Community Health Nursing
 Health Service
Unit I: Introduction To Community Health Nursing
01 Definition of Health and Community
Community/ Public health nursing is the synthesis of nursing practice and
public health practice.
Major Goal of CHN
 Community - Preserve the health of the community
 Medical care - Medical Practice which focuses on people's well
being
 Education - Promoting and focusing on health promotion
Mission is social justice that entitles all people to basic necessities
Definition of Health
a. WHO- "a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity."
b. Murray- "a state of well-being in which the person is able to use
purposeful, adaptive responses and processes physically, mentally,
emotionally, spiritually, and socially
c. Pender- "actualization of inherent and acquired human potential through
goal directed behavior, competent self-care, and satisfying relationships
with others."
d. Orem- “a state of person that is characterized by soundness or wholeness
of developed human structures and of bodily and mental functioning."
Definition of Community
a. Allender- "a collection of people who interact with one another and
whose common interests or characteristics form the basis for a sense of
unity or belonging."
b. Lundy and Janes- "a group of people who share something in common
and interact share with one another, who may exhibit a commitment with
one another and may geographic boundary."
c. Clark- "a group of people who share common interests, who interact with
each other, and who function collectively within a defined social structure
to address common concerns."
d. Shuster and Goeppinger- "a locality-based entity, composed of systems
of formal organizations reflecting society's institutions, informal groups
and aggregates."
Maurer and Smith (2009)- two main types of communities:
a. Geopolotical communities- also called as territorial communities.
b. Phenomenological communitiesalso called as functional communities.
Population- is typically used to denote a group of people having common
personal or environmental characteristics.
Aggregates are subgroups or subpopulations that have some common
characteristics or concerns.
02 Determinants of Health
 Income and social status
 Education
 Physical environment
 Employment and working conditions
 Social support networks
 Culture
 Genetics
 Child Development
 Personal Behavior and Coping skills
 Gender
03 Indicators of Health and Illness
 National Epidemiology Center of DOH, PSA and local health
centers/ offices/ departments
 Local health centers/ offices/ departments
 Nurses
04 Definition and Focus of Public Health and Community Health
Definition of public health according to:
a. C. E. Winslow- “Public health is the science and art of (1) preventing
disease, (2) prolonging life, and (3) promoting health and efficiency
through organized community effort for:
1. sanitation of the environment
2. control communicable infections
3. education of the individual in personal hygiene
4. organization of medical and nursing services for the early
diagnosis and preventive treatment of disease, and
5. “development of the social machinery to ensure everyone a
standard of living adequate for the maintenance of health, so
organizing these benefits as to enable every citizen to realize his
birthright of health and longevity.” (Hanlon)
Public health key phrase definition: “through organized community effort”.
Connotes organized, legislated, and tax-supported efforts that serve all
people through health departments or related governmental agencies.
Community Health - Extends the realm of public health to include
organized health efforts at the community level through both government
and private efforts
9 Essential Public Health Functions according to :WHO Regional Office
for the Western Pacific
1. Health situation monitoring and analysis
2. Epidemiological surveillance/ disease prevention and control
3. Development of policies and planning in public health
4. Strategic management of health systems and services for
population health gain
5. Regulation and enforcement to protect public health
6. Human resources development and planning in public health
7. Health promotion, social participation and empowerment
8. Ensuring the quality of personal and population-based health
service
9. Research, development, and implementation of innovative public
health solution
05 Preventive Approach to Health
Health Promotion - Activities enhance resources directed at improving
well-being
Disease Prevention - Activities protect people from disease and effects of
disease
Leavell and Clark’s Three levels of Prevention
 Primary prevention aims to prevent disease or injury before it
ever occurs. Ex: Immunization
 Secondary prevention aims to reduce the impact of a disease or
injury that has already occurred. Early detection and intervention
ex: screening for STD
 Tertiary prevention aims to soften the impact of an ongoing
illness or injury that has lasting effects. Ex. Teaching insulin
administration in the home
06 Levels of Clientele of the Community Health Nurse
Individual as the Client/Patient - Since the health problems of individuals
are intertwined with those of the other members of the family and
community, they are also considered as an entry point in working with
these clients
Family as the Client/Patient
 Because most people belong to a family and their health is
strongly influenced by the home situation, the family is
considered the basic unit of care in community health nursing.
 The nurse in the clinic or health focuses on the individual client.
Still, the nurse has to interview the client on family health,
considering the health status of the other members of the family,
the values and behavior of the family members in relation to
health, and the psychosocial and physical environment in the
home
Population Group as the Client/Patient
 At this third level of care, community health nurses direct and
focus their activities to certain population groups with common
unique health needs, are at risk of developing or have already
developed certain defined health problems, and to whom the
nurse delivers health-promotive, preventive, curative or
rehabilitative nursing services.
 Examples of population groups given priority attention in public
health work are childbearing women, infants and pre-school age
children, school children and workers in industrial
establishments.
Community as the Client/Patient - When the nurse uses community
organizing as a strategy for health promotion and disease prevention, the
focus of care is the entire community. For community analysis, however,
the nurse conducts interviews with families as the units of data collection.
07 Public Health Interventions and Definition
A public health intervention is an organized effort to promote those specific
behaviors and habits that can improve physical, mental and emotional
health.
 Surveillance - Describes and monitors health events through
ongoing and systematic collection, analysis, and interpretation of
health data for the purpose of planning, implementing, and
evaluating public health interventions.
 Disease and other health event investigation - Systematically
gathers and analyzes data regarding threats to the health of
populations, ascertains the source of the threat, identifies cases
and others at risk, and determines control measures.
 Outreach - Locates populations of interest or populations at risk
and 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 - Assists individuals, families, groups,
organizations, and/or communities to identify and access
necessary 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.
 Delegated functions - Are direct care tasks that a registered
professional nurse carries out under the authority of a health care
practitioner as allowed by law.
 Health teaching - Communicates facts, ideas, and skills that
change knowledge, attitudes, values, beliefs, behaviors, and
practices of individuals, families, systems, and/or communities.
 Counseling - Establishes an interpersonal relationship with a
community, a system and a family or individual, with the
intention of increasing or enhancing their capacity for self-care
and coping.
 Consultation - Seeks information and generates optional solutions
to perceived problems or issues through interactive problem
solving with a community system and family or individual.
 Collaboration - Commits two or more persons or an organization
to achieve a common goal through enhancing the capacity of one
or more of the members to promote and protect health.
 Coalition building - Promotes and develops alliances among
organizations or constituencies for a common purpose.
 Community organizing - Helps community groups to identify
common problems or goals, mobilize resources, and develop and
implement strategies for realizing the goals they collectively have
set.
 Advocacy - Pleads someone's cause or acts on someone's behalf,
with a focus on developing the community, system, and
individual or family's capacity to plead their own cause or act on
their own behalf.
 Social marketing - Utilizes commercial marketing principles and
technologies for programs designed to influence the knowledge,
attitudes, values, beliefs, behaviors, and practices of the
population of interest.
 Policy development and enforcement - Places health issues on
decision makers' agendas, acquires a plan of resolution, and
determines needed resources, resulting in laws, rules, regulations,
ordinances, and policies. Policy enforcement compels others to
comply with laws, rules, regulations, ordinances, and policies.
08 History of Public Health and Public Health Nursing in the
Philippines
 In 1577, Franciscan Friar Juan Clemente opened a medical
dispensary in Intramuros for the indigent.
 In 1690, Dominican Father Juan de Pergero worked toward
installing a water system in San Juan del Monte (now San Juan
City, Metro Manila) and Manila.
 Smallpox vaccination was introduced by Dr. Francisco de
Balmis, the personal physician of King Charles IV of Spain, who
came to the Philippines in 1805.
 The first medicos titulares (medical officer) were appointed by
the Spanish government in 1876.
 A 2-year course consisting of fundamental medical and dental
subjects was first offered in the University of Santo Tomas in
1888. Graduates of this course known as cirujanos ministrantes
(one who administers surgery).
 In 1901, the United States Philippine Commission, through Act
157, created the Board of Health of the Philippine Islands, with a
Commissioner of Public Health as its chief executive officer.
 The Fajardo Act of 1912 created sanitary divisions made up of
one to four municipalities.
 In 1915, the Philippine General Hospital began to extent public
health nursing services in the homes of patients by organizing a
unit called Social and Home Care Service, with two nurses as
staff.
 Founded by the Asociacion feminista Filipina in 1905, La Gota
de Leche was the first center dedicated to the service of mothers
and babies.
 In 1947, the DOH was reorganized into bureaus: quarantine,
hospitals that took charge of the municipal and charity clinics,
and health with the sanitary divisions under it.
 In 1954, Congress passed R.A. 1082 or the Rural Health Act.
 R.A. 1891, enacted in 1957, amended certain provisions in the
Rural Health Act. As a result of decentralization efforts in 1958,
Regional health officers were created.
  In the 1970s, the Philippine health care delivery system was
restructured.
 R.A. 7160 or the Local Government Code was enacted in 1991,
the law mandated devolution of basic services, including health
services, to local government units and the establishment of a
local health board in every province and city municipality.
 In September 2000, The Philippines is a signatory to the United
Nations Millennium Declaration adopted during the World
Summit.
 The DOH has directed efforts toward comprehensive reforms in
health care with the Health Sector Reform Agenda launched in
1999, its implementation framework FOURmula One (F1) for
Health in 2005, and Universal Health Care in 2010.
II. Community Health and Development Concepts, Theories and
Strategies
Theoretical Foundation of Community Health Nursing Practice
A General Systems Theory
 The basis, in part, of several nursing theories.
 It is applicable to the different levels of the community health
nurse’s clientele
This theory is useful when…
 Analyzing interrelationships of the elements within the client and
the environment
o Culture and the Family Code dictate the boundaries of
the Filipino Family.
o The Family Environment constitutes everything outside
its boundaries that may affect it.
o The family gets inputs of matter, energy, and
information from the environment.
 OUTPUTS
 FEEDBACK
 SUBSYSTEMS
 SUPRASYSTEMS
B Social Learning Theory
 Is based on the belief that learning takes place in a social context.
 It assumes that all personas are thinking beings that are capable
of making decisions and acting according to expected
consequences of their behavior.
 Learning is affected by the environment but the learning
outcomes depends on the learner’s individual characteristics.
The theory can be applied by…
 Catching the person’s attention with different strategies
 Promoting retention of learning
 Providing opportunities for reproduction or imitation of the
procedures
 Motivating the person by explaining the benefits possible by
practicing the behavior
C The Health Belief Model
 A theory that attempts to predict or explain health behavior
choices.
 The model is based on the theory that a person’s willingness to
change their health behaviors primarily comes from their health
perceptions.
 1950’s - first developed by psychologist Irwin M. Rosenstock,
Godfrey M. Hochbaum, Stephen Kegeles of the U.S. Public
Health Services.
 1980’s - updated to incorporate the role of self-efficacy in
decision-making.
Two Components of Health Related Behavior
1. To avoid illness or getwell if already ill.
2. Belief on effectiveness of health actions.
Components of Health Belief Model
1. Perceived Susceptibility - One’s belief regarding the chance of
getting given conditions.
2. Perceived Severity - One’s belief regarding the seriousness of a
given condition.
3. Perceived Benefits - One’s belief in the ability of an advised
action to reduce the health risk or seriousness of a given
condition.
4. Perceived Barriers - One’s belief regarding the tangible and
psychological costs of an advised action.
5. Cues to Action - Strategies or conditions in one’s environment
that activate readiness to take action.
6. Self-efficacy - One’s confidence in one’s ability to take action to
reduce health risk.
Milio’s Framework for Prevention
 Milio (1976) proposed that health deficits often result from an
imbalance between a population’s health needs and its health
sustaining resources.
 Personal and social resources affect the range of health
promoting or health damaging choices available to individual.
 She proposed that most human beings make the easiest choices
available to them most of the time.
 This theory is broader that HBM.
E Pender’s Health Promotion Model
 Nola J. Pender (born August 16, 1941) is a nursing theorist,
author, and academic. She is a professor emerita of nursing at the
University of Michigan. She created the Health Promotion
Model. She has been designated a Living Legend of the
American Academy of Nursing.
 It was designed to be a “complementary counterpart to models of
health protection.”
 It defines health as a positive dynamic state not merely the
absence of disease.
The Major Concepts and Definitions of the Health Promotion Model
 Individual Characteristics and Experience
 Behavior-specific cognitions and affect
 Behavioral Outcome
1. Individual Characteristics and Experience
Personal factors - categorized as biological, psychological and socio-
cultural. These factors are predictive of a given behavior and shaped by the
nature of the target behavior being considered.
 Personal Biological Factors
 Personal Psychological Factors
 Personal Socio-Cultural Factors
2. Behavioral Specific Cognition and Affect
 Perceived benefits of action - Anticipated positive outcomes that
will occur from health behavior.
 Perceived barriers to action - Anticipated, imagined or real blocks
and personal costs of understanding a given behavior
 Perceived self efficacy - Judgment of personal capability to
organize and execute a health-promoting behavior.
 Activity related affect - Subjective positive or negative feeling
that occur before, during and following behavior based on the
stimulus properties of the behavior itself.
  Interpersonal influences - Interpersonal influences include: 10. Stimulus Control - Re-engineering the environment to have
norms, social and modelling. reminders and cues that support and encourage the healthy
 Situational influences - Personal perceptions and cognitions of behavior and remove those that encourage the unhealthy
any given situation or context that can facilitate or impede behavior.
behavior
LIMITATIONS OF TRANSTHEORETICAL MODEL
3. Behavioral Outcome
There are several limitations of TTM, which should be considered when
 Commitment to plan of action - The concept of intention and using this theory in public health. Limitations of the model include the
identification of a planned strategy leads to implementation of following:
health behavior.
 The theory ignores the social context in which change occurs,
 Immediate competing demands and preferences - Competing
such as SES and income.
demands are those alternative behavior over which individuals
 The lines between the stages can be arbitrary with no set criteria
have low control because there are environmental contingencies
of how to determine a person's stage of change. The
such as work or family care responsibilities.
questionnaires that have been developed to assign a person to a
 Health promoting behaviour - Endpoint or action outcome
stage of change are not always standardized or validated.
directed toward attaining positive health outcome such as optimal
 There is no clear sense for how much time is needed for each
well-being, personal fulfillment, and productive living
stage, or how long a person can remain in a stage.
F The Transtheoretical Model  The model assumes that individuals make coherent and logical
plans in their decision-making process when this is not always
 The Transtheoretical Model (also called the Stages of Change true.
Model) was developed by Prochaska and DiClemente in the late
1970s.
 Focuses on the decision-making of the individual and is a model
of intentional change.
 The TTM operates on the assumption that people do not change
behaviors quickly and decisively.
 Rather, change in behavior, especially habitual behavior, occurs
continuously through a cyclical process.
 The TTM is not a theory but a model; different behavioral
theories and constructs can be applied to various stages of the
model where they may be most effective.
 The TTM posits that individuals move through six stages of
change: precontemplation, contemplation, preparation, action,
maintenance, and termination.
 Termination was not part of the original model and is less often
used in application of stages of change for health-related
behaviors.
 For each stage of change, different intervention strategies are
most effective at moving the person to the next stage of change
and subsequently through the model to maintenance, the ideal
stage of behavior.

To progress through the stages of change, people apply cognitive, affective,

and evaluative processes. Ten processes of change have been identified
with some processes being more relevant to a specific stage of change than
other processes. These processes result in strategies that help people make
and maintain change.

1. Consciousness Raising - Increasing awareness about the healthy

behavior.
2. Dramatic Relief - Emotional arousal about the health behavior,
whether positive or negative arousal.
3. Self-Reevaluation - Self reappraisal to realize the healthy
behavior is part of who they want to be.
4. Environmental Reevaluation - Social reappraisal to realize how
their unhealthy behavior affects others.
5. Social Liberation - Environmental opportunities that exist to
show society is supportive of the healthy behavior.
6. Self-Liberation - Commitment to change behavior based on the
belief that achievement of the healthy behavior is possible.
7. Helping Relationships - Finding supportive relationships that
encourage the desired change.
8. Counter-Conditioning - Substituting healthy behaviors and
thoughts for unhealthy behaviors and thoughts.
9. Reinforcement Management - Rewarding the positive behavior
and reducing the rewards that come from negative behavior.