COMHEN220
Community Health Nursing
Community Health Nursing Concepts
A. Definition
COMMUNITY HEALTH NURSING
- (Bailon-Reyes) is a field of nursing practice
where services are delivered outside of purely
curative institutions (i.e. hospitals), but in
community settings such as the home, the
school, places of work, health centers & clinics.
- (ANA, 1980 ) is the synthesis of nursing
practice & public health to promote & preserve
the health of populations. Care is directed to
individuals, families, & groups. Contributes to
the health of the total population.
B. Philosophy of CHN:
1. Nursing is a unique & distinct component of
health care.
2. CHN subscribes to the philosophy of
interdependence among the health
professions.
3. As a special field of nursing practice, CHN
shares the humanistic beliefs & values of the
nursing profession.
4. CHN believes in the primacy of health as a
goal & as an essential element that affects the
quality of life of individuals, families, groups &
communities.
5. The goal of nursing care is independence &
self-reliance in health care for the client/ patient.
6. Nursing in general, & CHN in particular,
recognizes the relationship of non-health
problems to health problems, & the role of non-
health interventions in the solution of health
problems.
7. To achieve the goal of community health, the
nurse works with, not for, individual clients/
patients, families, specific population groups &
the community at large.
8. Nursing goals & standards of care should
consider constraints imposed by client, health
agency & community resources.
9. CHN practice is not a body or set of the same
repeating tasks.
10. Nurses have the responsibility to keep their
knowledge & skills current & up-to-date
according to developments in nursing, public
health & other related sciences.
CARMELA ORONGAN BSN-N31
Principles of CHN
1. Focus on the community as the unit of care.
2. Give priority to community needs.
3. Work with the community as an equal partner
of the health team.
4. In selecting appropriate activities focus on
primary prevention.
5. Promote a healthful physical & psychosocial
environment.
6. Reach out to all who may benefit from a
specific service.
7. Promote optimum use of resources.
8. Collaborate with others working in the
community.
C. Features of CHN
1. CHN is characterized by its being population-
focused approach & CHN interventions.
2. Levels of clientele of the community health
nurse
3. The prepayment mechanism in community
health nursing practice
D. Theoretical Models/ approaches
1. Health Belief Model (HBM) – initially
proposed in 1958 (Hochbaum) that provides the
basis for much of the practice of health
education & health promotion today.
- One of the most widely used conceptual
frameworks in health behavior to explain
behavior change & maintenance of behavior
change & to guide health promotion
interventions. (Janz, et al., 2002).
- Has several constructs:
a. Perceived susceptibility – one’s
belief regarding the chance of getting a given
condition
b. Perceived severity – one’s belief
regarding the seriousness of a given condition
c. Perceived benefits – one’s belief in
the ability of an advised action to reduce the
health risk or seriousness of a given condition
d. Perceived barriers – one’s belief
regarding the tangible & psychological costs of
an advised action.
e. Cues to action – strategies or
conditions in one’s environment that activate
readiness to take action
 COMHEN220
Community Health Nursing
f. Self-efficacy – one’s confidence in
one’s ability to take action to reduce health risks
2. Milio’s Framework for Prevention – (1976)
provides a complement to the HBM & provides
a mechanism for directing attention upstream &
examining opportunities for nursing intervention
at the population level.
 Outlined 6 propositions :
a. Population health deficits result from
deprivation &/ excess of critical health
resources
b. Behaviors of populations result from selection
from limited choices; these arise from actual &
perceived options available as well as beliefs &
expectations resulting from socialization,
education & experience.
c. Organizational decisions & policies (both
governmental & nongovernmental) dictate
many of the options available to individuals &
populations & influence choices.
d. Individual choices related to health promotion
or health damaging behaviors are influenced by
efforts to maximize valued resources.
e. Alteration in patterns of behavior resulting
from decision making of a significant number of
people in a population can result in social
change.
f. Without concurrent availability of alternative
health-promoting options for investment of
personal resources, health education will be
largely ineffective in changing behavior
patterns.
3. Nola Pender’s Health Promotion (HPM)
(Pender et al.,2006)– developed in the 1980s &
revised in 1996. Pender’s HPM explores many
biopsychosocial factors that influence
individuals to pursue health promotion
activities.
a. Individual characteristics & experiences –
each person’s unique characteristics &
experiences affect his or her actions. Their
effect depends on the behavior in question.
b. Prior related behavior – prior behaviors
influence subsequent behavior through
perceived self-efficacy, benefits, barriers, &
CARMELA ORONGAN BSN-N31
affects related to that activity. Habit is also a
strong indicator of future behavior.
c. Personal factors – personal factors that may
influence behavior are biological factors such as
age, body mass index, strength, & agility;
psychological factors include self-esteem, self-
motivation, & perceived health status;
sociocultural factors include race, ethnicity,
acculturation, education, & socio-economic
status.
d. Behavior - specific cognitions & affect – in
the HPM, these variables are considered to be
very significant in behavior motivation. They are
a “core” for intervention because they may be
modified through nursing actions. Assessment
of the effectiveness of interventions is
accomplished by measuring the change in these
variables.
e. Perceived benefits of action – the
perceived benefits of a behavior arev strong
motivators of that behavior motivation. These
motivate behavior through intrinsic & extrinsic
benefits. Intrinsic benefits include increased
energy & decreased appetite. Extrinsic benefits
include social rewards such as compliments &
monetary rewards.
f. Perceived barriers to action – barriers are
perceived unavailability, inconvenience,
expense, difficulty, or time regarding health
behaviors.
g. Perceived self-efficacy – self-efficacy is
one’s belief that he or she is capable of carrying
out a health behavior. If one has high self-
efficacy regarding a behavior, one is more likely
to engage in that behavior than if one has low-
efficacy.
h. Activity-related affect – the feelings
associated with a behavior will likely affect
whether an individual will repeat or maintain the
behavior.
i. Interpersonal influences – in the HPM, these
are feelings or thoughts regarding the beliefs or
attitudes of others. Primary influences are
family, peers, & health care providers.
j. Situational influences – these are perceived
options available, demand characteristics, &
aesthetic features of the environment where the
behavior will take place. For example, a lovely
 COMHEN220
Community Health Nursing
day will increase the probability of one taking a
walk; the fire code will prevent one from
smoking indoors.
k. Commitment to a plan of action – Pender
states that “commitment to a plan of action
initiates a behavioral event” (Pender et al.,
2006, p.56). this commitment will compel one
into the behavior until completed, unless a
competing demand or preference intervenes.
l. Immediate competing demands &
preferences – these are alternative behaviors
that one considers as possible optional
behaviors immediately prior to engaging in the
intended, planned behavior. One has little
control over competing demands, but one has
great control over competing preferences.
m. Health-promoting behavior – this is the
goal or outcome of the HPM. The aim of health-
promoting behavior is the attainment of positive
health outcomes.
4. Lawrence Green’s PRECEDE-PROCEDE
MODEL
- provide a model for community assessment,
health education planning, & evaluation.
PRECEDE= stands for Predisposing,
Reinforcing, Enabling Constructs in Educational
Diagnosis & Evaluation; is used for community
diagnosis.
PROCEED= an acronym for Policy, Regulatory
& Organizational Constructs in Educational &
Environmental Development; is a model for
implementing & evaluating health programs.
• Predisposing factors – refer to people’s
characteristics that motivate them toward
health-related behavior.
• Enabling factors – refer to conditions in
people & the environment that facilitate or
impede health-related behavior.
• Reinforcing factors – refer to feedback given
by support persons or groups resulting from the
performance of the health-related behavior.
E. Different Fields
1. School Health Nursing
- -”To learn effectively, children need good
health.” (stated by WHO Expert Committee on
School Health Services)
CARMELA ORONGAN BSN-N31
- In the Phil., around 1.2M preschools children ,
13.7M elementary, 6.8M high schools go to
school
- School nurse visits 4 – 6 schools/ month x 3
days
SCHOOL NURSING – a specialized practice of
professional nursing that advances the well-
being, academic success, & lifelong
achievements of students.
2. Occupational Health Nursing
- According to the American Association of
Occupational Health Nurses (AAOHN), it is the
specialty practice that focuses on the promotion,
prevention, & restoration of health within the
context of a safe & healthy environment. It
includes the prevention of adverse health
effects from occupational & environmental
hazards. It provides for & delivers occupational
& environmental health & safety programs &
services to clients.
- R.A. 1054 is also known as the Occupational
Health Act
3. Community Mental Health Nursing
- Is the application of specialized knowledge to
populations & communities to promote and
maintain mental health & to rehabilitate
populations at risk that continue to have residual
effects of mental illness.
Nurses role in National Mental Health
Programs:
a. Understand the characteristics of mentally
healthy person & differentiate abnormal from
normal behavior in the community.
b. Identified refer follow-up the mentally ill
person in the community.
c. Provide first aid during emergencies.
d. Assist & coordinate the activities related to
care of mentally ill in the community health
center.
e. Conduct mental health education to patient &
their family members.
 COMHEN220
Community Health Nursing
Concept of the Community
COMMUNITY – is a group of people who:
 have common interests or characteristics
(Allender et al., 2009; Lundy & Janes,
2009; Clark, 2008)
 Interact with one another (Allender et al.,
2009; Lundy & Janes, 2009; Clark, 2008)
 Have a sense of unity or belonging
(Allender et al., 2009)
 Function collectively within a defined
social structure to address common
concerns. (Clark, 2008)
A. Types of Communities
1. Phenomenological – functional
2. Geopolitical – territorial
B. Characteristics of a Healthy Community
- (adapted from Hunt, 1997; Duhl, 2002)
1. A shared sense of being a community based
on history & values.
2. A general feeling of empowerment & control
over matters that affect the community as a
whole.
3. The ability to cope with change, solve
problems, & manage conflicts within the
community through acceptable means.
4. Open channels of communication &
cooperation among the members of the
community.
5. Equitable & efficient use of community
resources with the view towards sustaining
natural resources.
C. Components/ Features of a Community
1. People
2. Location
3. Social system
D. Factors Affecting Health of the Community
1. Characteristics of the Population
a) size & density – negative effects of
overcrowding include:
(1) easy spread of communicable
diseases,
(2) increased stress among members of
the community,
CARMELA ORONGAN BSN-N31
(3) rapid degradation of housing facilities,
& water, air, & soil pollution.
- sparsely populated areas have limited
resources resulting in difficulty in providing
health services.
b) differences in population composition by
age, sex, occupation, level of education &
other variables
c) rapid growth or decline – usually results
from migration of a large number of people
into the community & from disturbances
brought about circumstances
d) cultural characteristics of the community
e) level of education & social class
2. Location of the Community
a) natural variables such as geographic
features, climate, flora, & fauna
b) man-made variables such as community
boundaries, presence of open spaces,
quality of the soil, air, & water, & the
location of health facilities are influenced
by human decisions & behavior (Benson,
1980; Allender et al., 2009)
3. Social Systems within the Community
- it is the patterned series of
interrelationships existing between
individuals, groups, & institutions &
forming a coherent whole. ( Merriam-
Webster Online Dictionary, 2012b)
- its components that affect health include
the family, economic, educational,
communication, political, legal, religious,
recreational, & health systems (Allender et
al., 2009)
Types of organizations
a. Formal – examples: A government
agency, a bank, a school
b. Informal – examples: neighborhood
friends, volunteers in a barangay clean-up
drive
E. Roles and Activities of Community Health
Nurse
1. Advocate - seeks to promote an
understanding of health problems; looks for
beneficial public policy & stimulates the
 COMHEN220
Community Health Nursing
emergence of a supportive community action for
health.
2. Care manager - Clients need help in making
decisions about appropriate health care services.
Achieving service delivery integration &
coordination is a major task of the CHN.
3. Case finder - The CHN looks for clients at risk
among the population served.
4. Counselor - Clients in the community health
setting frequently face difficult & complex health
concerns & desire supportive & problem solving
assistance. They deal with stress related to
health concerns.
5. Clinic nurse – Clinic services are increasingly
expanding to meet the needs of aggregates at
risk.
6. Epidemiologist – the CHN uses the
epidemiological method to study disease &
health among various population groups & to
deal with community- wide health problems.
7. Group leader -The CHN works in groups in
practice.
8. Health planner - The CHN provides health
programs for the community.
9. Home visitor - The CHN enters the clients’
setting. He/ She assesses the environment &
works within it. He/ She also gathers information
about how a family system functions within its
own setting. The CHN also provides direct care
services with clients.
10. Occupational health nurse - The CHN is
also concerned with risks & problems in the work
environment of the people.
11. Researcher - The CHN assists health care
professionals in reaching their goals through
research.
12. School nurse - The CHN works with
students in school.
CARMELA ORONGAN BSN-N31
13. Teacher - The CHN facilitates change in
behavior among clients which is a basic
intervention strategy in community health.
CHN ACTIVITIES
1. Health education
2. Actively participate in the training component of
the service like in Food Handler’s class, & attend
training/ workshops related to environmental
health
3. Assist in the deworming activities for the school
children & targeted groups.
4. Effectively & efficiently coordinate programs/
projects/ activities with other government & non-
government agencies.
5. Act as an advocate or facilitator to families in
the community in matters of program/ projects/
activities on environment health in coordination
with other members of Rural Health Unit (RHU)
especially the Rural sanitary Inspectors.
6. Actively participate in environmental sanitation
campaigns & projects in the community.
7. Be a role model for others in the community to
emulate in terms of cleanliness in the home &
surrounding.
8. Participate in the research/ studies to be
conducted in their respective area of assignment.
9. Help in interpretation & implementation of P.D.
856 commonly known as Sanitation Code of the
Philippines.
10. Assist in the Disaster Management, which will
be implemented at all levels.
Health Statistics and Epidemiology
 HEALTH STATISTICS – (WHO) include
both empirical data and estimates related
to health, such as mortality, morbidity, risk
factors, health service coverage, and
health systems.
 EPIDEMIOLOGY - Originated from the
Greek words epi, meaning “upon”, demos,
meaning “people,” and logos, meaning
“study”. It is the study of the distribution &
determinants of health-related states or
events in specified populations, & the
 COMHEN220
Community Health Nursing
application of this study to the prevention
& control of health problems.”
Term: Explanation:
 Study -Includes surveillance, observation,
hypothesis testing, analytic research &
experiments
 Distribution- Refers to analysis by time,
places, & classes of people affected
 Determinants- Include all the biological,
chemical, physical, social, cultural,
economic, genetic, & behavioral factors
that influence health
 Health-related states or events - Refer
to diseases, causes of death, behaviors
such as the use of tobacco, positive health
states, reactions to preventive regimens
&, provision & use of health services.
 Specified populations - Include those
with identifiable characteristics such as
occupational groups
 Application to prevention & control -
The aim of public health, - to promote,
protect, & restore good health.
A. Tools
1. Demography - the study of statistics such as
births, deaths, income, or the incidence of
disease, which illustrate the changing structure of
human populations.
a. Sources of Data :
a.1. PRIMARY - is the original data
collected for a specific purpose. Collecting
primary data is expensive and time-
consuming, and it usually is undertaken
only when secondary data is not
available.
a.2. SECONDARY - includes
census, hospital data, vital registration
system, health insurance, disease
notification, school health program,
disease registries, downloadable data
sets, surveillance system & surveys
(morbidity, demographic & health).
• Disease notification – an integral part of
disease surveillance.
• Disease registry – is a compilation of
information about a particular disease.
CARMELA ORONGAN BSN-N31
• Surveillance system – were developed for
monitoring high burden diseases, detecting
disease outbreaks that could escalate into
epidemic proportions, & monitoring progress
toward attainment of targets for the control,
elimination, or eradication of a specific disease
a. Active surveillance – is a system in which
public health staff members actively & regularly
contact health care providers or the population to
obtain information about the disease of interest.
b. Passive surveillance – is a system by which
public health staff receives reports from hospitals,
clinics, public health units, or other sources.
b. Population Size – influences the number &
size of health care institutions. Knowing
community size provides important information for
planning.
c. Composition
d. Distribution
2. Health Indicators – are quantitative measures,
usually expressed as rates, ratios, or proportions,
that describe & summarize various aspects of the
health status of the population.
 RATE – shows the relationship between a
vital event & those persons exposed to the
occurrence of said event, within a given
area & during a specified unit of time. It is
evident that the persons experiencing the
event (the numerator) must come from the
total population exposed to the risk of
same event (the denominator).
 RATIO – used to describe the relationship
between two (2) numerical quantities or
measures of events without taking
particular considerations to the time or
place.
 CRUDE OR GENERAL RATES – these
rates referred to the total living population.
It must be presumed that the total
population was exposed to the risk of the
occurrence of the event.
 SPECIFIC RATE – the relationship is for a
specific population class or group. It limits
the occurrence of the event to the portion
of the population
 COMHEN220
Community Health Nursing
a. Crude Birth Rate (CBR) - A measure of one
characteristic of the natural growth or increase of
a population.
CBR= Number of registered live births in a
year X 1,000
Midyear population
b. Crude Death Rate (CDR) - A measure of one
mortality from all causes which may result in a
decrease of population
CDR = Total no. of deaths registered in a given
calendar year X 1,000
Estimated population as of July 1 of same
year
c. Infant mortality Rate (IMR) - Measures the
risk of dying during the 1st year of life. It is a
good index of the general health condition of a
community since it reflects the changes in the
environment & medical condition of a
community.
IMR = Deaths under 1 year of age registered in a
calendar year X 1,000
Number of live births in the same
year
d. Neonatal Mortality Rate (NMR) - Measures
pregnancy wastage. Death of the product of
conception occurs prior to its complete expulsion,
irrespective of duration of pregnancy
No. of deaths among those under 28 days
of age in a calendar year
NMR = -------------------------------------------------------
-------------------------------- X 1,000
Number of live births in the same year
e. Postneonatal Mortality Rate (PMR) -
Measures the risk of dying the 1st month of life. It
serves as an index of the effects of prenatal care
& obstetrical management of the newborn.
Number of deaths among those 28 days to less
than
1 year of age in a calendar year
PMR = -------------------------------------------------------
---------------- X 1,000
Number of live births in the same year
f. General Fertility Rate (GFR) - This is more
specific rate than the CBR since births are
related to the segment of the population deemed
to be capable of giving birth, that is, the women
in the reproductive age groups.
CARMELA ORONGAN BSN-N31
GFR = Number of registered live births in a
year X 1,000
Midyear population of women 15-44 years
of age
g. Maternal Mortality Rate (MMR)- Defined as a
“death of a female from any cause related to or
aggravated by pregnancy or its management
during pregnancy & childbirth or within 42 days of
termination of pregnancy, irrespective of the
duration & the site of the pregnancy.
Number of deaths due to pregnancy, delivery,
puerperium
in a calendar year
MMR = -------------------------------------------------------
------------------------- X 100
Number of live births in the same
year
h. Specific Rates of Mortality
1. Specific Death Rate (SDR) - describes more
accurately the risk of exposure of certain classes
or groups to particular diseases.
SDR = Deaths in specific class/ group registered
in a given calendar year X 100,000
Estimated population as of July 1 in same
specified class/ group of said year
2. Age Specific Death Rate (ASDR)
No. of death in a particular age group
registered in a given calendar year
ASDR = ------------------------------------------------------
------------------------------------------ X 100,000
Estimated population as of July 1 in
same age group of same year
3. Sex Specific Death Rate (SSDR)
No. of deaths of a certain sex
registered in a given calendar year
SSDR = ------------------------------------------------------
--------------------------------- X 100,000
Estimated population as of July 1 in
same sex for same year
i. Incidence Rate (IR) - Measures the number of
new cases, episodes, or events occurring over a
specified period of time, commonly a year, within
a specified population at risk. The best measure
to use for evaluating the effectiveness of health
interventions.
 COMHEN220
Community Health Nursing
No. of new cases of a particular disease 7. Urinary 83, 569 88.9
registered during a specified period of time Tract
IR = ----------------------------------------------------------- Infection
---------------------------------------------- X 100,000 8. TB 72, 516 77.1
Population at Risk Respiratory
j. Prevalence Rate (PR) – Measures the total 9. Injuries 51, 201 54.5
number of existing cases of a disease at a 10. Disease 37, 589 40.0
particular point in time divided by the number of of the Heart
people at that point of time
Number of existing cases of a disease at a  SOURCE: DOH Website
particular point in time  REFERENCE YEAR: 2020
PR = ----------------------------------------------------------
--------------------------- X 100
Number of people examined at that point
in time
k. Attack Rate (AR) - A more accurate measure
of the risk of exposure.

LEADING CAUSES OF MORBIDITY

 Source : DOH Website
 REFERENCE YEAR: 2010

 ARI was included in the list of notifiable

diseases in 2008 only, while UTI and
Injuries are news in the list

 Acute Febrile Illness was included in

the list of notifiable diseases in 2006
only, 3-year average only. LIFE EXPECTANCY
 This statistics shows the life expectancy
2010 at birth in the Philippines from 2008 to
DISEASES NUMBER
RATE 2018. In 2018, the average life
1. Acute 1, 289, 168
1371.3 expectancy at birth in the Philippines was
Respiratory 71. 1 years.
Infection
2. Acute 586, 135 623.5  The current life expectancy in the
Lower Philippines in 2020 is 71. 28years, a
Respiratory 0.18% increase from 2019.
Tract  The life expectancy for Philippines in
Infection and 2019 was 71. 16 years, a 0.18% increase
Pneumonia from 2018.
3. Bronchitis 351, 126 373.5  The life expectancy for Philippines in
4. 345, 412 367.4 2018 was 71.03 years, a 0.23% increase
Hypertension in 2017.
5. Acute 326, 551 347.3  The life expectancy for Philippines in
Watery 2017 was 70.87, a 0.23% increase from
Diarrhea 2016.
6. Influenza 272, 001 209.3
CARMELA ORONGAN BSN-N31