Community Health Nursing 2 | NCM 0113

MODULE 1 • Strategy employed by public health is to:

o Identify and define health problems = primary and
Concepts, Principles and Theories in secondary data, interview, surveys
Community Health Nursing o Identify the determinants (factors associated with the
CONCEPTS AND PRINCIPLES problem “risk factors”)
o Develop and test intervention to control or prevent
Community health is facilitated by the development of the community the problem
and the active participation of its members. The resources of the o Assess the effectiveness of interventions
community and non-governmental agencies can help in attaining = monitoring and evaluating
community health. o Improvements in maternal and child health
Community development is defined as an organized effort of o Family planning
people to improve the conditions of community life and the capacity of Everyone – even the poorest member of the community can
the people for participation, self-direction and integrated efforts share something, maybe not in terms of money, but in terms of
in community affairs. It advocates the principles of self-help, and talents and skills.
the voluntary participation and cooperation of the people of the People – as long as a person is ready and willing to learn,
community. his/her potentials can be enhanced and nurtured.
The development of a healthy community is the ultimate end of all
the efforts and energy in the implementation of community organizing, CORE FUNCTIONS OF PUBLIC HEALTH PROGRAMS
participatory action research, effective primary health care delivery § Providing leadership on matters critical to health and engaging
system, training seminars and the empowerment of the residents of in partnerships where joint action is needed = Junior Chamber
depressed, underserved, and far-flung communities (Jimenez, 2008). International (JCI Angeles), Lion’s Club, RSL, Rotary Club
§ Shaping a research agenda and stimulating the generation,
ASSUMPTIONS OF COMMUNITY DEVELOPMENT
– Worth and dignity of the individual are the basic translation dissemination of valuable knowledge
§ Setting norms and standards and promoting and monitoring
values in a democratic society. Community
development is rooted in human development. their implementation
§ Articulating ethical and evidence-based policy options
– Everyone has something to contribute to the life of the
§ Monitoring the health situation and assessing health trends
community.
– People have the ability to learn and grow.
WAYS OF IDENTIFYING AND ASSESSING
PUBLIC HEALTH POPULATION NEEDS THROUGH PUBLIC HEALTH
• The science and art of preventing disease, prolonging life and § Assessing current services and evaluating whether they are
promoting human health through organized efforts and informed meeting the objectives of the health care system
choices of society, organizations, public and private, communities § Ascertaining requirements as expressed by health professionals, the
and individuals – Najorda public and other stakeholders
• Public health as the science and art of preventing disease, § Identifying the most appropriate interventions
prolonging life, and promoting physical health and efficiency § Considering the effect on resources for proposed interventions and
through organized community efforts for the sanitation of the assessing their cost-effectiveness
environment, the control of community infections, the education § Supporting decision making in health care and planning health
of the individual in principles of personal hygiene, the services including any necessary changes
organization of medical and nursing service for the early diagnosis § Informing, educating, and empowering people about health
and preventive treatment of disease, and the development of the issues
social machinery which will ensure to every individual in the
community a standard of living adequate for the maintenance of COMMUNITY HEALTH
health so organizing these benefits as to enable every citizen to • Focuses on the maintenance, protection and improvement of the
G.M.M.E. – MARILAG

realize his birthright to health and longevity – Winslow, Charles health status of population groups and communities as
1920 opposed to the health of the individual patients.
• In addition, prevention of disease both prolongs life and • WHO defines community health as environmental, social, and
improves the quality of life. In a sense, public health is the economic resources to sustain emotional and physical well-being
disease that never developed, the epidemic that didn’t happen, the among people in ways that advance their aspirations and satisfy
outbreak of food-borne illness that never occurred, and the child their needs in their unique environment.
that would develop asthma, but didn’t.
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CATEGORIES OF COMMUNITY HEALTH SOCIAL FACTORS

PRIMARY HEALTH CARE AND PRIMARY PREVENTION • Social determinants of health reflect the social factors and
• Community-based health promotion emphasizes physical conditions of the environment in which people are
primary prevention and population-based perspective. It is the born, live, learn, play, work, and age.
goal of community health to have individuals in a certain • Also known as social and physical determinants of health, they
community improve their lifestyle or seek medical impact a wide range of health, functioning, and quality-of-life
attention. outcomes.
• Primary health care is provided by health professionals, HEALTH SERVICES
specifically the ones a patient sees first that may refer them to • Both access to health services and the quality of health services
secondary or tertiary care. can impact health.
• Primary prevention refers to the early avoidance and • Lack of access, or limited access, to health services greatly
identification of risk factors that may lead to certain diseases impacts an individual’s health status.
and disabilities. INDIVIDUAL BEHAVIOR
• Community focused efforts including immunizations, • Individual behavior also plays a role in health outcomes.
classroom teaching, and awareness campaigns are all • Many public health and health care interventions focus on
good examples of how primary prevention techniques are changing individual behaviors such as substance abuse, diet,
utilized by communities to change certain health behaviors. and physical activity.
• Prevention programs, if carefully designed and • Positive changes in individual behavior can reduce the rates of
drafted, can effectively prevent problems that children and chronic disease in this country.
adolescents face as they grow up. Prevention programs are one BIOLOGY AND GENETICS
of the most effective tools health professionals can use to • Some biological and genetic factors affect specific populations
greatly impact individual, population, and community health. more than others. (Najorda, 2019)
SECONDARY HEALTHCARE AND SECONDARY PREVENTION
• Secondary prevention refers to improvements made in PRIMARY HEALTH CARE
a patient’s lifestyle or environment after the onset of Concept:
disease or disability. • Primary health care is a practical approach to the effective
TERTIARY HEALTHCARE provision of health services that are community-based, accessible,
• In tertiary health care, community health can only be acceptable and sustainable, at a cost which the community and the
affected with professional medical care involving the government can afford.
entire population. Patients need to be referred to specialists • It includes the full participation and active involvement of the
and undergo advanced medical treatment. people towards the development of a self-reliant community
o Public health professionals diagnose community capable of achieving an acceptable level of health and well-being.
health problems using scientific research and • The Director General of the World Health Organization
disease surveillance systems. emphasized that the world health will improve only if the people
o The primary goal of public health is to prevent themselves become involved in the planning and
disease and promote health at the implementing of their own health and health care. The
population level. Public health professionals people must be concerned not only with disease prevention and
employ many different disease prevention control but also with health promotion and care; and that health
strategies, such as health education, workers must all act as facilitators of actions of individuals, families,
community vaccination, sanitation and communities. Thus, they should recognize their roles as
initiatives, and health policy. partners and find ways to help individuals and families become self-
reliant. He also emphasized that both lay people and health
THE DETERMINANTS OF HEALTH
professionals are essential. Training and education of health
– It is the interrelationships among these factors that determine workers are needed to acquire the necessary skills to carry out the
individual and population health. Because of this, new roles effectively.
G.M.M.E. – MARILAG

interventions that target multiple determinants of health are • The WHO pointed out that primary health care is people-oriented.
most likely to be effective. Sectors such as education, housing, Its success rests on the people. WHO identified four (4) pillars on
transportation, agriculture, and environment can be which the actions towards the health-for-all principle must be based:
important allies in improving population health. 1. Political and social commitment and the
POLICY MAKING determination to move towards “health for all” as
• Policies at the local and national level affect individual and the main social target for the coming decades
population health.
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2. Community participation or the active communities, concerned with the promotion of health, prevention
involvement of people and the mobilization of of disease and disability and rehabilitation (Dr. Araceli Maglaya,
societal forces for health development et.al)
3. Cooperation between the health sector and other • GOAL of CHN: To raise the level of health of the citizenry by helping
development sectors such as education, communities and families cope with the discontinuities in and
communication, industry, public works, threats to health in such a way to maximize their potential for high-
transportation and housing level wellness (Nisce, Reyala, et al)
4. System support to ensure that essential health
PHILOSOPHIES OF CHN PRACTICE
care and scientifically sound, affordable health
technology are available to all people H Humanistic values of the nursing profession upheld
U Unique and distinct component of health care
OBJECTIVES OF PRIMARY HEALTH CARE (WHO, 1978) M Multiple factors of health considered
1. To enable the people to seek better health at home, in schools, in A Active participation of clients encouraged
fields and in factories N Nurse considers availability of resources
2. To enable the people to prevent injury and diseases, instead of I Interdependence among health team members practices
relying on doctors to repair damages that could have been avoided S Scientific and up-to-date
3. To enable the people to exercise the right and responsibility T Tasks of CH nurse vary with time and place
in shaping the environment and bringing about conditions that I Independence or self-reliance of the people is the end goal
make it possible and easier to live a healthy life C Connectedness of health and development regarded
4. To enable the people to exercise control in managing health
BASIC PRINCIPLES OF CHN
and related systems and to ensure that the basic pre-requirements
1. The community is the patient in CHN; the family is the unit of care;
for health and access to health care are available to all people.
and there are four levels of clientele: the individual, the family,
the population group (sub-units of the population who share
PRINCIPLES AND STRATEGIES IN PRIMARY HEALTH CARE
common characteristics, developmental stages, and common
1. Accessibility, Availability, and Acceptability of Health Services
exposure to health problems), and the community
2. Provision of Quality Basic and Essential Health Services
2. In CHN, the client is considered as an active partner, not a passive
3. Community Participation
recipient of care
4. Self-Reliance
3. CHN practice is affected by developments in health
5. Recognition of the Relationship Between Health and Development
technology, in particular; and changes in society, in general
6. Social Mobilization
4. The goal of CHN is achieved through multi-sectoral efforts
7. Decentralization (Jimenez, 2008)
5. CHN is a part of health care system and the larger human
services system *Community Information System
PUBLIC HEALTH NURSING
• The practice of nursing in national and local government health
THE POPULATION GROUP AS A CLIENT
departments (which include health centers and rural health units),
• A population group or aggregate is a group of people sharing the
and public schools.
same characteristics, developmental stage, or common exposure to
• It is a special field of nursing that combines the skills of nursing,
particular environmental factors.
public health, and some phases of social assistance and functions as
• These commonalities, thus, result in common health problems.
part of the total public health program for the promotion of health,
• Examples of population groups include children, women,
the improvement of conditions in the social and physical
farmers, cultural minorities, and the elderly.
environment, rehabilitation, and the prevention of illness and
A. CHILDREN – children in the Philippine setting are most
disability. (WHO Expert Committee on Nursing)
vulnerable to different types of diseases, especially those
brought about by socio-economic difficulties (+ infectious
COMMUNITY HEALTH NURSING diseases and malnutrition). M and M among infants
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• Service rendered by a professional nurse to communities, groups, B. ELDERLY – census of elderly; the elderly experience
families, and individuals at home, in health centers, in clinics, in various changes in their life that could be viewed as
schools, and in places of work for the promotion of health, developmental, physiological, or psychosocial in nature.
prevention of illness, care of the sick at home, and rehabilitation Changes may help caregivers understand the special
(Ruth Freeman) characteristics and needs of this particular group of
• The utilization of the nursing process in the different levels individuals.
of clientele – individuals, families, population groups and C. WOMEN
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THE COMMUNITY AS A CLIENT • Population – group of people having common personal or

Definition: environmental characteristics; all people in a defined community
• The community is a group of people sharing common geographic (Maurer and Smith, 2009)
boundaries/common values and interests (Maglaya, 2000). A • Aggregates – subgroups or subpopulations that have some
community functions within a socio-cultural context in that the common characteristics / concerns
people share the same cultural heritage, making each community o These common characteristics or concerns may make
unique from others. The physical characteristics of the environment the members of an aggregate vulnerable to similar health
also vary and this affects the economic production of the people. The problems
dynamics in one community is different from another due to the o Examples of aggregates are age groups or groups
varying biological characteristics, interests, and socio-economic undergoing similar physiologic processes like pregnancy
status of the people. (Gesmundo,2000) and menopause
• (Before 1996) - The definition of a community focused on o Depending on the situation, needs, and practice
geographical boundaries, combined with social attributes of the parameters, community health nursing interventions
people, (later part) – geographical location became a secondary may be directed toward a community (e.g. residents of a
characteristic in the discussion of what defines a community. small town), a population (e.g. all elders in a rural region),
• Recent literature, community has been defined as “a collection of or an aggregate (e.g. pregnant teens within a school
people who interact with one another and whose common interests district)
or characteristics form the basis for a sense of unity or belonging” • According to Maglaya (2000),
(Alexander et. al, 2009). a community has the following characteristics:
• A group of people who share something in common and interact 1. It is defined by its geographic boundaries within
with one another, who may exhibit a commitment with one another certain identifiable characteristics.
and may share a geographic boundary (Lundy and Janes, 2009) 2. It is made up of institutions organized into a social
• A group of people who share common interests, who interact with system, with the institutions and organizations linked in
each other, and who function collectively within a defined social a complex network having formal and informal power
structure to address common concerns (Clark, 2008). structures and a communication system.
• A locality-based entity composed of systems of formal organizations 3. It has a common or shared interest that binds the
reflecting society’s institutions, informal groups and aggregates members together.
(Shuster and Goeppinger, 2008). 4. It has an area with fluid boundaries within which a
• Four defining attributes of a community: problem can be identified and solved.
(Maurer and Smith, 2009) 5. It has a population aggregate concept.
1. People (Gesmundo, 2000).
2. Place
3. Interaction Classification of a Community
4. Common characteristics, interests, goals o Rural (Open lands) – Places in the provincial areas
• Community is seen as a group or collection of locality-based where people earn their living by agriculture; less
individuals, interacting in social units and sharing common dense and more spacious
interests, characteristics, values and goals. (Maurer and Smith, o Urban (City) – Non-agricultural type; dense; major
2009) source of income are industrial products and
• 2 main types of communities: technology
(Maurer and Smith, 2009) o Suburban (Capitals) – Capital of provinces where there
1. Geo-political – formed by both natural and man-made is a mix of agriculture and industry
boundaries and includes barangays, municipalities,
cities, provinces, regions, and nations. DETERMINANTS OF HEALTH AND DISEASE
Aka territorial communities § Health care access
2. Phenomenological – refer to relational, interactive § Economic conditions
G.M.M.E. – MARILAG

groups, in which the place or setting is more abstract, and § Social and environmental issues
people share a group perspective or identity based on § Physical environment
culture, values, history, interests, and goals. § Cultural practices
Examples: schools, colleges, and universities; churches o WHO
and mosques; and various groups or organizations.
Aka functional communities
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ü Income and social status – higher income and social status PUBLIC HEALTH AND COMMUNITY HEALTH
are linked to better health; the greater the gap between the Definition and Focus:
richest and poorest people, the greater the differences in • Public health is the science and art of preventing disease,
health prolonging life, and promoting health and efficiency through
ü Education – low education levels are linked with poor health, organized community effort for:
more stress, and lower self-confidence 1. Sanitation of the environment
ü Physical environment – safe water and clean air, healthy 2. Control of communicable infections
workplaces, safe houses, communities and roads all 3. Education of the individual in personal hygiene
contribute to good health 4. Organization of medical and nursing services for the
ü Employment and working conditions – people in early diagnosis and preventive treatment of disease
employment are healthier; particularly those who have in Integrated Management of Childhood Illness
control over their working conditions (IMCI)
ü Social support networks – greater support from families, 5. Development of the social machinery to ensure
friends and communities is linked to better health everyone a standard of living adequate for the
ü Culture – customs and traditions, and the beliefs of the maintenance of health (Famorca, 2000)
family and community all affect health Purpose: Improve the health of the public by promoting healthy
ü Genetics – inheritance plays a part in determining lifespan, lifestyles, preventing disease and injury, and protecting the health of
healthiness and the likelihood of developing illness communities.
ü Personal behavior and coping skills – balanced eating,
keeping active, smoking, drinking, and how we deal with THREE PRIMARY FUNCTIONS OF PUBLIC HEALTH
life’s stresses and challenges all affect health 1. ASSESSMENT – regular collection, analysis, and information
ü Health services – access and use of services that prevent and sharing about health conditions, risks, and resources in the
treat disease influences health community *local and general assembly ® identify
ü Gender – men and women suffer from different types of problems and how to solve
diseases at different ages 2. ASSURANCE – focuses on the availability of necessary health
ü Policies and interventions (education) can improve health services throughout the community. It includes maintaining the
by targeting detrimental or harmful factors related to ability of both public health agencies and private providers to
individuals and their environment. manage day-to-day operations and having the capacity to respond
Community health nurses must work with policy makers and community to critical situations and emergencies
leaders to identify patterns of disease and death and to advocate for 3. POLICY DEVELOPMENT – use of information gathered during
activities and policies that promote health at the individual, family, and assessment to develop local and state health policies and to direct
community levels. resources toward policies *Evaluation - KSA
It is essential for the community health nurse to understand the All nurses working in community settings should develop knowledge and
determinants of health and recognize the interaction of the factors that skills related to each of these primary functions.
lead to disease, death, and disability.
PUBLIC HEALTH EFFORTS AT THE NATIONAL LEVEL – concentrate on
INDICATORS OF HEALTH AND ILLNESS providing support and advisory services to public health structures at the
§ Life expectancy local level.
§ Infant mortality
§ Maternal mortality PUBLIC HEALTH EFFORTS AT THE LOCAL LEVEL – provide direct
§ Age-adjusted death rates services to communities through:
§ Disease incidence rates 1. Environmental health services, which protect the public
§ Indicators of mortality from hazards such as polluted water and air and tainted food
– illustrate the health status of a community and/or population 2. Personal health care services such as immunization and
because changes in mortality reflect a number of social, family planning services, well-infant and maternal care, and
G.M.M.E. – MARILAG

economic, health service, and related trends (Torrens, 2008). treatment-prevalent health conditions, both communicable
Nurses should participate in investigative efforts to determine and non-communicable
what is precipitating the increased disease rate and work to • Public health efforts are multi-disciplinary because they require
remedy the identified threats or risks. people with many different skills.
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• Essential public health functions Delegated functions – Are direct care tasks that a registered
1. Health situation monitoring and analysis professional nurse carries out under the authority of a health care
2. Epidemiological surveillance / disease prevention and control practitioner as allowed by law
3. Development of policies and planning in public health Health teaching – Communicates facts, ideas, and skills that change
4. Strategic management of health systems and services for knowledge, attitudes, values, beliefs, behaviors, and practices of
population health gain individuals, families, systems, and communities
5. Regulation and enforcement to protect public health Counseling – Establishes an interpersonal relationship with a
6. Human resources development and planning in public health community, a system, and a family or individual, with the intention of
7. Health promotion, social participation, and empowerment increasing or enhancing their capacity for self-care and coping
8. Ensuring the quality of personal and population-based health Consultation – Seeks information and generates optional solutions to
service perceived problems or issues through interactive problem solving with a
9. Research, development, and implementation of innovative community system and family or individual
public health solutions Collaboration – Commits two or more persons or an organization to
achieve a common goal through enhancing the capacity of one or more
Community-based Nursing – Community-based nursing practice of the members to promote and protect health
refers to “application of the nursing process in caring for individuals, Coalition building – Promotes and develops alliances among
families and groups where they live, work or go to school or as they move organizations or constituents for a common purpose
through the health care systems”. (Famorca, 2000) Community organizing – Helps community groups to identify
common problems or goals, mobilize resources, and develop and
Community Health Nursing Community-based Nursing implement strategies for realizing the goals they collectively have set
Emphasizes preservation and Emphasizes managing acute
protection of health or chronic conditions THEORETICAL FOUNDATIONS
Primary client is the Primary clients are the OF CHN PRACTICE
community individual and the family
Services are both direct and Services are largely direct
General Systems Theory
indirect
• The general systems theory is applicable to the different levels
of the community health nurse’s clientele: individual,
PUBLIC HEALTH INTERVENTION
families, groups, and communities.
Surveillance – Describes and monitors health events through ongoing • Viewed as an open system, the client is considered as a set of
and systematic collection, analysis, and interpretation of health data for
interacting elements that exchange energy, matter, or
the purpose of planning, implementing, and evaluating public health
information with the external environment to exist.
interventions
• The individual is a set of several dimensions – physical,
Disease and other health event investigation – Systematically
psychological, social, and spiritual – that are independent and
gathers and analyzes data regarding threats to the health of populations,
interrelated. (Famorca, 2000)
ascertains the source of the threat, identifies cases and others at risk, and
• Based on assumption that there are universal principles of
determines control measures
organization, which hold for all systems, be they physical,
Outreach – Locates populations of interest or populations at risk and
chemical, biological, mental or social
provides information about the nature of the concern, what can be done
about it, and how services can be obtained
Screening – Identifies individuals with unrecognized health risk factors
or asymptomatic disease conditions
Case finding – Locates individuals and families with identified risk
factors and connects them with resources
Referral and follow-up – Assist individuals, families, groups,
organizations, and communities to identify and access necessary
G.M.M.E. – MARILAG

resources to prevent or resolve problems or concerns

Case management – Optimizes self-care capabilities of individuals and
families and the capacity of systems and communities to coordinate and
provide services
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Social Learning Theory • One of the most widely used conceptual frameworks in
• Social learning theory is based on the belief that learning takes health behavior, has been used to explain behavior change
place in a social context, that is, people learn from one and maintenance of behavior change and to guide health
another and that learning is promoted by modeling or promotion interventions. (Janz, et al, 2002).
observing other people. CONCEPT DEFINITION
• It is anchored on the fact that persons are thinking beings with
One’s belief regarding the chance of
self-regulatory capacities, capable of making decisions and Perceived susceptibility
getting a given condition
acting according to expected consequences of their behavior.
One’s beliefs regarding the
• The environment affects learning, but learning outcomes Perceived severity
seriousness of a given condition
depend on the learner’s individual characteristics (Bandura,
One’s belief in the ability of an
1977)
advised action to reduce the health
• Examples: Perceived benefits
risk or seriousness of a given
Demonstrating infant care procedures,
condition
giving detailed verbal instructions (teaching a patient on how
One’s belief regarding the tangible
to collect an early morning sputum specimen),
Perceived barriers and psychological costs of an advised
or by using print or multimedia strategies for health education.
action
• Application:
Strategies or conditions in one’s
Consider the nurse teaching a group of young mothers about
Cues to action environment that activate readiness
giving solid food in addition to breastmilk to infants who are
to take action
older than 6 months. The nurse facilitates the
One’s confidence in one’s ability to
mother’s learning through: Self-efficacy
take action to reduce health risks
1. Catching the mother’s attention through different
strategies • All of these constructs relate to the client’s perception.
2. Promoting retention of learning by demonstrating • Behavior is based on current dynamics confronting an
the step-by-step procedure of preparation of solid individual rather than prior experiences (Maiman and Becker,
food for infants 1974).
3. Providing the mothers with occasions for the • The HBM is based on the assumption that the major
reproduction or imitation of the procedures of determinant of preventive health behavior is disease
straining, pureeing, mashing, grinding, and avoidance.
chopping appropriate foods • Example:
4. Motivating the mothers by explaining the benefits A community health nurse explores a group of teenagers’
derives from the behavior (Bandura, 1977) beliefs about the seriousness of eating disorders and their
• Attention (stimuli focus) ® Retention (rehearse encode) ® related susceptibility
Motor Reproduction (practice feedback) ® Motivation • Offers indicators of the perceived seriousness, perceived
(reward reinforce) susceptibility, and cues to action related to specific health
behaviors.
• Modifying factors ® Individual beliefs ® Actions
• Modifying factors
o Age, Gender, Geographic location, Education,
Ethnicity, Health knowledge, Immigration status,
Income, Race, Wealth
• Individual beliefs
o Perceived susceptibility to disease
Health Belief Model o Perceived severity of disease
o Perceived benefits of preventative action
G.M.M.E. – MARILAG

• Through this work, information alone is rarely enough to

o Perceived barriers to preventive action
motivate one to act.
o Perceived self-efficacy
• Individuals must know what to do and how to do it before they
• Actions
can take action.
o Individual behaviors Þ cues to action (media
• Also, the information must be related in some way to the
campaigns, physical reminders, friend/family
individual’s needs.
member’s illness)
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gain health and for society to improve health status. Milio’s

framework can enable a nurse to reframe this view by
understanding the historic play of social forces that have
limited the choices available to the parties involved.
• Compared with the HBM, Milio’s framework provides for the
inclusion of economic, political, and environmental
health determinants; therefore, the nurse is given broader
range in the diagnosis and interpretation of health problems.
• Lifestyles are patterns of choices made from available
alternatives according to people’s socioeconomic
Milio’s Framework for Prevention circumstances and how easily they are able to choose some
• Nancy Milio outlined six propositions that relates an over others.
individual’s ability to improve healthful behavior to a society’s • Whereas the HBM allows only two possible outcomes (acts or
ability to provide accessible and socially affirming options for fails to act) according to the recommended action, Milio’s
healthy choices. Milio used these propositions to move the framework encourages the nurse to understand health
focus of attention upstream in the attempt to create a behaviors in the context of their societal milieu.
framework for initiating upstream policies. • No scarcity of resources ® Obesity, High blood pressure,
• She noted that the range of available health choices is critical alcoholism
in shaping a society’s overall health status. In addition, she • Milio's framework for prevention (1976) provides a
stated that policy decisions in governmental and private complement to the HBM and a mechanism for directing
organizations shape the range of choices available to attention upstream and examining opportunities for nursing
individuals. intervention at the population level.
• She believed that national-level policy making was the
best way to favorably impact the health of most people rather Pender’s Health Promotion Model
than concentrating efforts on imparting information in an • Pender’s heath promotion model (HPM) explores many
effort to change individual patterns of behavior. biophysical factors that influence individuals to pursue
• Milio proposed that health deficits often result from an health promotion activities.
imbalance between a population’s health needs and its health-
sustaining resources. She stated that the diseases associated VARIABLES OF HPM
with excess (obesity and alcoholism) afflict affluent societies, Individual Each person’s unique characteristics and
and the diseases that result from inadequate or unsafe food, characteristics experiences affect his or her actions.
shelter, and water afflict the poor. Within this context, the poor and experiences
in affluent societies may experience the least desirable Prior behaviors influence subsequent
combination of factors. behavior through perceived self-efficacy,
• Personal and societal resources affect the range of health- Prior related benefits, barriers, and affects related to that
promoting or health-damaging choices available to behavior activity.
individuals. Personal resources include the individual’s Habit is also a strong indicator of future
awareness, knowledge, and beliefs and the beliefs of the behavior.
individual’s family and friends. Money, time and the urgency Personal factors that may influence
of other priorities are also personal resources. Community behavior: Age, body mass index, strength,
and national conditions strongly influence societal and agility.
resources. These resources include the availability and cost of Psychological factors: Self-esteem, self-
Personal factors
health services, environmental protection, safe shelter, and motivation, and perceived health status.
penalties or rewards for failure to select the given options. Sociocultural factors: Race, ethnicity,
• Milio challenged health education’s assumption that acculturation, education, and socio-
G.M.M.E. – MARILAG

knowledge of health-generating behaviors implies an act in economic status.

accordance with that knowledge. She proposed that “most Very significant in behavior motivation.
Behavior-specific
human beings, professional or nonprofessional, They are a “core” for intervention because
cognitions and
provider or consumer, make the easiest choices they may be modified through nursing
affect
available to them most of the time.” actions.
• Health-promoting choices must be more readily available
and less costly than health-damaging options for individuals to
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Assessment of the effectiveness of • Pender’s model does not include threat may not be a
interventions is accomplished by measuring motivating factor for clients in all age groups (Pender, 2006).
the change in these variables. • Individual characteristics and experiences ®
The perceived benefits of a behavior are Behavior-specific cognitions and affect ® Behavior
strong motivators of that behavior. outcome (Attaining a positive health outcome)
Perceived Intrinsic benefits include increased energy • Similar to Health Belief Model
benefits of action and decreased appetite.
Extrinsic benefits include social rewards
such as compliments and monetary rewards.
Barriers are perceived unavailability,
Perceived barriers
inconvenience, expense, difficulty, or time
to action
regarding health behaviors.
Self-efficacy is one’s belief that he or she is
capable of carrying out a health behavior. If
Perceived self-
one has high self-efficacy regarding a
efficacy
behavior, one is more likely to engage in that
behavior than if one has low self-efficacy.
The feelings associated with a behavior will
Activity-related
likely affect whether an individual will repeat
affect The Transtheoretical Model
or maintain the behavior.
• The TTM is based on the assumption that behavior change
In the HPM, these are feelings or thoughts
takes place over time, progressing through a sequence of
Interpersonal regarding the beliefs or attitudes of others.
stages. It also assumes that each of the stages is both stable
influences Primary influences are family, peers, and
and open to change. In other words, one may stop in one
health care providers.
stage, progress to the next stage, or return to the previous
These are perceived options available,
stage.
demand characteristics, and aesthetic
Situational features of the environment where the
STAGES OF CHANGE
influences behavior will take place.
CONSTRUCTS DESCRIPTION
Ex. The fire code will prevent smoking
The individual has no intention to take
indoors
action toward behavior change in the next
Pender states that “commitment to a plan of
6 months.
action initiates a behavioral event” (Pender, Pre-contemplation
Due to lack of information about the
Commitment to a 2006). This commitment will compel one
consequences of the behavior or due to
plan of action into the behavior until completed, unless a
failure on previous attempts at change.
competing demand or preference
intervenes. The individual has some intention to take
action toward behavior change in the next
These are alternative behaviors that one Contemplation
6 months.
considers as possible optional behaviors
Immediate Weighing pros and cons to change.
immediately prior to engaging in the
competing The individual intends to take action within
intended, planned behavior. One has little
demands and the next month, and has taken steps
control over competing demands, but one Preparation
preferences toward behavior change.
has great control over competing
preferences. Has a plan of action.
The individual has changed overt behavior
Goal of HPM.
Health-promoting for less than 6 months.
The aim of health-promoting behavior is Action
G.M.M.E. – MARILAG

behavior Has changed behavior sufficiently to

the attainment of positive health outcomes.
reduce risk of disease
The individual has changed overt behavior
• The HPM depicts the complex multidimensional factors
with which people interact as they work to achieve optimum for more than 6 months.
Maintenance
health. Strives to prevent relapse.
This phase may last months to years.
 Community Health Nursing 2 | NCM 0113

DECISIONAL BALANCE Precede-Proceed Model

Pros The benefits of behavior change • The precede-proceed model provides a model for community
Cons The costs of behavior change assessment, health education planning, and evaluation.
PRECEDE, which stands for predisposing, reinforcing, and
THE TTM AND CHANGE
enabling constructs in educational diagnosis and evaluation,
Change is difficult, even for the most motivated individuals. People
is used for community diagnosis. PROCEED, an acronym for
resist change for many reasons. Change may:
policy, regulatory, and organizational constructs in educational
§ Be unpleasant (exercising)
and environmental development, is a model for implementing
§ Require giving up pleasure (eating desserts / watching TV)
and evaluating health programs based on PRECEDE.
§ Be painful (undergoing insulin injections)
• In this model, predisposing factors refer to people’s
§ Be stressful (eating new foods)
characteristics that motivate them toward health-related
§ Jeopardize social relationships
behavior. Enabling factors refer to conditions in people and
(meeting friends and family during gatherings involving food)
the environment that facilitate or impede health-related
§ Not seen important anymore
behavior. Reinforcing factors refer to feedback given by
(among older individuals or those with the ill effects of lifestyle
support persons or groups resulting from the performance of
choices such as DM and HPN)
the health-related behavior.
§ Require change in self-image
(from being a couch potato to an athlete)
OTHERS THEORIES:
The stages of Change Model:
Orem's Self-Care Deficit Theory is based on individual self-
(Enter) Precontemplation ® Contemplation ® Determination
care needs and explains the level of nursing interventions required to
® Action ® Relapse ® Maintenance Þ Precontemplation… (exit
assist clients to obtain optimal health.
and re-enter at any stage)
o Precontemplation ("not ready") – People are not intending Critical Social Theory uses societal awareness to expose social
to take action in the foreseeable future, and can be unaware inequalities that keep people from reaching their full potential.
that their behavior is problematic
o Contemplation ("getting ready") – People are beginning to TRENDS, STATISTICS AND
recognize that their behavior is problematic, and start to look THE SITUATION IN THE PHILIPPINES
at the pros and cons of their continued actions
o Preparation ("ready") – People are intending to take action in
THE PHILIPPINE SITUATION
the immediate future, and may begin taking small steps
SELECTED HEALTH OUTCOMES
toward behavior change
o Action – People have made specific overt modifications in
modifying their problem behavior or in acquiring new healthy
behaviors
o Maintenance – People have been able to sustain action for at
least six months and are working to prevent relapse
§ Reinforcement
o Termination – Individuals have zero temptation and they are
sure they will not return to their old unhealthy habit as a way
of coping
G.M.M.E. – MARILAG

Selected indicators serve as proxy measure for determining if the

strategies and interventions implemented by the health sector and other
stakeholders led to overall improvements in health outcomes. Results
using selected indicators such as life expectancy, maternal
mortality ratio (MMR), infant mortality rate (IMR), under-five
 Community Health Nursing 2 | NCM 0113

mortality rate (U5MR), prevalence of stunting among under-five TEN LEADING CAUSE OF MORBIDITY
children, and TB prevalence showed mixed results. (Figure 1.2) *air quality, environmental factors, highly populated, lack of
program implementation
Stunting was observed to be high among those residing in rural areas
(38.1 percent) and those belonging to the poorest quintiles (49.7
percent)

Despite living longer than in previous years, Filipinos now bear a triple
burden of disease with the high prevalence of communicable diseases
and NCDs.

Filipinos are also susceptible to risks brought by the increasing impact

of globalization and climate change, with the Philippines ranking third
in the world in terms of exposure to disaster risks (Dayrit et al., 2018).

Thousands have died from previous rapid onset disasters that struck the
country, commonly owing to trauma, drowning or crush-related
injuries.

Moreover, flooding can increase transmission of certain diseases such

as leptospirosis and dengue, while power cuts may disrupt water
treatment and supply, exposing the population to the risk of water-
borne diseases (WHO, 2018b). Leading causes of morbidity were all communicable diseases, except
for hypertension; INDONESIA as epicenter in SE Asia
Hinder the normal growth, development, or progress.
MIXED - Availability, accessibility and affordability of quality
TEN LEADING CAUSE OF MORTALITY healthcare have impeded healthcare utilization. The archipelagic nature
of the country, uneven distribution of its population and the varying
levels of economic growth in the regions led to human resource for health
maldistribution, with health workers, particularly doctors and nurses,
concentrated in more urbanized and economically developed areas. The
country also lacked over 2,500 RHUs or health centers and more than 500
barangay health stations to serve the population in 2016, despite the
DOH support to the new construction of 351 BHSs and 107 RHUs under
the 2016 Health Facility Enhancement Program (HFEP).
DISJOINTED - Overlapping and sometimes, conflicting mandates of the
DOH and LGUs on health owing to devolution led to the disintegration
of the originally integrated referral system that linked public health
services and hospital services. Decentralization was pushed too far,
leading to fragmentation in service delivery as each health unit was
inefficiently assigned to a different local government rather than keeping
the integrated provincial health system in place. The flow of health
funds was also made more complicated and inequitable with the weak
Several NCDs share common lifestyle-related risk factors: cigarette
link between health budget allocation and devolved health
smoking, hypertension, hyperglycemia, dyslipidemia, obesity,
functions.
physical inactivity and poor nutrition.
HIGH - More than half of health expenditures remained to be funded by
While assault did not appear on this table, it was included in the top 10
out-of-pocket (OOP) payments despite increased resources for health
leading causes of death for males in 2016.
G.M.M.E. – MARILAG

in recent years. While the huge budgetary infusion translated to higher

In the previous years, accident figured prominently in the list, ranking PhilHealth coverage and led to the design of pro-poor schemes such as
as the fifth highest among the leading causes of mortality from 2012- the No Balance Billing (NBB) policy, social health insurance remained
2014. inadequate in protecting Filipinos from the financial burden of
healthcare. This may be indicative of issues such as low member
awareness and availment of benefits, inadequate scope and
amount of PhilHealth benefit packages.
 Community Health Nursing 2 | NCM 0113

THE PHILIPPINES AND ITS HEALTH SYSTEM Strategic Goal 1: Better health outcomes
• Mixed health outcome
o Ratio of doctors and nurses
o Problem with urbanization
o Limited health centers, midwife, doctors, nurses
• Disjointed health system
o Problems with devolution (national government
vests power and authority upon LGUs to perform
specific functions and responsibilities)
• High out-of-pocket expenditure
o PhilHealth coverage (20% discount on healthcare
services, should be an active payer)
• Philippine Health Agenda (2016-2022)
• “All for Health Towards Health for All”

SUSTAINABLE DEVELOPMENT GOALS (SDG)

Strategic Goal 2: Responsive health system
• Goal 1 “No poverty”
• Goal 2 “Zero hunger”
• Goal 3 “Good health and well-being”
• Goal 6 “Clean water and sanitation”
• Goal 7 “Clean energy”
• Goal 11 “Sustainable cities and communities”
• Goal 13 “Climate action”
• Goal 16 “Peace, justice and strong institutions” Strategic Goal 3: Equitable health financing
• Goal 17 “Partnerships for the goals”

FORMULA 1 PLAN

VISION, MISSION, GOALS, STRATEGIC PILLARS,

"PLUS", VALUES, AND QUALITY POLICY

NBB (No balance billing)

G.M.M.E. – MARILAG

In response to the challenges identified in improving health outcomes

and the health system, the DOH pursues FOURmula One Plus (F1
Plus) for Health, which aims to provide Universal Health Care (UHC)
for all Filipinos. The national policy on UHC espouses three strategic
thrusts: better health outcomes, responsive health system, and
equitable and sustainable health financing.
 Community Health Nursing 2 | NCM 0113

CHARACTERISTICS OF A HEALTHY COMMUNITY 4. Self-reliance

§ Members are aware of their own health and biologic status Strategies:
§ Members give credit to the governing authority o Community gives support to the health program
§ The natural and biological resources are open for everybody, Cash, kind or labor
but the consumption is controlled to help in preserving these o Use of local resources
resources o Training of the community on leadership and
§ Has a strong and reliable governing body management of skills
§ The people work together to attain independence o Incorporation of income-generating projects
§ Environmental and physiologic needs are sustained by the (ex. cooperatives)
community and families Small-scale industries
§ Parents and guardians serve as role models for the 5. Recognition of the Relationship Between Health and
children Development
§ The people are concerned with their health status Strategies:
§ Health needs are accessible and affordable to the public o (comes together) Convergence of health, food,
and free for the indigent nutrition/water, sanitations and population services
o Integration of the PHC into national, regional, provincial,
PRINCIPLES AND STRATEGIES IN PRIMARY HEALTH CARE municipal and barangay development plans
1. Accessibility, Availability, and Acceptability of Health o Coordination of activities with economic planning,
Services education, agriculture, industry, housing, public works,
Strategies: communication and social services
o Health services must be delivered where the people are 6. Social Mobilization
o Indigenous/indigent volunteer workers must be tapped Strategies:
as care providers o Establishment of an effective health referral system
o Traditional (herbal) medicine must be used together with o Multi-sectoral and interdisciplinary linkages
essential drugs o Information, education and communication support
o 1 CHW = 10-20 households using multi-media
2. Provision of Quality Basic and Essential Health Services o Collaboration between GO and NGOs
Strategies: 7. Decentralization
o Training design and curriculum are based on community Strategies:
needs and priorities o Re-allocation of budgetary resources
Training – task analysis of community health o Re-orientation of health professionals on PHC
workers (CHW) are competency-based *Transfer of authority from central to local
o Attitudes, knowledge and skills developed are on government
promotive, preventive, curative and rehabilitative health
care (IMCI)
o Regular monitoring and periodic evaluation of CHW
performances are conducted by the community and
health staff
3. Community Participation
Strategies:
o Awareness-building and consciousness-raising on health
and health-related issues
o Planning, implementation, monitoring and evaluation
through small group meetings (10-12 households)
o Selection of community health workers by the community
G.M.M.E. – MARILAG

o Community-building and community organizing

o Formation of health committees
o Establishment of a CHW organization at the parish or
municipal level
o Mass health campaign and mobilization to combat health
problems (ex. commercials)