General Hospital, under the

Bureau of Health, sent 4 nurses to Cebu to
take care of mothers and babies while

 the St. Paul’s Hospital School of Nursing in

Intramuros assigned 2 nurses to perform
home visiting in Manila and gave nursing care
to outpatient mothers and newborns at PGH.
1914-1915

 School nursing was rendered by a nurse employed

by the Bureau of Health in Tacloban, Leyte.
 The Reorganization Act 2462 created the Office
of General Inspection which organized the Office
District Nursing headed by a lady physician who
was also a nurse, Dr. Rosario Pastor.
 This office was created due to the increasing
demands for nurses to work outside hospital, in
the homes, and the need for direction,
supervision, and guidance of public health nurses
1919

 The first Filipino Nurse Supervisor under the

Bureau of Health, Ms. Carmen del Rosario,
was appointed

 with a staff of 84 PHNs, assigned in 5 health

stations.
1927

 The office of District Nursing under the Office

of General Inspection, Philippine Health
Service was abolished
 It was supplanted by the Section of Public
Health Nursing
1930

 The Section of Public Health Nursing was

converted into Section of Nursing – due to
pressing need for guidance not only in public
nursing service but also in hospital nursing
and nursing education.
 The Section of Nursing was transferred to the
Office of General Services to the Division of
Administration.
1941

 The first City Health Officer of Manila was

appointed – Dr. Mariano Icasiano

 Dec. 8, 1941 – World Ward II

- PHNs in Manila were assigned to
devastated areas to attend to the sick and
wounded.
1942

 31 nurses were taken as prisoners of war by

Japanese army and confined at Bilibid prison
and were released to the then director of
Bureau of Health, Dr. Eusebio Aguilar

 Many PHNs joined guerillas or went o hide in

the mountains during World War II.
1990-1992

 The Local Government Code of 1991 (RA

7160) was passed and implemented which
resulted to “devolution” or the transferring of
power and authority from the national to the
local government units.
 Its aim was to build the capacities for self-
government and develop local government
units (LGUs) as fully self-relaiant
communities.
February 1946

 Nursing Office was created in the

Department of Health through the initiative
of the Technical Assistant in Nursing of DOH
and president of the Filipino Nurses
Association.
Oct. 7, 1947

 EO No. 94 – reorganized govt. offices and

created the Division of Nursing under the
Office of the Secretary of Health. This was
implemented on Dec. 16, 1947.
 One Chief of the Division and 3 assistants for
Nursing Education, Public Health Nursing,
and Staff Education were appointed.
1948

 The first training Center of the Bureau of

Health was organized in cooperation with
pasay City Health Dept. This was housed in
Tabon Health Center which was later
renamed as Doña Marta Health Center.
1950

 The Rural Health Demonstration and Training

Center (RHDTC) was established
1953

 RA No. 1082 (Rural Health Law)

 It created the first 81 RHUs.
 Each unit has a physician, PHN, Midwife, a
sanitary inspector and a clerk driver.
 Among the first PHNs to undergo pre-service
training prior to the assignment in the RHUs
were two graduates of Class 1952 of PGH
School of Nursing.
1957

 RA 1891
amending Sec. 2,3,4,7, and 8 of RA 1082
“Strengthening Health and Dental Services in
the Rural Areas and Providing Funds
thereto.”
1958-1965

 RA 977 passes by Congress in 1954 was

implemented.
 Division of Nursing was abolished.
 It created nursing positions at different levels
of health organization.
 DOH National League of Nurses was
founded. Ms. Annie Sand in 1961 – the first
President and adviser.
1975

 Restructuring of health care delivery system

based on findings of the Operation research
(WHO assisted)
 Functions of the health team members were
redefined.
Jan. 1999

 Department Order No. 29 designated Mrs.

Nelia F. Hizon, Nurse VI, then President of
National League of Philippine Government
Nurses, as Nursing Adviser.
 She was detailed at the Office of Public
Health Services with Undersecretary Milagros
Fernandez as Chief.
 As Nursing Adviser, matters affecting nurses
and nursing are referred to her.
May 24, 1999

 EO No. 102 was signed by the then-President

Joseph Estrada redirecting the functions and
operations of the Depatment of Health.
 Based on this EO most of the nursing
positions at the Central Office were either
transferred or devolved to other offices and
services
1999-2004

 The Health Sector Reform Agenda (HSRA)

was developed to describe major strategies,
organizational and policy changes, and public
investments to improve how health care
delivery is delivered, regulated, and financed.
2005-2006

 A plan to rationalize or streamline the

bureaucracy which includes the Department
of Health was developed.
 Community Health and
Development Concepts

The Philippine Health Care

Delivery System
Philippine Health Care Delivery
System
 Public Health – is defined as the science and art of
preventing disease, prolonging life, promoting health,
and efficiency through the following (Winslow, 1982)
1. Organized community effort for environmental sanitation.
2. Control of communicable diseases,
3. The education of individuals in personal hygiene,
4. The organization of medical and nursing services for the
early diagnosis and treatment of disease, and
5. The development of the social machinery to insure
everyone a standard living adequate for the maintenance
of health for everyone.
Philippine Health Care Delivery
System
 Public health
-is dedicated to the common attainment of the
highest level of physical, mental, and social well-
being and longevity consistent with available
knowledge and resources at a given time and
place
Philippine Health Care Delivery
System
 The 1987 Philippine Constitution (Article II,
Section 15) mandates the state to observe
health as a fundamental human right.

 As fundamental human and constitutional

right, access to healthcare services in the
Philippines is not without inherent difficulties
– high cost and physio-socio-cultural barriers.
Philippine Health Care Delivery
System
 Two Sectors:
1. Public Sector
▪ Largely financed through a tax-based budgeting system at
both national and local levels and where health care is
generally given free at the point of service

2. Private Sector
▪ For profit and non-profit providers, which is largely market-
oriented and where health care is paid through user fees at the
point of service.
The Philippine Health Care Delivery
System
 Public Sector
 National level
▪ DOH – lead agency in health
▪ Regional Field Office – maintains specialty hospitals. Regional
hospitals and medical centers
▪ Provincial Health Office – made up of DOH rep.
▪ National Government agencies - PGH
The Philippine Health Care Delivery
System
 Public Sector
 Local level
▪ Run by Local Governement Units
▪ Provincial and District hospital – under provincial govt.
▪ City/municipal government – manages health centers/RHUs, and
BHSs.
▪ National Government agencies - PGH
Department of Health

 The principal health agency in the

Philippines.
 The executive department of the Philippine
government responsible for ensuring access
to basic public health services to all Filipinos
through the provision of quality health care
and the regulation of providers of health
goods and services.
Department of Health

 EO No. 119 Section 3

▪ States the “DOH shall be responsible for the
following – in relation to its main function of
promotion, protection, preservation or
restoration of the health of people through the
provision and delivery of providers of health
goods and services:
1. Formulation and devt. of national health policies,
guidelines, standards, and manual of operations for
health services and programs;
Department of Health

2. Issuance of rules and regulations, licenses, and

accreditations;
3. Promulgation of national health standards, goals,
priorities, and indicators
4. Development of special health programs and
projects and advocacy for legislation on health
policies and programs
DOH – Mission, Vision, &
Strategies
DOH – Vision Statement

“Health For All Filipinos”

DOH – Mission Statement

Guarantee equitable,
sustainable, and quality health
for all Filipinos, especially the
poor, and shall lead the quest for
excellence in health
 Roles and Functions of
Department of Health
1. Leadership in Health
2. Enabler and Capacity Builder
3. Administrator of Specific Services
Roles and Functions of DOH

1. Leadership in Health
▪ Serve as the national policy and regulatory institution
▪ Provide leadership in the formulation, monitoring, and
evaluation of national health policies, plans, and
programs.
▪ Serve as advocate in the adoption of health policies,
plans and programs to address national and sectoral
concerns.
Roles and Functions of DOH

2. Enabler and Capacity Builder

▪ Innovate new strategies in health to improve
effectiveness of health programs
▪ Exercise oversight functions and monitoring and
evaluation of national health plans, programs, and
policies
▪ Ensure the highest achievable standards of quality
health care, health promotion, and health protection
Roles and Functions of DOH

3. Administrator of Specific Services

▪ Managed selected health facilities and hospitals with
modern and advanced facilites that shall serve as national
referral centers (ie. Special hospital), and selected health
facilities at sub national levels that are referral centers for
local health facilities (tertiary hosp.
▪ Administer direct services for emergent health concerns
that require new complicated technologies
▪ Administer health emergency response services, including
referral, and networking system for trauma. In case of
epidemic and other widespread public danger, upon the
direction of the President and in consultation with
concerned LGU.
Multi-Sectoral Approach to Health
Other Health-related
Systems
Governement/Private

Ways of the People Health Care System

COMMUNITY HEALTH
(Cultural)

Environment (Social,
Ecoomic, physical, etc)

Fig. 2. Integration of Multi-Sectoral Approach to Healthcare Delivery

Health Sector Reform Agenda (HSRA)

 The overriding goal of the DOH.

 Support mechanisms will be through sound
organizational devt., strong policies, systems,
and procedures, capable human resources
and adequate financial resources.
Rationale for Health Sector Reform

 Slowing down in the reduction of IMR and MMR

 Persistence of large variations in health status
across population groups and geographic areas.
 High burden from infectious diseases.
 Rising burden from chronic and degenerative
diseases.
 Burden of disease is heaviest in the poor
 Unattended emerging health risks from
environmental and work related factors
Five areas that need to be reformed

1. Health financing
2. Health regulation
3. Local health systems
4. Public health programs
5. Hospital systems
Framework for Implemetation of
HSRA
 FOURmula One for Health
 It was adopted as the implementation framework for health sector
reforms. It intends to implement critical interventions as the single
package backed up by effective management infrastructure and
financing arrangements.
 Four elements of Strategy:
1. Health Financing
1. The goal is to foster greater, better, and sustained investments in health. (Philippine Health
Insurance Corporation, National health Insurance Program and Department of Health)
2. Health Regulation
1. The goal is to ensure the quality and affordability of health goods and services.
3. Health Service Delivery
1. The goal is to improve and ensure the accessibility and avilability of basic and essential health
care in both public and private facilities and services
4. Good Governance
1. The goal is to enhance health system performance at the national and local levels.
FOURmula ONE for Health
implemetation strategy key feature:

 The engagement of the National Health

Insurance Program (NHIP) as the main level to
effect desired changes and outcomes in each of
the four implementation components.
 NHIP supports each of the elements in terms of:
1. Financing
2. Governance
3. Regulation
4. Service Delivery
Primary Health Care as an
Approach to Delivery of
Health Care Services
Primary Health Care

 Is essential health care based on practical,

scientifically sound and socially acceptable
methods and technologically made universally
accessible to individuals and families in the
community through their full participation and
at cost that the community and country can
afford to maintain at every stage of their
development in the spirit of self-reliance and
slef-determination. (Alma Ata Declaration of
1978)
Alma Ata Declaration

 PHC was declared during the First International

Conference on Primary Health Care which was
held in Alma Ata, USSR on September 6-12,
1978, sponsored by WHO and UNICEF
 Adopted by the Philippines through Letter of
Instruction 949 on October 19, 1979 – signed by
Pres. Ferdinand Marcos with the goal “Health in
the Hands of the People by Year 2020’.
Legal Basis of Primary Health Care

 Universal Declaration of Human Rights Article

25 Section 1 which states that:
“Everyone has the right to a standard of living
adequate for the health and well-being of
himself and his family, including food, clothing,
housing, and medical care and necessary social
services and the right to security in the event of
unemployment, sickness, disability, old age,
widowhood, or lack of livelihood.
Legal basis of PHC

 Philippine Constitution of 1987, Art. XIII, Sec 11,

state that:
“The state shall adopt an integrated and
comprehensive approach to health development
which shall endeavor to make essential goods,
health, and other social services available to all
the people of the underpriviledged sick, elderly,
disabled, women, and children. The State shall
endeavor to provide free medical services to
paupers”.
Legal Basis of PHC

 WHO (1995) believes that “govts have a

responsibility for the health of their people
which can be fulfilled only by the provision of
adequate health and social measures.
Core Strategy of PHC

 Full participation and active involvement of

the community towards the development of
self-reliance.
Components of Primary Health Care

1. Environmental Sanitation
2. Control of Communicable Diseases
3. Immunization
4. Health Education
5. Maternal and Child Health and Family Planning
6. Adequate Food and Proper Nutrition
7. Provision of Medical care and Emergency
Treatment
8. Treatment of Locally Endemic Diseases
9. Provision of Essential Drugs and Herbal medicines
Four Pillars in Primary Health Care

1. Active Community participation

2. Intra and Inter Sectoral linkages
3. Use of Appropriate Technology
4. Support Mechanism Made available
Characteristics of PHC Essential
Services
1. Community-based -
2. Accessible
3. Acceptable
4. Sustainable
5. Affordable
Levels of Health Care Facilities
(Tungpalan, 1981)
1. Primary Level
Rhus, sub-centers, community hospitals, specialty clinics,
health centers operated by both government and private
entities
2. Secondary Level
smaller, non-departmentalized hospitals that offer a variety of
healthcare services which require moderately-specialized
knowledge and technical resources – Provincial and Regional
hospitals
3. Tertiary Level
health facilities that offer highlytechnological and sophisticated
healthcare services such as those offered by sepecialty national
hospitals and medical centers.
Health Workers at the Primary Level

1. Village or Grassroots healthcare workers

These serve as the first contact of the community and the
initial link to the health care system.
BHWs, volunteers, or traditional birth attendants “hilots”
2. Intermediate-level health workers
represents the first source of professional health care.
doctors, nurses, midwives
3. First-line hopsital personnel
provide back-up services for cases that require
hospitalization
specialty doctors, nurses, dentist, pharmacist, and other
healthcare professionals in the hospital setting
Fig. 3 Levels of Health Care Facilities

National
Health Services TERTIARY
Medical centers
Teaching and
Training Hospitals

Regional Health Services

Regional Medical Centers
And Training Hospitals

Provincial/City Health Services

SECONDARY
Provincial / City Hospitals
Emergency / District Hospital

Rural Health Unit

Community Hospitals and Health Centers PRIMARY
Private Practitioners
Barangay Health Stations