Public Health

According to WHO
Art of applying Science in the Context of
Politics so as to Reduce Inequalities in
Health while ensuring the best health for
the greatest number.
According to Dr. Charles Edward Winslow,
Father of Public Health
Science and Art of Preventing Disease,
Prolonging Life, Promoting Health and
efficiency

PS
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al
lcH
Ase
sa
sl
th
a
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c
e

PS
ou
cb
i
il
i
i
acH
lAe
sa
i
sl
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it
sh
t
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e
Includes nurses in the public sector or the
government.

Community Health Nursing

Through: Organized
Community Effort
for
Medical &
Nursing
services for
Communicabl 1. Early
Diagnosis
e Disease
2. Preventive
Control

Environmental
Sanitation

According to Dr. Araceli Maglaya

Standard
of living
adequate
to
maintain
health

Goal: to Enable
Every Citizen to
Realize His
Birthright to
Health and

Public Health Nursing

According to WHO Expert Committee on
Nursing
Special Field of Nursing that 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
the social and physical environment,
rehabilitation of illness and disability.

The utilization of the Nursing Process in

the Different Levels of ClienteleIndividuals, Families, Population Groups
and Communities, concerned with the
Promotion of Health, Prevention of
Disease
and
Disability
and
Rehabilitation.
Broader -includes CHNs in both public &
private sectors.
CHN Process:
Assessment (diagnosis is
embedded)
Planning
Implementation
Evaluation
Goal:

Maglaya
1. Promotion of Health
2. Preservation of Health

Nisce, et. al
"To raise the level of health of the
citizenry by helping communities and
families to cope with
the discontinuities
in and threats to health in
such a way
as to maximize their potential for
highlevel wellness"
Setting: Community -place where people
under usual or normal conditions are found
(villages,
schools, workplaces, etc.)
-must be outside the institutional
setting
(hospitals, etc. are excluded)
Nature
of
Practice:
Comprehensive,
general, continual
Not
limited
to
a
particular
specialization, not episodic, and spans the
entire life cycle.

Knowledge: Integration of nursing with

public health as well as sociology,
psychology, anthropology,
economics
and political science
Important concepts to note in
answering questions:
1. Greatest good for the greatest
number
2. Health promotion & disease
prevention are prioritized over curative
care
3. The primary responsibility of the
nurse is to the population as a whole
4. Client is an active, equal partner
of the nurse, not a passive recipient of care
5. CHN is affected by its immediate
context,
the healthcare delivery system,
as well as
overall political, economic,
socio-cultural, and environmental factors
6. CHN is dynamic and flexible due
to varying objective and subjective
realities in different
settings
7. Community PARTICIPATION is
key!!!
Remember! CHN
means
Community the
client
Health the goal

The philosophy
of CHN is based
on the worth and
dignity of man.
-Dr. Margaret
Shetland

other health professionals, government

agencies, the private sector, nongovernment organizations and people's
organizations to address health
problems

CHN is HUMANISTIC. It is guided by

these beliefs:

Humanistic values of nursing are upheld

Unique and distinct component of healthcare
Multiple factors of heath considered
Active participation of clients encouraged
Nurse considers availability of resources
Interdependence among health team members

monitors and supervises the

performance of midwives and other
auxiliary health workers; also initiates
the formulation of staff development and
training programs for midwives and
other auxiliary health workers as part of
their training function as supervisors

practiced
Scientific and up-to-date
Tasks of CH nurse vary with time and place
Independence or self-reliance of the people is
the end-goal

Roles of a Community Health

Nurse
Clinicia
n
Coordinator
and
Collaborator
Manag
er

Educat
or

Health Educator
utilizes teaching skills to improve the
health knowledge, skills and attitude of
the individual, family and the
community and conducts health
information campaigns to various
groups for the purpose of health
promotion and disease prevention
Coordinator and Collaborator
establishes linkages and
collaborative relationships with

Manager
organizes the nursing service
component of the local health agency or
local government unit (ex. Nursing
service plan component of the overall
municipal health plan); also, as program
manager, the PHN is responsible for the
delivery of the package of services
provided by the health program to the
target clientele (ex. The PHN is almost
always the program manager of the
National Tuberculosis Program)

Leader and
Change
Agent
Researc
her

utilizes the nursing process in the

care of the client in the home
setting through home visits and in
public health care facilities;
conducts referral of patients to
appropriate levels of care when
necessary

Leader and Change Agent

influences people to participate in the

overall
process
of
community
development

Supervis
or

Clinician or Health Care Provider

Supervisor

Researcher

participates in the conduct of research

and utilizes
research findings in
practice (ex. disease
surveillance or the
continuous collection and
analysis of
data on diseases and causes of death)
In the event that the Municipal Health
Officer (MHO) is unavailable or is
unable to perform his duties, the
Public Health Nurse will take charge.

Specialized Fields in CHN

Community Mental Health Nursing
A unique clinical process which includes
an integration of concepts from nursing,
mental health, social psychology,
psychology, community networks, and
the basic sciences
Occupational Health Nursing
The application of nursing principles and
procedures in conserving the health of
workers in all occupations

 School Health Nursing

The application of nursing theories and
principles in the care of the school
population

Three Levels of Healthcare Services

Primary Level of Care - the first contact between the community people and the different
levels of health facility; refers to health care provided by the health center staff
Secondary Level of Care - rendered by physicians with basic health training in district
hospitals, provincial hospitals and city hospitals; these facilities are capable of basic surgical
procedures and simple laboratory examinations; serves as the referral center of primary health
facilities
Tertiary Level of Care - rendered by specialists in medical centers, regional hospitals and
specialized hospitals like the Heart Center of the Philippines; serves as the referral center of
secondary health facilities

PRIMARY

SECONDARY

TERTIARY
R

Health problems that are beyond the capability of the primary health care units are referred to
an intermediate health facility like the rural health unit (RHU). The RHU team usually consists of:
Rural Health Physician or the Municipal Health Officer (MHO)
Dentist
Public Health Nurse (PHN)
Rural Health Midwife (RHM)
Sanitary Inspector
Community Volunteer Health Workers (CVHW) or Barangay Health Workers (BHW)
Health problems that are beyond the capability of the RHU Team are referred to the District
Hospital. Clients manifesting more complicated conditions need referral to higher levels of care.
Higher levels of health services at the provincial, regional and national levels provide secondary
or tertiary care to complete the health care given at the district and peripheral levels. With this,
the functionality and strengths of the health care delivery system lie on the strength of the
referral system. The two-way referral system creates and maintains the network of health
services.

Two levels of Primary Healthcare Workers

1. Village or Barangay Health Workers (V/BHWs) - refers to trained community health
workers or health auxiliary volunteers 6r traditional birth attendants or healers
2. Intermediate Level Health Workers - refers to general medical practitioners or their
assistants, public health nurses, rural sanitary inspectors, and midwives
Midwife 1:5,000
Nurse
1:20,000

E
X
A
M
P
L
E
C
H
A
R
A
C
T
E
R
I
S
T
I
C
S

MHO
1:20,000
Sanitary Inspector
1:20,000

Village/Grassroots
Health Workers
Trained community
health worker
Auxiliary health
volunteer
Traditional birth
attendant
Initial link, 1st contact
of the community
Works in liaison with
the local health service
workers
Provides elementary
curative and preventive
health care measures

Intermediate Level

Dentist:

1:50,000

General medical
practitioners
Public health nurses
Midwives

Health Personnel of
First-Line Hospitals
Physicians with
specialization
Nurses
Dentists

1st source of
professional health care
Attends to health
problems beyond the
competence of village
health workers
Provides support to the
frontline health workers
in terms if supervision,
training, referral services
and supplies thru
linkages with other
sectors

Establish close contact

with the village and
intermediate level health
workers to promote the
continuity of care from
hospital to community to
home
Provides back-up
health services for cases
requiring hospital or
diagnostic facilities not
available in health
centers, etc.

Board Exam Review Notes Volume 2

Adapted from CENE Nursing

Four Levels of Clientele in the

Community

-solid source of support to the young, elderly,

disabled, chronically ill

Individual
-sick or well individuals in homes and
health centers
-considered as entry point in working with
the family

Population group
-a group of people sharing the same
characteristics, developmental stage or
common exposure to
particular environmental factors thus
resulting in common health problems

Family
-2 or more persons bound together by
blood, marriage, or adoption (traditional
meaning)
-2 or more persons who are joined by bonds
of sharing and emotional closeness and
who identify themselves as being part of the
family (contemporary meaning)
-2 major functions: reproduction and
socialization
-basic unit of care in CHN
-may contribute to wellness or illness
-locus of decision-making on health matters

Community
-group of people sharing common
geographic boundaries and/or common
values and interests
-no 2 communities are alike
-exerts a strong influence on health of
individuals, families, and communities
-most service provisions are in the
community level

Healthcare Delivery System

MAJOR PLAYERS
Public Sector - tax-based
- generally free at point of service
National level - Department of Health as
lead agency
Local health system - run by local
government units
Private Sector usually profit-oriented but
some are also non-profit orgs e.g. NGOs like
Red Cross.
THE PUBLIC SECTOR
Department of Health
Vision:

Leader

Advocate
Model

in promoting health for all

Mission: Equitable
Sustainable
Filipinos
Quality
poor

Health for all

especially the

Roles and Functions (based on EO 102):

LACE

Local Government Units

Leadership in health
-Leader in the formulation, monitoring,
and evaluation of national health policies,
plans, and programs
-Advocate adoption of health policies,
plans, programs
-National policy and regulatory institution
Administrator of specific services
-Manage selected health facilities e.g.
national centers like special or tertiary
hospitals
-Administer service for emerging health
concerns the require complicated
technologies
-Provide emergency health response for
catastrophic events, epidemics, and
The Private Sector
widespread public danger upon
authorization by the President and
consultation with the local government.
Commercial
Non-Commercial
Capacity builder and Enabler

Profit
Oriented
to social
-Ensure highest achievable standards of
oriented
development,
relief,
quality health care, health promotion and
rehabilitation,
and community
health protection
organizing
-Innovate new strategies in health to

Socio-civic groups
improve the effectiveness of health
Manufacturi
Religious
programs
ng
organizations/foundations
-Initiate public discussion on health
companies
NGOs which assume the
issues and disseminate policy research

following roles
outputs to ensure informed public
Advertising
-Policy and Legislative
participation in policy decision-making
agencies
advocacies
Private
-Organizing, Human Rights
-Oversee implementation, monitoring
and evaluation of national health plans, practitioners advocacies
Private
-Research and Development
programs and policies
institutions
-Health Resource
Development
Goal of the DOH: Implementation of the
Personnel
HSRA (Health Sector Reform Agenda)
-Relief and Disaster
Management
Framework for implemention of
-Networking
HSRA: FOURmula One for Health
Elements of FOURmula One for
Health
GOod GOvernance enhance
performance; key player is PhilHealth
Health FInancing health investments
Health REgulation quality and
affordable health goods and services
Health Service Delivery accessibility
and availability of health services

Primary Health Care

Essential health care made universally

accessible to individuals and families in the
community by means acceptable to them,
through their full participation and at a
cost that the community and country can
afford at every stage of development. -WHO

Conceptual Framework:
a. Health is a fundamental human right
b.Health is both an individual and
collective responsibility
c. Health should be an equal opportunity
to all
d.Health is an essential element of
socio-economic development
TRANSLATED into ACTION, the PHC
APPROACH focuses on:

Partnership with the community

Equitable distribution of health
resources

Organized and appropriate health

Focus of Care
Setting for
Services
People
Structure

Process
Technology

system infrastructure

Prevention of disease and

promotion of health is the focus

Linked multisectorally
Emphasis on appropriate technology

Outcome

5As of PHC

vailable
ccessible
ffordable
cceptable
ttainable

PHC GOAL (in 1978): Health for All by the

year 2000
PHC was declared in Alma-Ata (now Almati),
Kazakhstan, USSR during the First
International Conference on PHC held on
September 6-12, 1978 through the
sponsorship of WHO and UNICEF.
LEGAL BASIS OF PHC IN THE
PHILIPPINES: Letter of Instruction (LOI) 949
signed in October 19, 1979 by former
President Ferdinand E. Marcos
NEW GOAL for the Philippine
implementation of PHC: Health in the
Hands of the People by 2020
PHC as a service delivery policy of the DOH
permeates all strategies and thrusts of
government health programs from the
national to the community levels.
Dimension
Goal

Commercialized
Healthcare
Absence of the disease for
the individual

Sick
Hospital-based
Urban-centered
Accessible only to a few
people
Passive recipients of
healthcare
Health is isolated from other
sectors of society

Decision-making from top to

bottom
Curative case based on

modern medicine and

sophisticated technology
Physician dominated

Reliance on health
professionals

Four Pillars of PHC

Use of appropriate
technology
Support mechanism made
available
Active community

Appropriate technology meansSuper

Capal FACES (SC FACES)!!!

Scope of technology serves a variety of

purposes

Complexity should be simple and easy to

Primary
HC conditions
apply
under local
ELEMENTs:

ealth education
FH
easibility
compatible with local conditions
ommunicable
disease in terms of the
AC
cceptability
measured
controlof utilization of the people
degree

Cost should be affordable

xpanded program on
EE
ffectiveness should produce the desired

immunization
effect
ocally endemic
SL
afety effect of utilization should
produce
no
Sectors
most
disease treatment
harm is a Multisectoral Approach
PHC

closely related
Environmental
recognizes
intra and intersectoral
linkages.
to health:
sanitation

LEAPPS

Maternal and
child means relationship
Intrasectoral
linkages
ocal Governments
healthand
andbetween
family different L
within
levels of
planning
Education
healthcare services
Essential drugs
provision

Nutrition and adequate

food provision

Treatment of

Agriculture
Public Works
Population Control
Social Welfare

6.
LAGUNDI
Indications: Cough, Asthma, Fever, Muscle
Pain
Preparation: Decoction or syrup
7.
ULASIMANG BATO
Indications: lowers serum uric acid in gouty
arthritis Preparation: Salad or decoction
8.
BAYABAS
Indications: wound cleansing, as mouthwash
in cases of oral cavity infections & gingivitis
(antiseptic properties)
Preparation: Decoction
9.
BAWANG
Indications: lowers serum cholesterol
Preparation: May be roasted, soaked in
vinegar or used for sauteing
10.
YERBABUENA
Indications: for muscle pain
Preparation: Decoction

DOH-Approved Medicinal Plants

Sambong
Ampalaya
Niyog-niyogan
Tsaang gubat
Akapulko

Lagundi
Ulasimang bato
Bawang
Bayabas
Yerba Buena

1.
SAMBONG
Indications: edema and urolithiasis (diuretic
effect)
Preparation: Decoction
2.
AMPALAYA
Indications: Diabetes Mellitus
Preparation: Decoction or steamed
3.
NIYUG-NIYOGAN
Indications: Ascaris lumbricoides intestinal
infestation
Preparation: Prepare dried, mature niyugniyugan seeds Dosage: Consume by chewing
the right amount of seeds two hours after
meals. Repeat same dose after 1 week.
Side-effects: stomachache, diarrhea
4.
TSAANG GUBAT
Indications: Stomachache
Preparation: Decoction
5.
AKAPULKO
Indications: Ringworm, Tinea Flava, Athlete's
foot and other types of fungal infection
Preparation: Poultice or ointment

In "23 in '93", the utilization of the 10

Herbal Plants was aggressively prescribed
through community wide implementation of
projects such as herbal garden in
communities
RA 8423: utilization of medicinal plants as
alternative for high cost medications.
Policies:
The indications/uses of plants
The part of the plant to be used
Preparation of herbal medicines
Guidelines:
Properly labelled herbal medicine containers
Appropriate herbal plant to specific
symptom only
Palayok or clay pots and a wooden spoon
are used when cooking herbal medicines

CHemical pesticides or insecticides should

not be used on herbal plants
Use only the recommended plant part
Administer only at recommended dose
Remove the pot cover when the herbal
preparation starts to boil
If the symptoms persists despite using the
herbal medicine 2-3 times, consult the
nearest physician
Watch out for allergic reactions ~ if
observed, stop using the herbal preparation
Always keep out of reach of children
Prepare the herbal medicine as suggested

Community Health Nursing

Process
Assessment
-initiate contact
-collect data
-identify health problems
-assess coping ability
-analyze and interpret data
2 Levels of Family Assessment
1. First level determine actual and
potential health problems. Answers what
questions.
2. Second level determine barriers to
familys performance of tasks. Answers
why questions.
Categories of Health Problems
(according to priority)
1. Wellness state readiness to achieve
higher level or state of health
Health deficit presence of illness; gap
between actual and ideal health
*both are equally considered as priority #1
2. Health threat condition that promote
disease or injury
3. Stress point/foreseeable crisis
anticipated periods of unusual demands
Initial Data Base
1. Family structure and characteristics
2. Socio-economic and cultural factors
3. Environmental factors
4. Health assessment of each member
5. Value placed on prevention of disease
Family Diagnosis
Poin Component
t
give
n
x1
Nature (1)Deficit/Wellness,
(2)Threat, (3)Stress Point
x2
Modifiability possibility of success
(highly, partially, or non-modifiable)
x1
Preventive potential magnitude
of future problems that can be
minimized by solving this
x1
Salience familys perception of the
problem
Total=5
Community Diagnosis
Poin Component

t
give
n
x1

Nature health status (illness,

stats), health resource (material,
manpower), health-related (social,
economic, political, environmental)
x4
Modifiability possibility of success
(highly, partially, or non-modifiable)
x1
Preventive potential magnitude
of future problems that can be
minimized by solving this
x1
Salience familys perception of the
problem
x3
Magnitude of the problem
severity: proportion of population
affected by problem
Total=10
Why Undertake Community Dx?
1. To have a clear picture of the problems of
the community and to identify the resources
available to the community people.
2. Community diagnosis enables the
nurse/program coordinator to set priorities
for planning and developing programs of
health care for the community. The data
gathered through the process serves as the
material for analysis.
Types of Community Dx
1. Comprehensive Community Dx general
view
2. Problem-oriented Community Dx specific
problem
Components of Community Dx
1. Demographic variables
2. Socio-economic and cultural variables
3. Health and illness patterns
4. Health resources
5. Political and leadership patterns
Components of Community Dx
1. Primary Data - source would be the
community people through survey,
interview, focused group discussions,
observation and through the actual minutes
of community meetings
2. Secondary Data - source would be
organizational records of the program, health
center records and other public records
through review of records

Planning

-goal setting
-constructing plan of action and operational
plan
Implementation
-put nursing plan to action
-coordinate care/services
-utilize community resources
-delegate and supervise
-provide health education
-document responses
2 Levels of Nursing Intervention in CHN
1. Anticipatory primary level of
prevention
2. Participatory secondary & tertiary
levels
Evaluation
-nursing audit
-evaluate care outcomes
-performance appraisal for workers
-estimate cost-benefit ratio (determine
efficiency)
-identify necessary alterations
-revise plans
Framework for Evaluation
1. Structural elements physical:
manpower, equipment, infrastructure
2. Process elements actions, procedures,
protocols
3. Outcome elements changes in clients
health status vis--vis objectives and goals of
care outcomes

COPAR (Community Organizing

Participatory Action Research)
CO: A Manual of Experience; PCPD
A continuous and sustained process of
educating the people to understand and
develop their critical awareness of their
existing conditions, working with the
people collectively & efficiently on their
immediate and long-term problems, and
mobilizing the people to develop their
capability and readiness to respond & take
action on their immediate needs
towards solving their long-term
problems
Principles of COPAR
People, especially the most oppressed,
exploited and deprived sectors are open to

change, have the capacity to change, and

are able to bring about change.
COPAR should be based on the interests
of the poorest sectors of society
COPAR should lead to
community and society

self-reliant

Processes/Methods Used
A Progressive Cycle of Action Reflection - Action -begins with the
already existing practice, experience,
and concrete conditions of the people,
sums practice up into a body of
theory, puts theory to practiceand
the
cycle
repeats,
constantly
modifying for the better.
Consciousness-raising
through
learning by experience. Related to AR-A cycle.
COPAR is Participatory and Massbased because it is primarily directed
towards and biased in favor of the
poor, the powerless and the oppressed
and seeks to empower the masses to
participate in the changing of their
conditions.
COPAR is Group-centered and not
Leader-oriented.
Leaders
are
identified, emerge and are tested
through action rather than appointed
or selected by some external force or
entity.
Phases of the COPAR Process
1. Pre-entry Phase
The initial phase of the organizing
process
where
the
community
organizer looks for communities to
serve/help
Designing criteria for the selection of
site
Actually
selecting
the
site
for
community care
2. Entry Phase
Sometimes
called
the
social
preparation phase as the activities
done here include the sensitization of
the people on the critical events in
their life, motivating them to share
their dreams and ideas on how to
manage their concerns and eventually
mobilizing them to take collective
action on these.
Signals the actual entry of the
community worker/organizer into the
community
with
the
following
guidelines:

recognize the role of the local

authorities by paying them visits to
inform them of their presence and
activities
his/her appearance, speech, behavior &
lifestyle should be in keeping with
those of the community residents
without disregard of their being role
model
avoid raising the consciousness of the
community residents; adopt a low-key
profile
3. Organization-Building Phase
Entails the formation of more formal
structures and the inclusion of more
formal
procedures
of
planning,
implementing,
and
evaluating
community-wide activities
Conduct of trainings for the organized
leaders or groups to develop their skills
in
managing
their
own
concerns/programs

4. Sustenance and Strengthening Phase

Occurs when the community
organization has already been
established and the community
members are already actively
participating in community-wide
undertakings
The different committees set-up in the
organization-building
phase
are
already expected to be functioning by
way of planning, implementing and
evaluating their own programs, with
the
overall
guidance
from the
community-wide organization
Strategies:
Education and training
Networking and linkages
Conduct of mobilization on health
and development concerns
Developing secondary leaders