1

UNIVERSITY VISION

A technologically advanced university producing professionals and competitive

leaders for local and national development

. UNIVERSITY MISSION

To provide quality education responsive to the national and global needs focused on
generating knowledge and technology that will improve the lives of the people.

UNIVERSITY CORE VALUES

● Excellence

Individual commitment to excellence is central to the values that ESSU promotes.

The university will be able to achieve excellence through adherence to the highest
standards of performance and by collaborating with the very best in the field of
instruction, research, extension and production.

● Accountability

Every member of the ESSU community is accountable for his every action, decision
or activities and for whatever money or property the university entrusts to him. He
must accept responsibility for whatever will be the consequences it may bring and
to disclose the results in a transparent manner. Thus, he must act with caution and
utmost consideration for ethics and honesty in the workplace.

● Service

Service is the commitment of the university to serve not only its stakeholders to
provide quality instruction, research, extension, and production but also to serve
the needs of every member of the ESSU community to advance their well-being.

i
 PREFACE

Primary Health Care is an integral and vital part of health and development program. It focuses
in promoting and protecting health and preventing diseases. It promotes the value of
community health in the Philippine health system.

Future Midwives should internalize all the concepts, theories, principles, and processes in
community health nursing. They should be fortified with knowledge, attitude, and skills in
community health care, mainly in the family and community care settings. They should be
aware the importance of recognizing approaches to support the government in promoting
primary health care as a key to health and national development.

In module is a product of a concerted effort of chosen faculty members teaching at the different
campuses of Eastern Samar State University, in answer to the existent problem brought forth
by the pandemic.

A year ago, the said faculty members attended a training on module-making and were made
to come up with a learning material output. The said output was pilot-tested during the
semester that followed. An evaluation of this material was gathered from faculty and students
alike and was made the basis in the upgrade of this module, a process that need to be done
to come up with a massive printing of this module.

iiiii
 TABLE OF CONTENTS
University Vision, Mission and Core Values i
Preface ii
Table of Contents iii
General Instructions iv

UNIT 1: The Philippine Health Care Delivery System

Lesson 1 - National Health Situation 1

Lesson 2 - Components of Philippine Health Care Delivery System 3
Lesson 3 - Levels of Health Care Facilities 6
Lesson 4 - Referral system 8
Lesson 5 - Multi – sectoral Approach to Health 11

UNIT 2: Primary Health Care

Lesson 1 - Definition, Rationale and Goals 18

Lesson 2 – Strategies, elements, and principles 21

UNIT 3: Community Health Process

Lesson 1 - Steps in Community Health Process 31

Lesson 2 - Principles of Community Health Nursing Process 35

UNIT 4: Health Care Process as Applied to the Family

Lesson 1 - Family Assessment 38

Lesson 2 - Statement of Family Condition 43
Lesson 3 - Formulating Goals and Objectives for Health Promotion 44
Lesson 4 - Family Health Care Strategies 45
Lesson 5 - Evaluation 50

UNIT 5: Clinic Activities: Immunization

Lesson 1 – EPI 53
Lesson 2 - Principles in Vaccination 55
Lesson 3 - Contraindications to Immunization 55
Lesson 4 - EPI Schedule 57
Lesson 5 - EPI Cold chain and Logistics 57
Lesson 6 - Types of Vaccine Wastage 59
Lesson 7 - EPI Vaccines 64
Lesson 8 - Role of Midwife on Immunization 74
Lesson 9 – National Immunization Program (Updates) 75

References

Course Guide

Quality Policy

iii
 GENERAL INSTRUCTIONS

• Use this module with care.

• Do not write, highlight, erase, alter or tear the pages

of this module.

• In answering activities or exercises, use a separate

sheet of paper or refer to your instructor for further
or other instructions.

• This module must be returned after the end of the

semester.

• If lost, the holder of this module will pay its

equivalent value.

If this module is lost and found, please return to:

EASTERN SAMAR STATE UNIVERSITY

iv
 UNIT 1: THE PHILIPPINE HEALTH CARE
DELIVERY SYSTEM

WARMING UP
You have certainly had an idea about health system. Describe the Philippine health
care system based on your observation or knowledge.

___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

DEFINITIONS:
1. HEALTH CARE SYSTEM
- An organized plan of health services (Miller-Keane, 1987)

2. HEALTH CARE DELIVERY

- Rendering health care services to the people (Williams-Tungpalan, 1981).

3. HEALTH CARE DELIVERY SYSTEM (Williams-Tungpalan, 1981)

- The network of health facilities and personnel which carries out the task of rendering
health care to the people.

4. PHILIPPINE HEALTH CARE SYSTEM

- Is a complex set of organizations interacting to provide an array of health services
(Dizon, 1977).

1
 LESSON 1: THE PHILIPPINE NATIONAL
HEALTH SITUATION

NOW LET’S TALK ABOUT THE NATIONAL HEALTH SITUATION……

• The Philippines is one of the countries that have a large population.

• The average life expectancy at birth was 68.6 years – 71.28 for females and 66.03 for
males.
• The dependency ratio was computed to be 79.
• Population in urban areas is increasing very rapidly from 37% of the total population
and has been increased to 44% ten years later.
• Annual population growth in the country is 2.3%, and 3.4% growth rate in urban areas
per year (National League of the Philippine Government Nurses Incorporated, 2007).
The influences of health to national situation are as follows:

1. Poverty and Health

The identified leading causes of morbidity and mortality are associated with
factors that could be attributed to poverty – illiteracy, unfounded health beliefs, harmful
practices, inadequate nutrition, poor environmental sanitation, inadequate source of
potable water supply, congested housing units, limited access to basic health services,
and inability to make decisions on matters which are important to health.

Access to basic health services is hindered by the clients lack of financial

resources and the government’s inadequate financial support for public health
programs and facilities. The health budget remains to be much lower than the WHO
recommended 5% of a country’s gross national product (GNP).

2. Cultural Influences on health

Culture, per se, may not be the culprit for poor health; in many instances, it is
poverty and adequacy of the health care delivery system, however, there is a need to
study the extent to which culture contributes to poor health among certain population
groups – rural population, urban poor and indigenous groups, among others.

1
3. Environmental influences on health
• Plays a direct influence on health of people.
• An unsanitary environment is a major factor in the causation of diarrheal
diseases., still one of the leading causes of morbidity in the country.
• Others: denudation of forest, polluted rivers, ultraviolet radiation, surface air
temperature and carbon dioxide.

4. Political Influences on health

• Refers to decision making/ policy making structures, processes and outcomes.
• Health spending has always been inadequate, translates the fact that almost
half of health expenditures is out of the pocket, in other words “the financial
burden on individual families is heavy, leaving access to care highly
inequitable”
• The severely limited health budget is the biggest hindrance to the
implementation of well meaning policies such as the Magna Carta of Public
Health Workers (RA 7305), National Health Insurance Act (RA 7875), and the
Senior Citizens Act (RA 7432)
• There are laws that affect the delivery of health services – the Local
Government Code, National Health Insurance Act and the Professional
practice acts of the different professions (nursing, midwifery, and medicine)
where in areas access to medical care is difficult, nurses and midwives perform
functions that are beyond the provisions of their own practice acts.

2
 LESSON 2: COMPONENTS OF THE HEALTH
DELIVERY SYSTEM
WHAT ARE THE COMPONENTS OF THE HEALTH DELIVERY SYSTEM?

The Department of Health, as mandated, shall be responsible for the following:

formulation and development of national health policies, guidelines, standards and manual of
operations for health services and programs; issuance of rules and regulations, licenses and
accreditations; promulgation of national health standards, goals, priorities and indicators;
development of special health programs and projects and advocacy for legislation on health
policies and programs. The primary function of the Department of Health is the promotion,
protection, preservation or restoration of the health of the people through the provision and
delivery of health services and through the regulation and encouragement of providers of
health goods and services (E.O. No. 119, Sec. 3).

The 5 major functions of the DOH:

1. Ensure equal access to basic health services

2. Ensure formulation of national policies for proper division of labor and proper
coordination of operations among the government agency jurisdictions
3. Ensure a minimum level of implementation nationwide of services regarded as public
health goods
4. Plan and establish arrangements for the public health systems to achieve economies
of scale
5. Maintain a medium of regulations and standards to protect consumers and guide
providers

The basic health services rendered by the DOH (ELEMENTS DAM):

• Education regarding Health

• Local Endemic Diseases
• Expanded Program on Immunization
• Maternal & Child Health Services
• Essential drugs and Herbal plants
• Nutritional Health Services (PD 491): Creation of Nutrition Council of the Philippines

3
 • Treatment of Communicable & Non communicable Diseases
• Sanitation of the environment (PD 856): Sanitary Code of the Philippines
• Dental Health Promotion
• Access to and use of hospitals as Centers of Wellness
• Mental Health Promotion

The DOH Vision (by 2030)

A Global Leader for attaining better health outcomes, competitive and responsive
health care systems, and equitable health financing

The DOH Mission:

To guarantee EQUITABLE, SUSTAINABLE and QUALITY health for all Filipinos,

especially the poor and to lead the quest for excellence in health.

The principles to attain the vision of DOH:

• Equity: equal health services for all-no discrimination

• Quality: DOH is after the quality of service not the quantity
Philosophy of DOH: “Quality is above quantity”

• Accessibility: DOH utilize strategies for delivery of health services

What are the strategies used to effectively deliver the health services?

• Creation of Restructured Health Care Delivery System (RHCDS) regulated by PD 568

(1976)
• Management Information Systems regulated by R.A. 3753: Vital Health Statistics Law
• Primary Health Care (PHC) regulated by LOI 949 (1984): Legalization of
Implementation of PHC in the Philippines

To conceptualize, here is the creation of the RHCDS (Restructured Health Care Delivery
System)

1. BHS & RHU (Barangay Health Station/Rural Health Unit)

4
 2. MHO & PHO (Municipal/Provincial Health Office)

3. RHO & National Health Agency or existing national agencies like PGH

or specialized agencies like Heart Center for Asia, Lung Center, and NKTI

Now what to know about the Local Health System? And how does it helped on the
delivery of health care services?

• One of the most significant laws that radically changed the landscape of health care
delivery in the country is the formulation of RA 7160 or more commonly known as the
Local Government Code.
• The code aims to: transform local government units into self reliant communities and
active partners in the attainment of national goals through a more responsive and
accountable local government structure instituted through a system of decentralization.
• Each province, city, and municipality has a Local Health Board (LHB) – is good venue
for making the local health system more responsive to the needs of the people, and is
mandated to propose annual budgetary allocations for the operation and maintenance
of health facilities and services within the municipality, city, or province.

Important Note

The devolution made local government executives responsible to operate local health
care services. New centers of authority for local health services emerged. These consist of
provincial, city, municipal governments, including an autonomous regional government and a
metropolitan authority.

Each center controls a portion of the health care system as part of its political and
administrative mandate. Now, provincial governments operate the hospital system, Provincial
and District Hospitals, while city/municipal governments operate the Health Centers/ RHU and
BHS.

5
 LESSON 3: LEVELS OF HEALTH CARE

WHAT ARE THE LEVELS OF HEALTH CARE?

1. Primary level of health care

- Primary care is devolved to the cities and municipalities. It is health care provided by
center physicians, public health nurses, rural health midwives, barangay health
workers, traditional healers and others at the barangay health stations and rural health
units. The primary health facility is usually the first contact between the community
members and other levels of health facility.

2. Secondary level of health care

- Secondary care is given by physicians with basic health training. This is usually given
in health facilities either privately owned or government operated such as infirmaries,
municipal, and district hospitals and out – patient departments of provincial hospitals.
This serves as a referral center for the primary health facilities. Secondary facilities can
perform minor surgeries and perform some simple laboratory examinations.

3. Tertiary level of health care

- Tertiary care is rendered by specialists in health facilities including medical centers as

well as regional and provincial hospitals, and specialized hospitals such as the
Philippine Heart center. The tertiary health facility is the referral center for the
secondary care facilities. Complicated cases and intensive care require tertiary care
and all these can be provided by the tertiary care facility.

6
To understand more on the type and services provided, see the figure below.

According to Increasing Complexity of the According to the Type of Service

Services Provided

Type Service Type Example

Health Promotion,
Preventive Care,
Health promotion Information
Continuing Care for
and illness Dissemination
Primary common health problems,
prevention
attention to psychological
and social care, referrals

Surgery, Specialists Diagnosis and

Treatment
Secondary Medical Screening

Services

Advanced, specialized,
diagnostic, therapeutic &
Tertiary Rehabilitation PT/OT
rehabilitative care

For things to be easier….

1. Primary level of care – focuses on prevention of illness or promotion of health

2. Secondary level of care – focuses on curative procedures
3. Tertiary level of care – focuses more on rehabilitative procedures
NOW YOU KNOW!

7
 LESSON 4: REFERRAL SYSTEM

THE REFERRAL SYSTEM:

BHS RHU MHO

NATIONAL AGENCIES
RHO PHO

SPECIALIZED AGENCIES

8
Do you know that….

• The Barangay Health Station (BHS) is under the management of Rural Health Midwife
(RHM)
• The Rural Health Midwife (RHM) caters 1:5,000 population and acts as the manager
in the implementation of the policies and activities of BHS, directly under the
supervision of the PHN.
• The Rural Health Unit (RHU) is under the management or supervision of PHN
• The Public Health Nurse (PHN) caters to 1:10,000 populations, acts as managers in
the implementation of the policies and activities of RHU, directly under the supervision
of MHO (who acts as administrator).

WHAT ARE THE THREE LEVELS OF PRIMARY HEALTH CARE WORKERS?

Various categories of health workers make up the primary health care team. The types vary
in different communities depending upon:
• available health manpower resources
• local health needs and problems
• political and financial feasibility

1. Village or grassroot health workers

- first contacts of the community and initial links of health care.
- Provide simple curative and preventive health care measures promoting healthy
environment.
- Participate in activities geared towards the improvement of the socio-economic level
of the community like food production program.
- Community health worker, volunteers or traditional birth attendants.

2. Intermediate level health workers

- represent the first source of professional health care

9
 - attends to health problems beyond the competence of village workers
- provide support to front-line health workers in terms of supervision, training, supplies,
and services.
- Medical practitioners, nurses and midwives.

3. First line hospital personnel

- provide back up health services for cases that require hospitalization
- establish close contact with intermediate level health workers or village health workers.
- Physicians with specialty, nurses, dentist, pharmacists, other health professionals.

THE TWO-WAY REFERRAL SYSTEM (Niace, et. al. 8th edition 1995)

A two-way referral system need to be established between each level of health facility
e.g. barangay health workers refer cases to the rural health team, who in turn refer more
serious cases to either the district hospital, then to the provincial, regional or the whole health
care system.

P Barangay Public Health

O Health Worker Nurse 2nd 3rd

P HF HF

U EA EA

L Barangay RHU AC AC

A Health Midwife Physician LI LI

T Stations TL TL

I HI HI

O T T

N RHS Sanitary Y Y

Midwife Inspector

10
 LESSON 5: THE MULTI-SECTORAL
APPROACH TO HEALTH

THE MULTISECTORAL APPROACH TO HEALTH (NLGNI, 8th

edition, 1995)

The level of health of a community is largely the result of a combination of factors.

Other health-related

Systems (government/private)

Ways of Community Health Care

The Health System

People

(Cultural)

Environment (Social, Economic, physical, etc)

Health, therefore, cannot work in isolation. Neither can one sector or discipline claim
monopoly to the solution of community health problems. Health has now become a
multisectoral concern. For instance, it is unrealistic to expect a malnourished child to
substantially gain in weight unless the family’s poverty is alleviated. In other words,
improvement of social and economic conditions need to be attended to first or tackled hand in
hand with health problems.

11
1. Intersectoral Linkages
- Primary Health Care forms an integral part of the health system and the over-all
social and economic development of the community. As such, it is necessary to
unify health efforts within the health organization itself and with other sectors
concerned. It implies the integration of health plans with the plan for the total
community development.

- Sectors most closely related to health include those concerned with:

a. Agricultural
b. Education
c. Public works
d. Local governments
e. Social Welfare
f. Population Control
g. Private Sectors

The agricultural sector can contribute much to the social and economic
upliftment of the people. Demonstration to mothers of better techniques and
procedures for food preparation and preservation can preserve the nutritive value of
local foods. Through joint efforts, agricultural technology that produces side effects
unsafe to health (for instance, insecticide poisoning) can be minimized or prevented.
The school has long been recognized as an effective venue for transmission of
basic knowledge to the community. Every pupil or student can be tapped for primary
health care activities such as sanitation and food production activities.

Construction of safe water supply facilities and better roads can be jointly undertaken
by the community with public works. Community organization (e.g. establishing a
barangay network for health) can be worked through the local government or
community structure. Likewise, better housing through social
welfare agencies, promotion of responsible parenthood through family planning
services and increased employment through the private sectors can be joint
undertakings for health……We have to recognize that oftentimes health actions
undertaken outside the health sector can have health effects much greater than those
possible within it.

12
 2. Intrasectoral Linkages
- In the health sector, the acceptance of primary health care necessitates the
restructuring of the health system to broaden health coverage and make health
service available to all. There is now a widely accepted pyramidal organization that
provides levels of services starting with primary health and progressing to specialty
care. Primary health care is the hub of the health system.

LET’S TALK ABOUT THE NATIONAL HEALTH PLAN (Niace, et. al 8th edition 1995)
The National Health Plan is the blue print which is followed by the Department of
Health. It defines the country’s health problems, policy thrusts, strategies and targets.
POLICY THRUSTS AND STRATEGIES
There are policy thrusts and strategies which are commonly important. These are:
1. Information, education, and communication programs will be implemented to raise the
awareness of the public, including policy makers, program planners and decision
makers;
2. An update of the legislative agenda for health, nutrition and family planning (HNFP),
and stronger advocacy for pending HNFP –related legislations will be pursued;
3. Integration of efforts in the health, nutrition and family planning sector to maximize
resources in the delivery of services through the establishment of coordinative
mechanisms at both the national and local levels;
4. Partnership between the public and the private sectors will be strengthen and
institutionalized to effectively utilize and monitor private resources for the sector;
5. Enhancement of the status and role of women as program beneficiaries and program
implementers will be pursued to enable them to substantially participate in the
development process.

13
 ASSESSMENT

Instruction: Select the best answer. Write your answer on a ¼ sheet of paper.

1. Intersectoral linkages refers to:

a. Coordination among government and NGOs in providing health services to the
people
b. Effective referral system among the different units of DOH
c. Discourage outside help to encourage self reliance among the community
members
d. Linking the people to the services provided by the government

2. A rural health midwife is identified at what level of primary health worker?

a. Village or grassroot
b. Health personnel of the first line hospital
c. Intermediate
d. Expert personnel

3. The devolution of health services to the local government unit was mandated by:
a. RA 7160
b. RA 6713
c. EO 51
d. RA 7392

4. In the Philippine Health Care Delivery System, the primary level of care services is
provided by the:
a. Regional Medical Centers
b. Provincial hospitals
c. District hospitals
d. Rural Health Units

14
5. All but one are considered as secondary level of care as per Philippine Health Care
Delivery System.
a. Schistosiomiasis Research Hospital
b. Research Institute for Topical Medicine
c. Philippine Lung Center
d. Eastern Samar Provincial Hospital
6. The basic integral unit of the society is:
a. Church
b. Family
c. Individual
d. Population group

7. The immediate supervisor of the RHM at the health center level is the:
a. MHO
b. PHN
c. BNS
d. RSI

8. Level of facility capable of performing minor surgeries and some laboratory

examinations.
a. Primary level of care
b. Secondary level of care
c. Tertiary level of care
d. None of the above

9. Which of the following characterize Primary Health Care?

1. Universally accessible to individuals and families
2. Cost of care affordable t individuals, families, and community
3. Acceptable health care services
4. Participated by rich families and individuals only

a. 1,2, and 4
b. 2, 3, and 4
c. 1,2,3 and 4
d. 1, 2, and 3

15
10. In addressing the health problems of the community, midwife esnsures
a. People identifying and prioritizing their own problems
b. Each health team member provides his/her share in health care
c. People act as recipient of services
d. DOH programs are being carried out

16
 UNIT 2: PRIMARY HEALTH CARE

WARMING UP

In a sheet of paper make an organizational structure composes of Health worker in

your community. Please indicate their designation/position.

PRIMARY HEALTH CARE (PHC)

Definition:

The World Health organization (WHO) defines Primary Health Care an essential health
care made universally acceptable 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
and afford at every stage of development (DOH Public Health Nursing in the Philippines,
2007).

17
 LESSON 1:
Definition, Rationale and Goals

The Alma Ata Declaration….

The Declaration of Alma-Ata was adopted at the International Conference on Primary

Health Care (PHC), Almaty (formerly Alma-Ata), Kazakhstan (formerly Kazakh Soviet Socialist
Republic), 6-12 September 1978

Eight essential elements based on the Alma Ata on PHC: An essential health care based on
practical, scientifically sound and socially acceptable methods and technology made
universally, accessible to individuals and families in the community by means of acceptable to
them, through their full participation and at a cost that community and country can afford to
maintain at every stage of their development in the spirit of self-reliance and self-
determination.

1. Health Education
2. Treatment of Locally Endemic Diseases
3. Expanded Program on Immunization
4. Maternal and Child Health
5. Provision of Essential Drugs
6. Nutrition
7. Treatment of communicable and non-communicable diseases
8. Safe water and good waste disposaL

What are the Goals of Primary Health Care?

• The ultimate goal of primary health care is better health for all. WHO has identified five
key elements to achieving that goal:
• Reducing exclusion and social disparities in health (universal coverage reforms);
• Organizing health services around people’s needs and expectations
(service delivery reforms);
• Integrating health into all sectors (public policy reforms);
• Pursuing collaborative models of policy dialogue (leadership reforms); and
• Increasing stakeholder participation

18
Let’s talk about a brief history of PHC…..

May 1977. The 30th World Health Assembly adopted resolution which decided that the
main social target of governments and of WHO should be the attainment by all the people of
the world by the year 2000 a level of health that will permit them to lead a socially and
economically productive life.

September 6-12, 1978. International Conference in PHC was held in this year at Alma
Ata, USSR (Russia). October 19, 1979. The President of the Philippines (Ferdinand Marcos)
issued Letter of Instruction (LOI) 949 which mandated the then Ministry of Health to adopt
PHC as an approach towards design, development, and implementation of programs which
focus health development at the community level. (DOH Public Health Nursing in the
Philippines, 2007).

What is the Rationale of PHC?

Adopting primary health care has the following rationales:

• Magnitude of Health Problems

• Inadequate and unequal distribution of health resources
• Increasing cost of medical care
• Isolation of health care activities from other development activities

What are the Objectives of PHC?

• Improvement in the level of health care of the community

• Favorable population growth structure
• Reduction in the prevalence of preventable, communicable and other disease.
• Reduction in morbidity and mortality rates especially among infants and children.
• Extension of essential health services with priority given to the underserved sectors.
• Improvement in basic sanitation
• Development of the capability of the community aimed at self- reliance.
• Maximizing the contribution of the other sectors for the social and economic
development of the community.

19
What are the types of Primary Health Worker (PHC) workers in community setting?

There are two types of primary health care workers in the Philippines:

1. Barangay Health Worker or Village Health Worker

✓ first contacts of the community and initial links of health care.

✓ Provide simple curative and preventive health care measures promoting healthy
environment.
✓ Participate in activities geared towards the improvement of the socio-economic level
of the community like food production program.
Community health worker, volunteers or traditional birth attendants
2. Intermediate level Primary Health Worker

✓ represent the first source of professional health care

✓ attends to health problems beyond the competence of village workers
✓ provide support to front-line health workers in terms of supervision, training, supplies,
and services.
✓ Medical practitioners, nurses and midwives

What are the Four Pillars of PHC?

1. Active Community Participation

2. Intra and Inter-sectoral linkages
3. Use of appropriate technology
4. Support mechanism made available

20
 LESSON 2:
STRATEGIES, ELEMENTS AND PRINCIPLES

What are the Major Strategies of PHC?

1. Elevating health to a comprehensive and sustained national effort

Attaining health for all Filipinos will require expanding participation in health and health-
related programs whether as service provider or beneficiary. Empowerment to parents,
families and communities to make decisions of their health is the desired outcome.

Advocacy must be directed to national and local policy making to elicit support and
commitment to major health concerns through legislations, budgetary and logistical
considerations.

2. Promoting and supporting community managed health care.

The health in the hands of the people brings the government closest to the people.
It necessitates a process of capacity building of communities and organization to plan,
implement and evaluate health programs at their levels.

3. Increasing efficiency in health sector

Using appropriate technology will make services and resources required for their
delivery, effective, affordable, accessible and culturally acceptable.

The development of human resources must correspond to the actual needs of the
nation and the policies it upholds such as PHC.

The Department of Health (DOH) continue to support and assist both public and private
institutions particularly in faculty development, enhancement of relevant curricula and
development of standard teaching materials.

4. Advancing essential national health research

Essential National Health Research (ENHR) is an integrated strategy for organizing

and managing research using intersectoral, multi-disciplinary and scientific approach to health
programming and delivery.

21
What are the ELEMENTS of PHC?

The following are the eight (8) essential elements of primary health care:

1. Education for Health

This is one of the potent methodologies for information dissemination. It promotes the
partnership of both the family members and health workers in the promotion of health as well
as prevention of illness.

2. Locally Endemic Disease Control

The control of endemic disease focuses on the prevention of its occurrence to reduce
morbidity rate. Example Malaria control and Schistosomiasis control

3. Expanded Program on Immunization

This program exists to control the occurrence of preventable illnesses especially of

children below 6 years old. Immunizations on poliomyelitis, measles, tetanus, diphtheria and
other preventable disease are given for free by the government and ongoing program of the
DOH

4. Maternal and Child Health and Family Planning

The mother and child are the most delicate members of the community. So the
protection of the mother and child to illness and other risks would ensure good health for the
community. The goal of Family Planning includes spacing of children and responsible
parenthood.

5. Environmental Sanitation and Promotion of Safe Water Supply

Environmental Sanitation is defined as the study of all factors in the man’s

environment, which exercise or may exercise deleterious effect on his well-being and survival.
Water is a basic need for life and one factor in man’s environment. Water is necessary for the

22
maintenance of healthy lifestyle. Safe Water and Sanitation is necessary for basic promotion
of health.

6. Nutrition and Promotion of Adequate Food Supply

One basic need of the family is food. And if food is properly prepared then one may be
assured healthy family. There are many food resources found in the communities but because
of faulty preparation and lack of knowledge regarding proper food planning, Malnutrition is one
of the problems that we have in the country.

7. Treatment of Communicable Diseases and Common Illness

The diseases spread through direct contact pose a great risk to those who can be
infected. Tuberculosis is one of the communicable diseases continuously occupies the top ten
causes of death. Most communicable diseases are also preventable. The Government
focuses on the prevention, control and treatment of these illnesses.

8. Supply of Essential Drugs

This focuses on the information campaign on the utilization and acquisition of drugs. In
response to this campaign, the GENERIC ACT of the Philippines is enacted. It includes the
following drugs: Cotrimoxazole, Paracetamol, Amoxycillin, Oresol, Nifedipine, Rifampicin, INH
(Isoniazid) and Pyranizamide, Ethambutol, Streptomycin, Albendazole, Quinine.

What are the principles of PHC?

Primary health care is run with the following principles:

1. 4A’s = Accessibility, Availability, Affordability and Acceptability, Appropriateness of

health services.

The health services should be present where the supposed recipients are. They should
make use of the available resources within the community, wherein the focus would be more
on health promotion and prevention of illness.

23
2. Community Participation - Community participation is the heart and soul of primary health
care.

3. People are the center, object and subject of development.

• Thus, the success of any undertaking that aims at serving the people is dependent
on people’s participation at all levels of decision-making; planning, implementing,
monitoring and evaluating. Any undertaking must also be based on the people’s
needs and problems (PCF, 1990)

• Part of the people’s participation is the partnership between the community and
the agencies found in the community; social mobilization and decentralization.

• In general, health work should start from where the people are and building on
what they have. Example: Scheduling of Barangay Health Workers in the health
center

But note that there are some barriers for Community Involvement which are: Lack of
motivation, Attitude, Resistance to change, Dependence on the part of community people, and
Lack of managerial skills.

4. Self-reliance

Through community participation and cohesiveness of people’s organization they can

generate support for health care through social mobilization, networking, and mobilization of
local resources. Leadership and management skills should be developed among these
people. Existence of sustained health care facilities managed by the people is some of the
major indicators that the community is leading to self-reliance.

5. Partnership between the community and the health agencies in the provision of
quality of life.

Providing linkages between the government and the non-government organization and
people’s organization

24
6. Recognition of interrelationship between the health and development

• Health is defined as not merely the absence of disease. Neither is it only a state
of physical and mental well-being. Health being a social phenomenon recognizes
the interplay of political, socio-cultural, and economic factors as its determinant.
Good Health, therefore, is manifested by the progressive improvements in the
living conditions and quality of life enjoyed by the community residents

• Development is the quest for an improved quality of life for all. Development is
multidimensional. It has political, social, cultural, institutional, and environmental
dimensions (Gonzales, 1994). Therefore, it is measured by the ability of people to
satisfy their basic needs.
7. Social Mobilization

It enhances people’s participation or governance, support system provided by the

government, networking and developing secondary leaders.

8. Decentralization

This ensures empowerment and that empowerment can only be facilitated if the
administrative structure provides local level political structures with more substantive
responsibilities for development initiators. This also facilities proper allocation of budgetary
resources.

25
26
 ASSESSMENT

Instruction: Select the best answer. Write your answer on a ¼ sheet of paper.

1. All except one are members of the health team who are professionals under public
health.
a. MHO
b. BNS
c. Medical Technologist
d. RHM

2. A rural health midwife is identified at what level of primary health worker?

a. Village or grassroot
b. Health personnel of the first line hospital
c. Intermediate
d. Expert personnel

27
3. Which of the following characterize Primary Health Care?
i. Universally accessible to individuals and families
ii. Cost of care affordable t individuals, families, and community
iii. Acceptable health care services
iv. Participated by rich families and individuals only
a. 1,2, and 4
b. 2, 3, and 4
c. 1,2,3 and 4
d. 1, 2, and 3

4. The goal of PHC according to the DOH is

a. Health for all by the year 2000
b. Health for all Filipinos in the year 2000 and health in the hands of the people by
2020
c. Health for all by 2000 and beyond
d. Provide equity and quality health care in partnership with people

5. All but one are the objectives of public health.

a. Organization of Medical and Nursing Services
b. Control of Non Communicable Diseases
c. Sanitation of the environment
d. Development of Social Machineries

6. The barangay has a population of 25,000. The number of midwives needed for this
community is:
a. 5
b. 2
c. 10
d. 1

7. The basis unit of service in public health practice is

a. Individual
b. Family
c. Community
d. Any of the above

28
8. Which of the following characterize Primary Health Care?
i. Universally accessible to individuals and family
ii. Cost of care affordable to individuals, family, and community
iii. Acceptable health care services
iv. Participated by rich families and individuals only

a. i,ii, and iv
b. ii,iii, and iv
c. i,ii,iii, and iv
d. I,ii, and iii

9. Essential elements of health care include the following except:

a. Provision of essential drugs
b. Expanded program on immunization
c. Provision of totally free hospitalization of any Filipino regardless of illness
d. Maternal and child care
10. Level of facility capable of performing minor surgeries and some laboratory
examinations.
a. Primary level of care
b. Secondary level of care
c. Tertiary level of care
d. None of the above

29
 UNIT 3: COMMUNITY HEALTH PROCESS

WARMING UP

Give an insight about the two photos below. What do you think the photos show?

COMMUNITY HEALTH PROCESS

•This process of rendering care can be done by making use of NURSING PROCESS and
PRINCIPLES as applicable in the community settings.

DEFINITION

• Community Health Nursing Process is a systematic, scientific, dynamic, on-going

interpersonal process in which the nurses and the clients are viewed as a system with each
affecting one and another and both being affected by the factors within the behaviour.

• “Community Health Nursing Process refers to systematic series of steps which are followed
by public health nurse in community health and nursing problems using community
approaches and resources”.

30
• Community Health Nursing process is an effective tool to help people solve their health
problems and meet their health and nursing needs.

LESSON 1:
STEPS IN COMMUNITY PROCESS

WHAT ARE THE STEPS IN COMMUNITY HEALTH NURSING

PROCESS?

1. Establishing & maintaining working relationship.

2. Assessment of health needs & health problems.

3. Setting objectives.

4. Planning and implementing interventions.

5. Evaluation of interventions.

LET’S DISCUSS THE STEPS ONE BY ONE….

I. ESTABILISHIBG & MAINTAINING WORKING RELATIONSHIP

• Community Health Nursing process is helping community people and families identify their
health problems and develop competencies to solve their health problems and meet their
health and nursing needs.

• This is enabled when the community health nurse establishes a good working relationship
with the families and communities.

• Working relationship is productive in nature.

• In “working relationship” between community health nurse and the community

people/families, there is a free dialoguing and an attitude of trust and confidence in the
integrality and capabilities of each other to meet health and nursing goals.

31
A working relationship between a nurse and the community is initiated and maintained by the
following means:

1. Knowing the client (community).

2. Communicating intensions and nature of help and assistance that would be

extended.

3. Attentive listening and responding in between.

4. Answering heir queries.

5. Considering their views.

6. Appreciating what is worthwhile.

7. Empathetic attitude.

8. Meeting their immediate needs and needs which are considered important by them.

II. ASSESSMENT OF HEALTH NEEDS & HEALTH PROBLEMS

• The community health nurse comes to know the health needs and problems of the
community as she explores the community.

• The problems could be a large family size, malnutrition in children, incomplete immunization,
anaemia in pregnant and nursing mothers, several morbidity conditons-TB, malaria, diarhoea
etc.,

• After obtaining the list of health needs and problems, the community health nurse needs to
prioritize the problems, as all the problems cannot be dealt with simultaneously.

32
The priority is determined on the basis of underlying criteria:

1. The nature of the problem, its prevalence, impact and prognosis.

2. Community’s perception of the problem i.e., whether the problem is felt by the
community and considers serious.

3. Preventive potential i.e., whether the problem can be prevented or not.

III. SETTING OBJECTIVES

• Once the problems are prioritized, it is very important to set up objectives relevant to each
of the problems identified.

E.g., - Malnutrition

• To assess the growth and development of all the under five children in a defined community
to find out malnourished children.

• To get the medical examination done for all the malnourished children.

• To carry out prescribed treatment and provide care to all malnourished children.

• To do a regular monitoring of nutrition status of all children.

• To enroll all children with nutritional conditions for availing food supplements.

• To educate mothers and population in general about the malnutrition and importance of
nutritious diet.

IV. PLANNING AND IMPLEMENTATION OF INTERVENTIONS

• This is otherwise called the ACTION PLAN.

• Once the objectives are formulated it is necessary to identify interventions to be implemented

to achieve the objectives.

• Various actions are decided and implemented as being most effective in order to solve
particular problems (e.g., problem of malnutrition among under 5)

33
• As the action is implemented, the community health nurse gives direct nursing care either by
herself or through ANM.

• She also helps the community to develop their own resources and mobilize outside resources
also.

V. EVALUATION OF ACTION PLAN

• Evaluation of interventions determines the effectiveness of actions implemented –

i.e.whether the desired results intended are achieved or not.

• Evaluation also helps in finding out the reasons for not achieving the desired goal.

• This helps in making further improvement (feedback and re plan, re implement and re-
evaluate)

• The effectiveness of intervention depends upon its objectives and is determined on the basis
of the following criteria:

✓ Population coverage.
✓ Utilization of services provided.
✓ Outcomes in terms of reduction in morbidity rates (increase in life expectancy).
✓ Change in knowledge, attitude and practice, degree of independence.

• Evaluation thus made is both qualitative and quantitative.

• An effective evaluation strategy has the following characteristics:

✓ Well defined measurable objectives.

✓ Well defined action plan.
✓ Has a base line statistical information for comparison.
✓ Observe changes in health knowledge, attitudes, and practices.
✓ Analyze and interpret the facts (data) observed and recorded.

34
 LESSON 2:
PRINCIPLES OF COMMUNITY HEALTH
NURSING

WHAT ARE THE PRINCIPLES OF COMMUNITY HEALTH NURSING PROCESS?

• Principles are rules for community health practice or actions.

• Theses provide guidelines to function in the community effectively & efficiently.

1. Community health nurse must explore and know various aspects of a defined
community to be able to plan and implement health services.

2. Community health nurse must make a map of the community showing the geographical
boundaries, important roads, streets, housing networks, church/temple/mosque,
school, post office. This helps in plotting the house for care.

3. Community health nurse must establish good working relationship as it helps in

providing need based care.

4. Community health nurse must know the health care delivery system, health policies,
health goals, health actions, national health care programmes while rendering health
services.

5. The community health nurse should provide realistic health services ( in terms of
available resources, funds).

6. Community health nurse must organize health services at large for the community and
render the services to the family which is the unit of community.

7. Community health nurse must continuously keep in touch with the community and
provide wellness oriented comprehensive services continuously.

8. Community health nurse must work in collaboration with other team members…
therefore she needs to know the roles and responsibilities of the other team
members.

9. Community health nurse educates in giving care to individual, family and community.
The health education should aim at providing a comprehensive health knowledge to
the community.

35
 10. Community health nurse must maintain proper health records, registers. (These are
legal documents) These records help in planning and evaluation of the services.

11. The community health nurse must evaluate her services to find out achievement. Eg.,
population covered, actions planned and recorded.

12. The community health nurse must provide services to all without any discrimination of
age, gender, colour, caste, nationality, political affiliation, religion, as every individual
has a right to optimum health.

13. The community health nurse must not interfere with people’s religious, political beliefs,
but respect every one without any prejudice.

14. Community health nurse should work in close consultation with employing authority
(Govt, public trust, NGO).

15. Community health nurse should develop and maintain professional relationship with
health and health allies agencies

16. Community health nurse must never accept any bribe or gift against professional
ethics.

17. The community health nurse must have an active participation with the community
people in taking care of their own needs and health problems. (This can be done by
mass awareness campaign).

18. The community health nurse must be aware and closely co- ordinate with the local
formal and informal leaders.

**Assessment will be included on the chapter.

36
 UNIT 4: HEALTH CARE PROCESS AS
APPLIED TO FAMILY

WARMING UP

In a sheet of paper, make a genogram of your family, starting with maternal and
paternal grandparents. Include your uncles, aunts and cousins. Write their names
below symbols.
Use a square to denote a male family member and a circle for a female family member.
Draw a line to signify marriage or a broken line to show cohabitation. If the couple got
separated, mark it with one slashed line.
Place the children from oldest to youngest or from left to right below the marriage line.
The death of a family member is indicated by an X through the shape. Indicate the
cause of death.

HEALTH CARE PROCESS AS APPLIED TO FAMILY

Classification of family structure:

• Based on internal organization and membership

 Nuclear – father , mother and the children
 Extended – composed of two or more families related to each other
economically or socially
• Based on place of residence
 Patrilocal – requires couple to live with the family of the bridegroom
 Matrilocal –requires couple to live with or near the residence of the bride’s
parents
 Bilocal – couple has a choice where to live
 Neolocal – they can decide on their own
 Avunculocal- prescribes the newly wed couple to reside with or near the
maternal uncle of the groom
• Based on descent

37
 1. Patrilineal – affiliates a person with a group of relatives through his or her father

2. Matrilineal – affiliates a person with a group of relatives through his mother

3. Bilateral – affiliates a person with a group of relatives related through both his or
her parents

• Based on authority
1. patriarchal – oldest male in the family , father

2. matriarchal – mother or mothers kin

3. Egalitarian – husband and wife are equal

4. matricentric – prolonged absence of the father gives the mother a dominant

position.

There are five (5) health care processes that can be applied to the family which are:

LESSON 1:
FAMILY ASSESSMENT

I. FAMILY ASSESSMENT (Maglaya, 2003)

By Initial Data Base

a. Family structure, characteristics and dynamics

1. Members of the household and relationship to the head of the family

2. Demographic data – age, civil status, position in the family

3. Place of residence- whether living with the family or elsewhere

4. Type of family structure

5. Dominant family members in terms of decision making especially in matters of

health care

6. General family relationship /dynamics

38
b. Socio-economic and cultural characteristics

• Income, occupation, place of work (of each member)

• Educational attainment of each member
• Ethnic background and religious affiliation
• Significant others and other roles they play in the family’s life
• Relationship of the family to the larger community (membership in organizations)
c. Home and environment

• Information on housing and sanitation facilities which includes:

 Housing agency, sleeping arrangements, food storage, cooking facilities, water
supply, source, ownership, potability, presence of accident hazards, toilet,
garbage disposal
 Availability of social, health , communication and transportation facilities in the
community.
d. Health status of each member

• Past /current significant illness

• Beliefs/practices about health
• Nutritional and development status
• Decision – making on which or whom to seek advice regarding health
e. Values and Practices on Health Promotion and Maintenance

• Preventive aspects- immunization status

• Adequate rest and sleep, exercise, relaxation activities
• Street management activities, utilization of health care facilities

The Typology of nursing problems in family nursing practice

First Level Assessment - is a process whereby existing and potential health conditions or
problems of the family are determined.

1. Presence of wellness condition

 Stated as potential or readiness- a clinical nursing judgment about a client in

transition from a specific level of wellness or capability to a higher level .
 Potential for enhanced capability for
1. Healthy lifestyle

39
 2. Health maintenance/health management

3. Parenting

4. Breastfeeding

5. Spiritual being

6. Others , specify

Wellness potential

 Is a nursing judgment on wellness state or condition based on clients performance,

current competencies or clinical data but no explicit expression of client desire.

 Readiness for enhanced wellness state

 is a nursing judgment on wellness or state condition based on client
competencies or performance, clinical data and explicit expression of desire to
achieve a higher level of state or function in a specific area on health promotion
and maintenance.
1. Healthy lifestyle

2. Health maintenance/health management

3. Parenting

4. Breastfeeding

5. Spiritual being

6. Others , specify

2. Presence of health threats

 Conditions that are conducive to disease and accident, or may result to failure to
maintain wellness or realize health potential.
a. Presence of risk factors of specific diseases- e.g. Lifestyle diseases, metabolic
syndrome
b. Threat of cross infection from a communicable disease case
c. Family size beyond what family resources can provide
d. Accident hazards
✓ Broken stairs
✓ Pointed sharp objects
✓ Fire hazards
✓ Fall hazards

40
 ✓ Others specify
e. Faulty /unhealthful nutritional/ eating habits or feeding techniques practices.
✓ Inadequate food intake both in quality and quantity
✓ Excessive intake of certain nutrients
✓ Faulty eating habits
✓ Ineffective breastfeeding
✓ Faulty feeding techniques
f. Stress –provoking factors
✓ Strained marital relationship
✓ Strained parent – sibling relationship
✓ Interpersonal conflict between family members
✓ Care giving burden
g. Poor home/environmental condition/sanitation
✓ Inadequate living space
✓ Lack of food storage
✓ Polluted water supply
✓ Presence of breeding or resting sites of vectors of diseases
✓ Improper garbage disposal
✓ Unsanitary waste disposal
✓ Improper drainage system
✓ Poor lighting and ventilation
✓ Noise pollution
✓ Air pollution
h. Unsanitary food handling and preparation
i. Unhealthful lifestyle and personal habits/practices
✓ Alcohol drinking
✓ Cigarette /tobacco smoking
✓ Walking barefooted or in adequate footwear
✓ Eating raw meat or fish
✓ Poor personal hygiene
✓ Self medication/substance abuse
✓ Sexual promiscuity
✓ Engaging in dangerous sports
✓ Inadequate rest or sleep
✓ Lack of/inadequate exercise/physical activity
✓ Lack of/inadequate relaxation activities
✓ Non- use of self protection measure( bednets)

41
 j. Inherent personal characteristics – e.g. Poor impulse control

k. Health history which may participate/ induce the occurrence of a health deficite.g.
Previous history of difficult labor

l. Inappropriate role assumption – e.g. Child assuming mother’s role, father not
assuming his role

m. Lack of immunization/ inadequate immunization status especially of children

n. Family disunity

✓ Self- oriented behavior of member(s)

✓ Unresolved conflicts of members
✓ Intolerable disagreement
✓ Others
3. Presence of health deficits- instances of failure in health maintenance

 Illness states, regardless of whether it is diagnosed or undiagnosed by medical

practitioner

 Failure to thrive /develop according to normal rate

 Disability – wether congenital or arising from illness : transient /temporary ( e.g.

Aphasia or temporary paralysis after a CVA) or permanent (e.g leg amputation
secondary to diabetes, blindness from measles, lameness from polio)
4. Presence of stress points / froseeable crisis situations – anticipated periods of
unusual demand on the individual or family in terms of adjustment/ family resources

 Marriage

 Pregnancy,labor, puerperium

 Parenthood

 Additional member

 Abortion

 Entrance at school

 Adolescence

 Divorce or separation

 Menopause

 Loss of job

 Hospitalization of a family member

42
  Death of a member

 Resettlement in a new community

 Illegitimacy

 Others.

Second Level Assessment

Second level assessment – the nature or type of nursing problems that the family encounters
in performing the health tasks with respect to a given health condition or problem, and the
etiology or barriers to the family’s assumption of these tasks

Family Health Task – Review

a. Recognizes signs of health and development

b .Manages health and non –health crisis

c. Provides health care to its members

d. Provides home environment conducive to good health and personal development

e. Utilizes community resources for health care

LESSON 2:
STATEMENT OF FAMILY HEALTH
CONDITIONS

II. STATEMENT OF FAMILY HEALTH CONDITIONS (Maglaya, 2003)

Family Health Condition – a statement of family’s capabilities to maintain health and prevent
illness

a. Ability to recognize the signs of health and development

b. Ability to manage health and non-health crisis

43
 c. Ability to provide health care to its members

d. Ability to provide a home environment conducive to good health and personal

development

e. Ability to utilize community resources for health care.

LESSON 3:
FORMULATINGGOALS AND OBJECTIVES
FOR HEALTH PROMOTION AND
MAINTENANCE

III. FORMULATING GOALS AND OBJECTIVES FOR HEALTH PROMOTION AND

MAINTENANCE (Maglaya, 2003)

Goal – general statement of the condition or the state to be brought about by specific
course or action.

 Eg. After 2-3 months the family will be able to maintain ability to recognize signs of
health and development.
Objectives- refer to more specific statements of the desired results or outcomes of care

 At the end of 2-3 months the family will be able to:

 Identify signs of health and development
 Perform usual activities for health and development

44
 LESSON 4:
FAMILY HEALTH CARE STRATEGIES

IV. FAMILY HEALTH CARE STRATEGIES (Maglaya, 2003)

1. Assisting in Prenatal Care

a. History – demographic data

 - LMP ( last Normal Menstrual period

 - History of previous pregnancy, nature of delivery, age in
mos.
b. Signs and Symptoms of pregnancy

 Early – missed menstrual period

 - nausea and vomiting
 - frequent urination
 - wt gain -1 Kg (1st 3 mos)

 Late – enlargement of the abdomen

 - fetal movement
 - fetal heartbeat
 5 kgs .(2nd 3 mos)

c.Check –ups during pregnancy

 1-7 mos – every month

 8 mos.- every 2 weeks

 9 month - weekly
d. Immunization

 TT1 – anytime during pregnancy ( preferably 1st trimester

 TT2 – 1 mo. After TT1

 TT3 – 6 mos.After TT2

45
  TT4 – 1 year .after TT3/or next pregnancy – 7 mos.

 TT5 – 1 yr. After TT4/ or next pregnancy -7 mos.

Question/answer....

1. What is the importance of tetanus toxoid immunization?

Answer – to prevent tetanus in both mother and baby.

2. When does the baby is protected against neonatal tetanus?

Answer – when two doses of TT injection is given at one month interval between each
dose during pregnancy.

3. How many doses of TT injection will provide lifetime immunity?

Answer - Five doses following the schedule provide lifetime immunity.

4. Give TT 0.5cc at the 6th and 7th month to woman who didn’t have this before.
5. Avoid exposure to persons who have the following diseases; german measles,
influenza, typhoid, polio, mumps , measles

e. Nutrition – Eat foods rich in CHON, vitamins and minerals especially iron , and calcium

 - drink at least 8 glasses of water per day

 - avoid to much sweet s and salty foods
f. Personal Habits – take a bath daily but avoid chilling

 Wear comfortable loose clothes

 Use low-heeled comfortable footwear

 Maintain regular bowel habits

 Eat plenty of fruits and vegetables – to avoid constipation

 Extra care should be given to the teeth (they easily decay)

 No smoking /alcohol
g. Others

 Sexual intercourse – not contraindicated unless no vaginal bleeding

 Travel – caution against long distance land travel especially on rugged roads

 Medications – take drugs only when necessary and upon doctors advice

46
  Activities – encourage walking and usual household activities that does not
overstrain

2. Care of the newborn

A. Breastfeeding

 Advantages : protects baby against infection

 Clean and has the right temperature
 Helps in child spacing
 Safe – more digestible than cow’s milk
 Lowers risk of getting breast CA (mother)
 Economical and convenient
When?

✓ immediately after birth until tolerated but needs to be supplemented with food rich
in iron.
How?

✓ Wash the breast with clean water and soap before breastfeeding
✓ Hold the breast and see to it that the thumb is gently pressing the nipple
✓ Good sucking position:
A. Move areola in baby’s mouth

B. Baby’s tounge comes forward over his lower jaw and up

C. Baby is close to the breast, mouth is wide open

D. Baby’s stomach faces mother’s stomach

E. Not painful

B. Supplementary feeding

 Gradual to detect allergies

 3-4 mos – meat broth, mashed sweet potatoes, fruits

 5-7 mos – shredded meat ,fish, soft rice, fruit juices

 9 mos – regular diet

47
 C. Cord care – care of the umbilical cord which had been cut after delivery to prevent
infection.

 Apply 70% alcohol or gentian violet in a circular motion from inside to outside ,

 Cover will sterilize clothe looosely – less likely to get infected if exposed to air

 Apply abdominal binder loosely and change it if it becomes wet or dirty with urine
or feces
D. Bathing

 Daily with warm or tepid water in a place where there is no wind to prevent chilling

E. Immunization

 Acquisition of antibodies to fight against diseases/ illness

Immunization and Vaccine

Vaccine Route Dose Age

BCG Intradermal 0.05 l *Birth or anytime

*School entrants

DPT IM 0.5 ml *1 ½ ,2 ½ ,3 ½ mos

don’t after 5 yr

OPV Oral 1 drops *Same as above

Measles Subcutaneous 0. 5ml *9 mos

Hepatitis IM 0.5 ml *1 ½, 2 ½ , 3 ½ mos.

48
The EPI Vaccines and its Characteristics

Type/ form of Vaccines Storage Temperature

Most sensitive to heat Oral Polio (live attenuated -15 C TO 25 C (at the
freezer)
Less sensitive to heat DPT/Hep B +2 C to 8 C ( in the body of
“D” toxoid which is a the refrigerator
weekend toxin
“P” killed bacteria
“T”toxoid which is a
weekend toxin
Hep B +2C to 8C in the body of the
refrigerator
BCG (freeze dried) - do
Tetanus toxoid - do

3. Parenting

Responsibilities – to each other , for love and support and helping in many ways

 To children, for love, support, shelter and education

 To society, for helping to make a good community and bringing about good and just
relationship

4. Environmental Care and Sanitation

a. Cleanliness in the home

 Screen to protect food from insects

 Food containers bowls be well sealed

 Place stove near window- smoke gets out

 Hang pots, ladles and pans on the wall

 Wash plates and utensils with soap and water – dry if possible under the sun

 Keep animals outside the house

 Collect and dispose garbage

 Kitchen and bathroom drainage should be coursed to a covered pit

49
  Toilet should be at least be 30 meters away from the nearest well water for home
use must come from cleans sources
b. Backyard Sanitation

 Keep animals in pens or tied , gather their manure regularly

 Clean your yard daily

 Plant fruit trees, vegetables and medicinal plants

5. Health Education

 An activity which provides of information, education and communication for the

improvement of the family’s health condition.

 Content of Health Education depends on the health care strategies of individual and
family that promotes health and prevent illness

LESSON 5:
EVALUATION

V. EVALUATION (Maglaya, 2003)

 Evaluation plan – specifies how the health care provider will determine the achievement
of the outcome of care.

 Evaluation – reflection of objectives

✓ Standards – desired achievable level of performance against with actual practice
is compared. It serves as a guide in the formulation of objectives (can be the
same with goal)
✓ Criteria – statement of performance , behavior and circumstances or a status
that describes what is implied.

50
 ASSESSMENT

Instruction: Select the best answer. Write your answer on a ¼ sheet of paper.

1. Mrs. Dela Cruz has not consulted at the Health center for prenatal check up. This
constitutes a:
a. Health threat
b. Health deficit
c. Stress point
d. Forseeable crisis

2. Mrs. Delimma’s husband dided 4 months ago. For the family, this is a:
a. Health threat
b. Health deficit
c. Stress point
d. Forseeable crisis

3. While interviewing a prenatal client who came to the health center for her first check –
up, you found out that since the woman’s LMP six months ago, she has not had any
antenatal check-up yet. You categorized this lack of prenatal care to the patient as:
a. Health threat
b. Health deficit
c. Stress point
d. Forseeable crisis

4. This step of the nursing process tells us whether objectives have been attained or not.
a. Assessment
b. Planning
c. Intervention
d. Evaluation

5. Community assessment is best done through a:

a. Home visit
b. Clinic visit
c. Survey
d. Community assembly

51
6. The RHM performs the following to determine the family’s problems/ needs:
a. Family Health care plan formulation
b. Assessment
c. Goal setting
d. Evaluation

7. An appropriate source of information about the family is/are the following:

a. Interview results with the members of the family
b. Family folder
c. Actual observation of family situation
d. All of these sources of information

8. An important factor which should serve as the basis in preparing the family health care
plan is:
a. Data gathered from the health center
b. Needs and problems as seen and accepted by the family
c. Needs and problems gathered and recognized by the midwife herself
d. Needs are expressed by the midwife assigned in the area where the family resides.

9. When collecting data to know the family copes with their problems, the midwife is
doing:
a. Implementation
b. Planning
c. Evaluation
d. Assessment

10. In health promotion, community wellness is ensured through the promotion of

a. Healthy lifestyle
b. Healthy environment
c. Healthy behavior and beliefs
d. Healthy norms

52
 UNIT 5: CLINIC ACTIVITIES - IMMUNIZATION

WARMING UP

In your opinion, does immunization important in your community? Explain briefly your
answer.

LESSON 1:
EPI

Expanded Program on Immunization

Objective:

To reduce the morbidity and mortality among infants and children caused by the seven
childhood immunizable diseases.

Four Major Strategies

✓ Sustaining high routine FIC coverage of at least 90% in all provinces and cities.
✓ Sustaining the polio free country for global certification.
✓ Eliminating measles by 2008
✓ Eliminating neonatal tetanus by 2008

53
Elements of EPI

✓ Target Setting (main element)

✓ Information, Education and Communication
✓ Cold chain logistic management
✓ Assessment and Evaluation of overall performance
✓ Surveillance, Studies and Research

Seven (7) Childhood Immunizable Diseases

✓ Tuberculosis (Primary Complex if less than 3 years old)

✓ Diptheria
✓ Pertussis
✓ Neonatal Tetanus
✓ Poliomyelitis
✓ Hepatitis B
✓ Measles

PD 996: “Providing for compulsory basic immunization for infants and children below 8 years
old.

✓ Concept and Importance of Vaccination

Immunization – is the process by which vaccines are introduced into the body before
infection sets in.

✓ Vaccines are administered to introduced immunity thereby causing the recipient’s

immune system to react to the vaccine that produces antibodies to fight infection.
✓ Vaccinations promote health and protect children from disease – causing agents.

✓ Infants and newborn need to be vaccinated at an early age since they belong to
vulnerable age group.

54
 LESSON 2:
PRINCIPLES IN VACCINATION

General Principles in Vaccinating Children

✓ It is safe and immunologically effective to administer all EPI vaccines on the same day
at different sites of the body.
✓ The vaccination schedule should not be restated from the beginning even if the interval
between doses exceeded the recommended interval by months or year.
✓ Giving doses of a vaccine at less than the recommended 4 weeks interval may lessen
the antibody response. Lengthening the interval between doses of vaccines leads to
higher antibody levels.
✓ No extra doses must be given to children who missed a dose of DPT/HB/OPV. The
vaccination must be continued as if no time had elapsed between doses.
✓ Do not give more than one dose of the same vaccine to a child in one session. Give
doses of the same vaccine at the correct intervals.
✓ Strictly follow the principle of never, ever reconstituting the freeze dried vaccine in
anything other than the diluent supplied with them.
✓ If you are giving more than one vaccine, do not use the same syringe and do not use
the same arm or leg for more than one injection.

LESSON 3:
CONTRAINDICATION TO IMMUNIZATION

Contraindication to Immunization

✓ Anaphylaxis or severe hypersensitivity reaction to a previous dose of vaccine is an

absolute contraindication to subsequent doses of vaccine.
✓ Person with a known allergy to a vaccine component should not be vaccinated.
✓ DPT2 or DPT3 is not t given to a child who has convulsions or shock within 3 days
after DPT1. Vaccines containing the whole cell pertussis component should not be
given to a children with an evolving neurological disease.

55
✓ Do not give live vaccines like BCG to a individuals who are immunosuppressed due to
malignant disease (child with AIDS), going therapy with immunosuppressive agents or
radiation.
✓ A child with a sign and symptoms of severe dehydration.
✓ Fever of 38.5C and above.

The following are NOT contraindication. Infants with these conditions SHOULD be
immunized:

✓ Allergy or asthma (except if there is a known allergy to a specific component of vaccine

mentioned above)
✓ Minor respiratory tract infection
✓ Diarrhea
✓ Temp. below 38.5 C
✓ Family History of convulsions, seizures
✓ Known or suspected HIV infection with no signs and symptoms of AIDS
✓ Child being breastfed
✓ Chronic illness such as diseases of heart, lung, kidney or liver
✓ Stable neurological condition such as cerebral palsy or Down’s Syndrome
✓ Premature or low imminent surgery (vaccination should not be postponed)
✓ Recent or imminent surgery
✓ Malnutrition
✓ History of jaundice at birth
Note:

If parent strongly objects to an immunization for a sick infant, do not give it. Ask the
mother to comeback when the child is well.

56
 LESSON 4:
EPI SCHEDULE

EPI Routing Schedule

Every Wednesday is designated as immunization day and is adopted in all part of the
country.

FIC “Fully Immunized Child” when a child receives one dose of BCG, 3 doses of OPV, 3
doses of DPT, 3 doses of HepB and one dose of measles before a child’s first birthday.

LESSON 5:
EPI COLD CHAIN AND LOGISTICS

EPI COLD CHAIN and LOGISTICS

Cold Chain Manager = Public Health Nurse

✓ Temperature monitoring of vaccines is done in all levels of health facilities to monitor

vaccine temperature.
✓ Temperature checking is done twice a day early in the morning and in the afternoon
before going home.
✓ Temperature is plotted every day in monitoring chart to monitor break in cold chain.

57
 Type of Vaccine Storage Temp. Hours of Life
after Opening

Most Sensitive to OPV -15 to -25 C

Heat At the freezer
Measles

Most Sensitive to Cold Hepa B 2 to 8 C 8 hours

Body of
DPT
refrigerator
Tetox

Sensitive to Sunlight BCG 4 hours

And Fluorescent light

Vaccine can be stored in Refrigerator:

Regional – 6 months

Municipal / City – 3 months

Main Health Center – 1 month

Transport Box : 5 days

Note: 3 trip in transport box with the same vaccine discard it

FEFO (first expiry and first out) vaccine is practiced to ensure that all vaccine are utilized
before its expiry date.

✓ Proper arrangement of vaccines and labelling of vaccines expiry date are done to
identify those near to expire vaccines.

58
 LESSON 6:
TYPES OF VACCINE WASTAGE

Vaccine Wastage

Wastage is defined as loss by use, decay, erosion or leakage or through wastefulness.

Wastage rate

= Doses supplied – doses administered x 100 Doses supplied

Types of Vaccine Wastage

✓ Expiry
✓ Heat exposure
✓ Freezing
✓ Breakage
✓ Missing inventory
✓ Theft
✓ Discarding unused vials returned from an outreach session

Vaccine wastage in opened vials

✓ Discarding remaining doses at end of session

✓ Not being able to draw the number of doses indicated on the label of a vial
✓ Poor reconstitution practices
✓ Submergence of opened vials in water
✓ Suspected contamination
✓ Patient reaction requiring more than one dose

59
1.1 Calculating Vaccine Needs

I. Essential Information

▪ Wastage factor
DPT Measles - 2

OPV 1.67 BCG - 2.5

TT Hep B – 1.1

▪ Doses/vial
DPT, TT, OPV, BCG (20 doses/vial)

Measles – 10 doses/vial

Hep B – 10/1 dose

▪ Doses to complete immunization

II. Steps in Calculating Annual Requirement
BCG – 1 OPV- 3 Measles – 1
• Determine Eligible Population (target setting)
DPT – 3 TT – 1 Hep B – 3
- children = 2.7 %

- pregnant = 3.5%

E.P. = Total Population X Target Population

= 15,000 X .027

E.P. = 405

• Total number of doses to immunize children/pregnant

Doses = 405 E.P. X 3 DPT = 1,215

 Determine vaccine required (EP x no. of doses)

Doses Required = 1,215 doses

 Wastage factor of vaccine

1.67 (DPT)
60
 III. Steps in Calculating Annual Requirement

✓ E.P.
✓ Total # of Doses
✓ Calculate Annual Vaccine Doses Required
(vaccine required x wastage factor)

Annual Vaccine Required = 1,215 doses X 1.67 wastage factor

= 2,029.05

 Determine Monthly Vaccine Required

(annual vaccine doses ÷12)

Monthly vaccine = 2,029 Annual Vaccine = 169.08 or 169

required 12 months

1.2 Vaccine Vial Size

- One, 10, 20 dose vials

- Multi-Dose Vial Policy (MDVP) – use w/in 4 weeks

61
1.3 Vaccine Wastage

Types

a. unopened vials

- expired - missing inventory

- VVM indication - theft

- Heat exposure - discarding unused

- Freezing - returned from outreach

- breakage

b. opened vials

- discarding remaining doses

- withdrawing excess dose

- wrong reconstitution

- vaccine submerged in water

- suspected contamination

- patient requiring more than one dose

1.3 Shake test – DPT, TT, Hepa B

1.4 Injection Safety

- Equipment: ADS, Conventional syringe

62
1.5 Calculating other EPI Logistics

- Calculating Annual ADS

1. Eligible Population

E.P. = 15,000 population X .027 (target children)

= 405

2. Vaccine Doses (EP x no. of doses)

= 405 E.P. X 3 DPT doses

= 1,215 Doses

3. Total ADS (annual vaccine doses x wastage factor)

= 1,215 Doses X 1.1 Wastage Factor

= 1,366.5 or 1,337

- Calculating Annual MS (mixing syringe) BCG & Measles

✓ Eligible population
E.P. = 15,000 population X .027 = 405

✓ Determine vaccine doses (EP x no. of doses)

Vaccine Doses = 405 E.P. X 3 DPT = 1,215 Doses

✓ Vaccine required = annual doses required x W. F. of vaccine

Vaccine required = 1,215 doses X 1.67 W.F.

= 2,029 Vaccine required

✓ Determine annual no. of vials required

(annual doses ÷ no. of doses/vial)

Vials = 2,029 vaccine required = 101.45 vials or 101

20 doses/vial

63
 ✓ Annual MS required
(no. of annual vials x (1.1.) wastage factor

Annual MS = 101 vials X 1.1 W.F.

= 111

SAFETY COLLECTOR BOX = ADS + MS

100

LESSON 7:
EPI VACCINES

EPI VACCINES

1. BCG (Bacille Calmette-Guerin) Vaccine

Type of Vaccine Live Bacterial
Form of Vaccine Freeze dried
Minimum Age at 1st Dose Birth or anytime at birth
Number of Doses to Complete 1st dose : at birth
the Immunization 2nd dose : school entrance
Reason BCG given at earliest possible age protects the possibility
of TB meningitis and other TB infectious in which infants
are prone.
Number of Doses per Ampule 20 (20 children)
Dosage At birth : 0.05 ml
At school entrance : 0.10 ml
Route of Administration Intradermal (a special syringe and needle is used for the
administration of BCG vaccine)
Site of Administration Right deltoid region of the arm

64
 Storage Temperature 2 C to 8 C (in the body or refrigerator)
Note: Freezing does not damage it but ampules may
break.
Diluents should also be kept cold before using.
Special Precautions Correct ID administration is essential. A special syringe
and needle is used for the administration of BCG vaccine
Side Effect A wheat formation
Koch phenomenon (inflammatory reaction 2-4 days)
Undesired Effect • Indolent ulceration
• Abscess on the injection site
• Enlarged lymph nodes
Note: Swollen glands or abscesses occur because an
unsterile needle or syringe was used, too much vaccine
was injected or most commonly, the vaccine was infected
incorrectly under the skin instead of its top layer.
Contraindication Immunosuppressed individual due to malignant disease
(child with clinical AIDS) ; therpay with
immunosuppressive agent or radiation.
Health Teaching • Do not massage the area of injection
• A scar will formed 12 weeks after injection
• Repeat BCG vaccination if the child does not
develop a scar after first injection

Reconstituting the freeze dried BCG Vaccine:

✓ Always keep the diluent cold

✓ Using a 5 ml. syringe fitted with along needle, aspirate 2 ml. of saline solution from the
opened ampule of diluent.
✓ Inject the 2 ml. Saline into the ampule of freeze dried BCG.
✓ Thoroughly mix the diluent and vaccine by drawing the mixture back into the syringe and
expel it slowly into the ampule several times.
✓ Return the reconstituted vaccine on the slit of the foam provided in the vaccine carrier.
✓ Note:

➢ Any remaining reconstituted vaccine must be discarded after 6 hours or at the end of
the immunization sessions, whichever comes first.

65
➢ The small raised lump appears at the injection site, usually disappears within 30
minutes.

➢ After 2 weeks, a red sore forms that is about the size of the end of an unsharpened
pencil.

➢ The sore remains for another two weeks and then heals, a small scar, about 5mm
across remains. This is a sign that the child does not develop a scar after the 1 st
injection.

➢ BCG vaccine is moderately effective. It has a protective efficacy of:

50% against any TB disease

64% against any TB meningitis

74% against death from TB

2. DPT (Diptheria-Pertussis-Tetanus) Vaccine

Type of Vaccine Diptheria and Tetanus as “toxoids” which is a
weakened toxin
Pertussis as killed whole-cell bacterium
Form of Vaccine Liquid vaccine

Minimum Age at 1st Dose 6 weeks

Number of Doses to Complete 3

the Immunization
Interval 4 weeks / minimum of 28 days

Reason An early start with DPT reduces the chance of severe

pertussis
Number of Doses per Ampule 20 or 10

Dosage 0.5 ml.

Route of Administration Intramuscular

Site of Administration Upper outer portion of the thigh (Vastus lateralis) in

infant ( R – L – R )
Outer upper arm if older

66
 Storage Temperature 2 C to 8 C ( in the body of refrigerator)
Note: “DT” component is damage by freezing
“P” component is damage by heat
Special Precautions DPT not usually given over 6 years of age

Side Effect * Fever in the evening after receiving the

injection.
* Soreness, children may have pain, redness or
swelling at the injection site.
Contraindication *DPT2 or DPT3 is not given to a child who has
convulsions or shock within3 days after DPT1
*Vaccines containing the whole cell pertussis
component should not be given to a children with an
evolving neurological disease.
Health Teaching *If the child has fever give paracetamol or any
appropriate antipyretic at the time and at four
and eight hours after immunization.
*Alternating cold compress for 24 hours to warm
compress if there is pain and soreness.

3. OPV (Oral Polio Vaccine)

Type of Vaccine Live attenuated vaccine

Form of Vaccine Liquid vaccine

Minimum Age at 1st Dose 6 weeks

Number of Doses to Complete 3

the Immunization
Interval 4 weeks / minimum of 28 days

Reason The extent of protection against polio is increased the

earlier the OPV is given
Number of Doses per Ampule 20 (10 children)

Dosage 2 drop

Route of Administration Oral

Site of Administration Mouth

67
Storage Temperature -15 C to -25 C (at the freezer)
Note: It is easily damaged by heat but is not harmed
by freezing.
Special Precautions Children known to have rare congenital immune
deficiency syndrome should receive IPV (injectable
polio vaccine) rather OPV
Side Effect Causes almost no side-effects. Less than 1% of the
people who receive the vaccine develop a headache,
diarrhea or muscle pain.
Contraindication None

Health Teaching *Nothing by mount (NPO) 30 minutes before

and after OPV.
* Do not touch the tip dropper bottle to the
tongue.

4. Hepatitis B Vaccine
Type of Vaccine “Monovalent vaccine” contain only one antigen

Form of Vaccine Cloudy liquid vaccine

Minimum Age at 1st Dose At birth

Number of Doses to Complete 3

the Immunization
Interval 6 weeks interval from 1st dose to 2nd dose
8 weeks interval from 2nd dose to 3rd dose
Reason An early start of HepB vaccine reduces the chance of
being infected and becoming a carrier. Prevent liver
cirrhosis and liver cancer.
Number of Doses per Ampule 1 for single dose vial
10 for multi dose vial (10 children)
Dosage 0.5 ml

Route of Administration Intramuscular

Site of Administration Upper outer portion of the thigh (Vastus laterals) in

infant (with DPT: L – R – L)

68
Storage Temperature 2 C to 8 C (in the body of refrigerator)
Note: Both heat and freezing damages the vaccine.
Special Precautions Birth dose must be given if there is a risk of perinatal
transmission.
Note: Combination vaccines should not be given at
birth, only monovalent HepB vaccine
Side Effect • Mild fever that lasts one to two days after
injection
• Soreness, children may have pain, redness
or swelling at the injection site.
Contraindication • Anaphylactic reaction such as severe rashes,
difficulty in breathing and choking to a
previous dose.
Health Teaching • If the child has fever give paracetamol or any
appropriate antipyretic at the time and at
four and eight hours after immunization
• Alternating cold compress for 24 hours to
warm compress if there is pain and soreness

5. Measles Vaccine

Type of Vaccine Attenuated Measles Virus

Form of Vaccine Freeze dried

Minimum Age at 1st Dose 9 months

6 months if there is an epidemic
Number of Doses to Complete 1
the Immunization
Reason Measles vaccine given at 9 months provide at least
85% protection against measles infection.
When given at one year and older provides 95%
protection.
Note: An infant with known or suspected HIV infection
should receive measles vaccine at 6 months and then
again at 9 months

69
Number of Doses per Ampule 10 (10 children)

Dosage 0.5 ml

Route of Administration Intramuscular

Site of Administration Outer part of the upper arm

Storage Temperature -15 C to -25C (at the freezer)

Note: But can also be safely stored between 0 C
to 8C until its expiry date.
Diluents should also be kept cold before
using.
Special Precautions Birth dose must be given if there is a risk of perinatal
transmission.
Note: Combination vaccines should not be given at
birth, only monovalent HepB vaccine
Side Effect • Fever that lasts one to two days after
injection
• Soreness, children may have pain, redness
or swelling at the injection site within 24 hours
of immunization. It usually resolve within two
to three days.
Side Effect • Fever that lasts one to two days after
injection
• Soreness, children may have pain, redness
or swelling at the injection site within 24 hours
of immunization. It usually resolve within two to three
days.
• About 1 in 20 children develop a mild rash
five to 12 days after receiving the vaccine. The rash
usually lasts about two days.
Contraindication • Severe reaction to previous dose
• Pregnancy
• Congenital or acquired immune disorder
Health Teaching • If the child has fever give paracetamol or any
appropriate antipyretic at the time and at four
or eight hours after immunization.

70
 • Alternating cold compress for 24 hours to
warm compress if there is pain and
soreness.
• It also prevent diarrhea

Reconstituting the Freeze Dried Measles Vaccine:

✓ Using a 10 ml. syringe fitted with a long needle, aspirate 5 ml of special diluent from
the ampule.
✓ Empty the diluent from the syringe into the vial with the vaccine.
✓ Thoroughly mix the diluent and vaccine by drawing the mixture back into the syringe
and expelling it slowly into the vial several times. Do not shake the vial.
✓ Protect reconstituted measles vaccine from sunlight. Wrap vial in foil.
✓ Place the reconstituted vaccine in the slit of the foam provided in the vaccine carrier.

Immunization Schedule For Infants Recommended by The EPI

Birth 6 weeks 10 weeks 14 weeks 9 months

BCG X

OPV X X X

DPT X X X

HepB Option B X X X
Option A
X X X

Measles X

71
 6. Tetanus Toxoid (TeTox) Vaccine
Type of Vaccine Weakened toxin

Form of Vaccine Liquid vaccine

Minimum Age at 1st Dose As early as possible during pregnancy

Number of Doses to Complete 5 doses (Tetox 1 – Tetox 5)

the Immunization Tetox 2 is the minimum required immunization during
pregnancy
Number of Doses per Ampule 10 or 20

Dosage 0.5 ml

Route of Administration Intramuscular

Site of Administration Outer upper arm

Storage Temperature 2 C to 8 C ( in the body of refrigerator)

Note: Never freeze
Side Effect • Fever in the evening after receiving the
injection .
• Soreness, woman may have pain, redness
or swelling and warmth at the injection site.
Contraindication • Anaphylactic reaction to previous dose

Health Teaching • NO MEDICATION FOR PREGNANT

• For Pain cold compress 24 hrs to warm
compress

72
Tetanus Toxoid Routine Immunization of Pregnant Women

Vaccine Minimum Percent Duration of Protection

Interval Protected
Tetanus As early as
Toxoid 1 Possible during
pregnancy
Tetanus 4 weeks after 80% • infant will be protected by
Toxoid 2 Tetox 1 neonatal tetanus
• 3 years protection for the mother
Tetanus 6 months after 95% • infant will be protected by
Toxoid 3 Tetox 2 neonatal tetanus
• 5 years protection for the mother
Tetanus 1 year after 99% • infant will be protected by
Toxoid 4 Tetox 3 neonatal tetanus
• 10 years protection for the
mother
Tetanus 1 year after 99% • all infant born to that mother will
Toxoid 5 Tetox 4 be protected
• lifetime protection for the mother

73
 LESSON 8:
ROLE OF MIDWIFE ON IMMUNIZATION

Role of a Midwife In Improving the Delivery of Immunization in the Community.

As a midwife you need to:

✓ Actively master list infants eligible for vaccination in the community.

✓ Immunize infants following the recommended immunization schedule, route of
administration, correct dosage and following the proper cold chain storage of vaccines.
✓ Observe aseptic technique on immunization and use one syringe and one needle per
child. This reduces blood-borne diseases and promote safety injection practices.
✓ Dispose used syringes and needles properly by using collector box and disposing it in
the septic vault to prevent health hazard.
✓ Inform, educate and communicate with the parents
→ to create awareness and motivate to submit their

child for vaccination.

→ to provide health teachings on the importance

and benefits of immunization, importance of

follow up dose to avoid defaulters and normal

course of vaccine.

to inform immunization schedule as adopted by local

units.

✓ Conduct health visits in the community to assess other health needs of the community
and be able to provide package of health services to targets.
✓ Identify cases of EPI target diseases per standard case definition.
✓ Manage vaccines properly by following the recommended storage of vaccines.
✓ Record the children given with vaccination in the Target Client list and GECD/GMC or
any standard recording form utilized.

74
 ✓ Submit report and record of children vaccinated, cases and deaths on EPI diseases,
vaccine received and utilized and any other EPI related reports.
✓ Identify and actively search cases and deaths of EPI target diseases following standard
case definition.

LESSON 9:
NATIONAL IMMUNIZATION PROGRAM

NATIONAL IMMUNIZATION PROGRAM (Updates)

Formerly known as Expanded Program of Immunization.

Milestones of the Immunization Program in the Philippines: Vaccines

Introduced by the Program

1976 BCG first administered among school entrants DPT introduced in priority areas

1979 BCG and DPT provided nationwide; OPV and tetanus toxoid (TT) for pregnant women
provided in high risk areas

1980 OPV and TT provided nationwide

1982 MV provided among 35% of the eligible population

1983 MV provided nationwide

1992 Hepatitis B provided among 40% of eligible population

2005 Hepatitis B provided nationwide

2010 MMR administered in selected areas

PENTA: DTwP-HepB-Hib in three selected regions

2012 PENTA administered Nationwide

Rotavirus vaccine provided among children in indigent families
Anti-Influenza Vaccine and PPV 23 provided for indigent senior citizens

2013 Td and MR vaccines provided in high schools in selected high risk provinces and cities
MMR second dose provided for children 12 – 15 months of age

2014 PCV 13 vaccine introduced in five seleted regions

HPV vaccine introduced in pilot areas in CAR and Region 7

75
2015 PV vaccine provided in the National Capital Region, Regions 3, 6 and 7
Td and MR vaccines provided in all public schools: Grades 1 (6-7 years) and Grade 7 (11-12
years)
HPV vaccine provided in 20 priority provinces among females age 9 – 10 years
PCV 13 provision expanded to 14 regions (excluding NCR, 4 A and 4 B)

2016 Switch from tOPV to bOPV

IPV provision expanded to 6 regions
Td and MR vaccines provided in all public schools
HPV vaccination expanded to 48 provinces

2017 MV was replaced with MMR

TT vaccine for CBAW was replaced with Td
Anti-Influenza Vaccine and PPV 23 provided for all senior citizen at ages 60 to 65 years

BENEFITS OF IMMUNIZATION

• Immunization saves lives, prevents diseases, and reduces direct and indirect health
costs.
• Vaccines are cost-effective and are a core component of any preventive services
package.
• Vaccines protect children from VPDs that once were top killers and disablers
worldwide. These include diphtheria, whooping cough, tuberculosis, smallpox, polio,
and measles.
• Vaccines continue to give protection against more diseases among various age groups
as new vaccines are developed and tested.
• Vaccines also prevent the spread of these diseases among families, loved ones and
neighbors, resulting in healthier communities.
• Immunization prevents disease transmission from one generation to another, freeing
the next generation from the threat of disease.
• Vaccination not only benefits the health and welfare of the whole population but is also
a source of high investment return to the government. Health is fundamental to
economic growth for developing countries and vaccinations form the foundation of
public health programs. Good health can promote social development and economic
growth. The yearly return on investment in vaccination is estimated to be between 12
to 18%, but the economic benefits of improved health continue to be largely
underestimated (WHO Bulletin, 86(2), February 2008).

76
WHAT HAPPENS WHEN CHILDREN ARE NOT VACCINATED?

• Unvaccinated children can develop diseases resulting in prolonged or long-term

disabilities, affecting their full physical, emotional, and social development and
wellbeing.
• Sick children are unable to go to school, which can hamper their becoming fully
productive individuals.
• Prolonged treatment and out-of-pocket spending burdens families with medical
expenses and lost time at work. This can eventually lead to a lower quality of life for
individuals and families.

NIP prevents

Source: Google.com.ph

DURATION
OF
RESERVOI IMMUNITY RISK FACTORS
DISEASE AGENT SPREAD
R INDUCED FOR INFECTION
BT
INFECTION

77
Tuberculosis Bacterium Humans Airborne Not known. Crowding
(Mycobacte droplets Reactivatio Immunodeficienc
rium n y
tuberculosi of old Malnutrition In
s) infection adults,
commonly alcoholism,
causes diabetes, and HIV
disease

Hepatitis B Virus Humans Mother to If infection Infected mother

newborn, resolves, Unsafe injections
child to life- long Unsafe blood
child, blood, immunity; transfusions;
sexual. In multiple sexual
developing partners
countries,
transmissio
n at birth
or early
childhood is
dominant.

Polio Poliomyeliti Humans Fecal-oral Lifelong Poor

s type environmental
virus - specific hygiene
serotypes immunity
1, 2, 3
Polio Poliomyeliti Humans Fecal-oral Lifelong Poor
s type environmental
virus - specific hygiene
serotypes immunity
1, 2, 3
Diphtheria Toxin- Humans Close Usually Crowding
producing respiratory lifelong
bacterium contact or
(Corynebac contact
terium with
diphtheriae infectious
) material

Pertussis Bacterium Humans Close No concrete Crowding

(Bordetella respiratory evidence
pertussis) contact

Tetanus Toxin- Soil Spores None Exposure to

producing Animal enter the animal
bacterium intestines body feces; infections
(Clostridiu through with rusty metals
m wounds Untreated
tetani) wounds

78
 Rotavirus Virus Humans Fecal-oral Unknown Globally
circulating
virus strain. Poor
environmental
hygiene

Measles Virus Humans Close Lifelong Crowding

respiratory
contact and
aerosolized
droplets

Mumps Virus Humans Close Lifelong Crowding

respiratory
contact and
airborne
droplets

Rubella Virus Humans Close Lifelong Crowding

respiratory
contact and
airborne
droplets

Human Virus Humans Sexual Not known Presence of high

Papilloma Virus intercourse burden of disease
causing vector

Influenza Virus Humans Close Unknown or Crowding

respiratory weak
contact and immunity
airborne
droplets

Pneumococcal Bacteria Humans Close Some type- Crowding

Disease respiratory specific
contact and immunity
airborne
droplets

VACCINES
Immunization is the process where a person is made immune or resistant to an infectious
disease, typically by the administration of a vaccine. Vaccines stimulate the body’s own
immune system to protect the person against subsequent infection or disease.

Immunity refers to protection from disease through the formation of antibodies.

• Passive Immunity - Acquired through the administration of products derived from

human or animals providing short-term protection, usually a few weeks or months.

79
 The three ways of gaining passive immunity are either from blood products, through
administration of immune globulins or vertical transmission from mother to newborn.

• Acquired Immunity - Formed by stimulating the immune system to produce cellular

and antibody immunity. Ways of producing active immunity include:
✓ Exposure to an infection or disease, although infection does not lead
to immunity in all cases.
✓ Vaccination to produce immune responses similarly evoked by natural
infection without the development of the disease and its complications.

SITE AND ROUTE OF ADMINISTRATION

• Oral Route (Per Oral - PO)

o Commonly oral polio, rota and oral cholera vaccines are the licensed-
vaccines administered by the oral route.
✓ Oral vaccines should be administered first before giving
injectable vaccines or performing other procedures that might
cause discomfort especially in children.
✓ Administer the liquid agent slowly down one side of the inside
of the cheek toward the back of the infant’s mouth.
✓ Take extra care not to trigger the gag-reflex while
Source: en.wikipedia.org administering the oral vaccine.
✓ Do NOT administer or spray the vaccine directly into the
throat.

• Subcutaneous Route (SC)

o Injections are administered into the fatty tissue underneath the
dermis and above the muscle tissue.
o Recommended sites are the upper outer triceps of the arm.

Source: en.wikipedia.org

Source: en.wikipedia.org

• Intramuscular Route (IM)

o Vaccines are administered into the muscle tissue below the dermis and the
subcutaneous tissue.
o Mostly inactivated vaccines are administered by intramuscular route.
o Many inactivated vaccines contain adjuvants that enhance immune response to
the antigen administered.
o The anterolateral thigh (vastus lateralis muscle, lower left photo) and upper arm
(deltoid muscle, lower right photo) are the two routinely recommended sites for
intramuscular route of administration.
o There is less chance of hitting nerves or blood vessels through this route.

80
 o Administration through this site depends on the individual’s age and degree of
muscle development.

• Intradermal Route (ID)

o The vaccine is administered in between the layers of the skin until a wheal
appears.
o This is the route of choice for only a very limited number
of vaccines such as Bacille Calmette Guerin (BCG)
against tuberculosis and post exposure rabies
vaccination.
o For intradermal injection, insert a small thin needle (25 or
27 gauge) and 3/8 to 3/4 inch (1-2 cm) underneath the Source: en.wikipedia.org
skin to introduce the vaccine. The bevel should be facing upward.

VACCINES IN PHILIPPINES

 Tuberculosis Vaccine - Bacillus Calmette-Guérin (BCG)

Source: en.wikipedia.org

This vaccine prevents an infant to have a tuberculosis. Bacillus describes the

shape of a bacterium while Calmette and Guérin are the names of the people who
developed the vaccine.

Type of Vaccine Live bacterial

Number of Doses 1 dose
Schedule Given preferrably 90 minutes after birth. Areas with high TB
infection incidence should routinely immunize infants with a single
dose of BCG at birth. If not given at birth, BCG may be given at the
infant’s first contact with the health system before turning one year
old. BCG immunization of infants born of mothers positive for TB
should be delayed and should be given after one month after
negative PPD Test.
Booster None
Contraindications Known HIV infection and other immune deficiency.

Adverse Reactions Local abscess, regional lymphadenitis; rarely, distant spread to

osteomyelitis, disseminated disease
Special Precautions Correct intradermal administration is essential. A special syringe
and needle is used to administer BCG vaccine. Health workers
must keep in mind that BCG is the most difficult vaccine to
administer because of the tiny arms of the newborn and the
vaccine must be injected intradermally (at the topmost layer of the
skin). They need extensive and continuing practice to master this
skill. A short narrow needle (15 mm, 26 gauge) is needed for this
injection.
Dosage 0.05ml

81
Injection Site Outer upper arm or shoulder just below the deltoid. Health workers.
MUST administer BCG in the same place on every child so that
their colleagues know where to look for the BCG scar.
Injection Type It is injected intradermally
Storage Store between +2°C to +8°C (vaccine maybe frozen for long-term
storage but not the diluent)

Source: en.wikipedia.org
 Hepatitis B (HepB) Vaccine

Type of Vaccine Recombinant DNA

Number of Doses 1 dose
Schedule Give within 24 hours, ideally 90 minutes after birth. If Hep B
vaccine is not given within 24 hours after birth, it can still be given
within seven days.
Booster Booster doses are not recommended. Hep B vaccinations is also
not usually recommended for health workers because it is likely
that they have been exposed to the virus during childhood, and are
less likely to be carriers if they become infected as adults.
Contraindications There are no contraindications, except if a very rare anaphylactic
reaction to a previous dose has occurred. In this case, Hep B
should not be given again.
Adverse Reactions Local soreness and redness, rarely anaphylactic reaction
Special Precautions Birth dose must be given if there is a risk of perinatal transmission
Dosage 0.5ml
Injection Site For infants, Hep B vaccine is injected usually into the outer part of
the mid-thigh. For children and adults, it is injected in the outer
upper arm. If more than one vaccine is injected at the same time,
different sites should be used for each injection.
Injection Type Intramuscular
Storage Store between +2°C to +8°C.

 Polio Vaccine
Polio vaccine protects against the poliovirus. There are two types of polio vaccines:
1. Oral Polio Vaccine (OPV)
• Contains live, attenuated (weakened) virus
Source: en.wikipedia.org

• Administered by drops
• Inexpensive
• Easy to administer
• Provides mucosal/gut immunity
• Protects close contacts who are unvaccinated
2. Inactivated Polio Vaccine (IPV)
• Contains killed virus
• Administered by injection

82
 • Highly effective
• Used commonly in developed countries
• More expensive than OPV
• Requires trained health workers
• Provides immunity through blood
• Carries no risk of vaccine-associated polio paralysis (VAPP) or vaccine-
derived poliovirus (VDPV)

Source: en.wikipedia.org

Type of Vaccine Live, attenuated virus, oral (OPV), inactivated virus, injectable
(IPV)
Number of Doses Three to four doses
Schedule 6, 10, 14 weeks
Three OPV doses initiated from six weeks of age with minimum
interval of four weeks; an IPV dose should be given from 14 weeks
of age (with OPV dose).

1–2 doses of IPV starting from two months of age, followed by

at least two doses of OPV; an interval of 4–8 weeks is required
between all doses

Three doses beginning at two months of age, with an interval of 4–

8 weeks between doses
Booster Supplementary doses given during polio eradication
Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose
Adverse Reactions OPV – Rare vaccine-associated paralytic polio (VAPP)
IPV – No known serious reactions; mild injection site reactions do
occur
Special Precautions Postpone vaccination if the child has moderate to severe illness
(with temperature ≥39 °C)
Dosage OPV: two (2) drops into the mouth; IPV: 0.5 ml
Injection Site For IPV left upper thigh (outer part); OPV is given orally through
mouth
Injection Type For IPV - intramuscular
Storage OPV must be kept frozen from -15°C to -25°C. Do not freeze IPV.
It should be stored from +2°C to +8°C.

 DPT-HepB+Hib Combination Vaccine (PENTA)

Source: en.wikipedia.org

It is called a pentavalent vaccine because it protects against five diseases:

diphtheria, tetanus, and pertussis, hepatitis B, and Haemophilus influenzae type b.

83
 Type of Vaccine Pentavalent vaccine
Number of Doses Three doses. PENTAVALENT vaccine is given as 3 dose infancy
schedule however some vaccines such as Diphtheria and Tetanus
need booster doses.
Schedule Given at 6, 10, 14 weeks of age
pentavalent1 starting at six weeks (minimum) with pentavalent2
and pentavalent3 at intervals of four weeks (minimum) after each
dose.
Booster For Tetanus vaccine:
Total childhood schedule of five (5) doses (3 in infancy), another
(Td) in early childhood (1–6 years), and another (Td) during
adolescence (12–15 years) is required. A further dose in adulthood
is likely to provide lifelong protection.
For Diphtheria vaccine:
Total childhood schedule of 6 doses is recently recommended by
WHO. Three (3) doses in infancy, 4th dose at two years old and
two other doses with Td vaccine at school age.
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse Reactions Mild local and systemic reactions are common
Special Precautions Do not use as a birth dose
Dosage 0.5 ml
Injection Site Right Outer Upper Thigh
Injection Type Intramuscular
Storage Store between +2°C to +8°C. Never freeze the vaccine.


Source: en.wikipedia.org

Pneumococcal vaccine
A vaccine against Streptococcus pneumoniae.

Type of Vaccine Pneumococcal Polysaccharide and Pneumococcal Conjugate

Number of Doses PCV - three doses for infants.
PPV - one dose for adults.
Schedule PCV - 6, 10 and 14 weeks of age for infants.
PPV - At 60 and 65 years old for adults.
Booster
Contraindications Anaphylaxis or hypersensitivity (allergy) after a previous dose
Adverse Reactions Severe: none known
Mild: injection site reactions and fever
Special Precautions Postpone vaccination if the child has moderate to severe illness
(with temperature ≥39 °C)
Dosage 0.5 ml
Injection Site Anterolateral (outer) part of the left thigh (vastus lateralis) for
infants, upper arm (deltoid) for adults
Injection Type Intramuscular
Storage Store between +2°C to +8°C

84
 Source: en.wikipedia.org

 Measles-Rubella (MR) and Measles-Mumps-Rubella (MMR) Combination

Vaccines

Type of Vaccine Live attenuated viral

Number of Doses Two (2) doses
Schedule Childhood Dose of MMR: 9 months and 12 months
Booster In Philippines, booster dose are given at school age children at
grade 1 and grade 7.
Contraindications For Measles Containing Vaccine(MCV)
• Known allergy to vaccine components (including neomycin and
gelatin)
• Pregnancy
• Severe congenital or acquired immune disorders, including
advanced HIV infection/AIDS
Adverse Reactions Mild: fever, rash 5–12 days following administration
Serious: Thrombocytopenia (decreased platelets), anaphylaxis,
encephalitis.
Joint pain when rubella containing vaccine (RCV) is given to adult
women; parotitis with mumps component.
Special Precautions None
Dosage 0.5ml
Injection Site Upper arm
Injection Type Subcutaneous
Storage Store between +2°C to +8°C.

 Rotavirus Vaccine
It protects children from rotaviruses, the leading cause of severe diarrhea among
infants and young children.

Source: en.wikipedia.org

Type of Vaccine Live attenuated virus, oral

Number of Doses Two (2) doses (Rotarix™); three (3) doses (Rotateq™)
Schedule Six (6) and 10 weeks of age
Booster
Contraindications • Severe allergic reaction to previous dose
• Severe immunodeficiency (but not HIV infection)
• History of uncorrected congenital malformation of gastrointestinal
(GI) tract.
Adverse Reactions • Mild: irritability, runny nose, ear infection, diarrhea, vomiting
• Severe: intussusception
Special Precautions • Should be postponed for acute gastroenteritis and/or fever with
moderate to severe illness
• Not routinely recommended if with a history of intussusception or
intestinal malformations that possibly predispose to
intussusception
Dosage 1 ml
Storage Store between +2°C to +8°C

85
 Source: en.wikipedia.org
 Tetanus Diptheria (Td) Vaccine

Type of Vaccine Toxoid

Number of Doses • Tetanus vaccine is given as five (5)-dose schedule. Three (3)
doses in infancy as Pentavalent and two (2) doses in school age
children as Td.
• Children (Grade 1 and Grade 7) who had received three primary
doses in the form of PENTA should receive at least two doses of
Td
• Pregnant women who had received three childhood DPT/PENTA
doses should receive three doses of Td.
• Pregnant women with no previous DPT/PENTA immunization or
unreliable immunization information should receive 5 Td.
Schedule After receiving primary doses during infancy (three doses in the
form of PENTA), Td should be given to children 5-7 years old
(Grade 1) and 12-15 years old (Grade 7). For pregnant women, Td
vaccine should be given as early as possible upon onset of
pregnancy.
For the prevention of tetanus in women through their childbearing
years and in newborns, women should receive five doses of
tetanus toxoid. The table below shows the schedule by dose and
the length of protection provided. Td can be used instead of TT to
protect against both tetanus and diphtheria.
Booster

Contraindications There are no contraindications to tetanus toxoid. It is safe to give

at any time, even in the first trimester of pregnancy. However,
PENTA, DT, and Td should not be given to individuals who have
suffered a severe reaction to a previous dose.
Adverse Reactions • Severe: rare anaphylaxis, brachial neuritis (inflammation of the
nerves that control the shoulder, arm and hand)
• Mild: injection site reactions and fever
Special Precautions
Dosage 0.5 ml
Injection Site Td is injected into the upper outer part of the arm
Injection Type Intramuscular
Storage Store between +2°C to +8°C. Never freeze.
Source: en.wikipedia.org

 Human Papilloma Virus (HPV) vaccine

It is primarily used for prevention of cervical cancer for women. Other benefits are
prevention of ano-genital warts, vulvular, vaginal and anal cancer and penile
intraepithelial neoplasia (precancerous disease of the outer skin layer of the penis).

Type of Vaccine Recombinant

Number of Doses Two (2) doses
Schedule Routinely given to females nine to 10 years old. Given in two (2)
doses six months apart

86
Booster
Contraindications Persons with history of immediate hypersensitivity to yeast or to
any vaccine component
Adverse Reactions • Mild: injection site reactions; fever, dizziness, nausea
• Severe: rare anaphylaxis
Special Precautions • Postpone vaccination for pregnancy
• Adolescents should be seated during injections and for
15 minutes afterwards since they sometimes faint
Dosage 0.5 ml
Injection Site Upper arm (deltoid)
Injection Type Intramuscular
Storage Store between +2°C to +8°C. Protect from light.

 Seasonal Influenza Vaccine

Type of Vaccine Inactivated influenza virus
Number of Doses Usually one dose to be given annually
Schedule Adults 60 years of age or older should get vaccine as it becomes
available in the health center near you ideally before flu season.
Booster
Contraindications Known hypersensitivity (allergy) or anaphylaxis to a previous dose
or to a vaccine component such as egg protein
Adverse Reactions • Mild: injection site reactions and fever
•Severe: rare anaphylaxis, Guillain-Barré syndrome, oculo-
respiratory syndrome
Special Precautions May postpone vaccination in case of moderate to severe illness
(with temperature ≥39 °C)
Dosage 0.5 ml
Injection Site Upper arm (deltoid)
Injection Type Intramuscular
Storage Store between +2°C - +8°

HANDLING VACCINES
MULTI-DOSE VIAL POLICY (MDVP)

The WHO multi-dose Vial Policy (MDVP) Statement (2014)

• All opened WHO prequalified multi-dose vials of vaccines should be discarded at the
end of the immunization sessions, or within six hours of opening.
• The policy further states: “For non WHO-prequalified vaccines, the recommendation is
to use as soon as possible after opening, and respecting the time limit for using opened
vials as indicated by the manufacturer’s instructions in the package insert. If this
information is not indicated in the package insert, the WHO recommends discarding
all non WHO-prequalified vaccine products within six hours after opening or at the end
of the immunization session, whichever comes first.”

GUIDELINES FOR MDVP

• Hep B, Td, bOPV and IPV are vaccines covered by MDVP.

87
 • All reconstituted vaccines should be discarded six hours after opening or at the end
of an immunization session, whichever comes first. These are: BCG, MR, MMR, JE
• A flu vaccine with no VVM is to be discarded seven days after opening.
• All single dose vaccines such as Pentavalent, Rotavirus, PCV, PPV, HPV are not
covered by MDVP.

SHAKE TEST

• The shake test tells you whether your suspected vials have been damaged by freezing.
Do the shake test when the temperature monitoring device indicates temperature
exposures below 0° or if a freeze-sensitive vaccine was left in direct contact with a
frozen icepack.

HOW TO PERFORM AND INTERPRET?

a. Select one vial from each type and batch of SUSPECT vaccines as CONTROL
sample. Freeze the control vials until they are solid frozen and label them “FROZEN”.
b. Allow the FROZEN control vials to thaw completely.
c. Shake the FROZEN control and SUSPECT vials from the same batch in one hand for
10 to 15 seconds.
d. Observe the sedimentation rate on both vials (the FROZEN control and the SUSPECT
vials) by placing both on a flat surface side-by-side in a well-lighted location. Natural
light is better. The sediments on the suspect vial fall to the bottom of the vials faster or
at the same rate.

Source: WHO

88
 THE VACCINE VIAL MONITOR (VVM)

• VVM is a label on a vaccine vial which serves as an indicator if the vaccines were
exposed to heat. The VVM sticker is found either on the vial label or cap. It looks like
a white square inside a light violet circle. The VVM changes color when the vial has
been exposed to heat over a period of time. The square becomes darker in color as
the vial is exposed to heat. Each vaccine preparation has different types of VVM.

Source: WHO

89
 ASSESSMENT

Instruction: Select the best answer. Write your answer on a ¼ sheet of paper.

1. Baby Tomarong was given the first dose of OPV on august 20, 2014. His mother will
be asked to bring back the child on?
a. September 20, 2014
b. August 20, 2014
c. 4 weeks after the first dose
d. A and C are both correct

2. You gave Mrs. Rosaline Dimaculangan the first dose of TT on August 15, 2014. She
will be asked to come back on:
a. One month after first dose
b. One year after
c. On the third month of her next pregnancy
d. On the 5th month of her next pregnancy provided the interval is 3 years or less

3. Cold chain is an essential components of the EPI. The following vaccines are most
likely to be damaged by heat:
a. BCG and measles
b. DPT and OPV
c. OPV and Measles
d. TT and Hepa B

4. DPT is administered at?

a. 0.5 cc subcutaneously for 3 doses
b. 0.1 cc IM for 3 doses
c. 0.5 cc IM for 3 doses
d. 1.0 subcutaneously for 2 doses with booster dose after one year

90
5. In order for a child to be classified as FIC, he should have received the following
immunizations before he reaches the age of one:
a. 3 doses of DPT, single dose of measles, 5 doses of TT, single dose of BCG, 3
doses of OPV, 3 doses of Hepa B
b. Single dose of BCG, 3 doses of each DPT, OPV, measles, and Hepa B
c. Single dose of BCG, 3 doses of OPV, one dose of measles vaccine, 3 doses of
Hepa B, 3 doses of DPT
d. 3 doses of OPV, one dose of BCG, 3 doses of measles vaccine, 3 doses DPT,
single dose Hepa B

6. Measles given at 9 months of age can give side effects of:

a. Wheal formation
b. Fever chills anemia
c. Fever and rashes
d. Convulsion
7. Which of the following vaccines has a dosage of 2 gtts?
a. OPV
b. DPT
c. Measles
d. TT
8. Which of the following is a live, attenuated bacterial vaccine?
a. Tetanus
b. Pertussis
c. Diphtheria
d. BCG

9. At what month should measles be given specially this Covid pandemic crisis?
a. 9 months
b. 10 months
c. 5 months
d. 6 months

10. You are aware that vaccines stored in rural health unit should be replaced every
a. 2 months
b. 3 months
c. 5 months
d. monthly

91
 REFERENCES
Araceli S. Maglaya, Nursing Practice in the Community. 2003

Department of Health. National Epidemiology Center. Manual of Procedures for the

Philippine Integrated Disease Surveillance and Response, Volume 1, 3rd Edition.
Manila: DOH, 2014

Department of Health. National Epidemiology Center. Manual of Procedures for the

Philippine Integrated Disease Surveillance and Response, Volume 2, 3rd Edition.
Manila: DOH, 2014

Department of Health. National Epidemiology Center. Training Manual for Vaccine

Preventable Disease Surveillance (Draft). Manila: DOH, 2014

Epidemiology and Prevention of Vaccine-Preventable Diseases. Seventh Edition.

Atlanta, GA: U.S. Centers for Disease Control and Prevention. January 2002.

Department of Health. Public Health Nursing in the Philippines. Manila: DOH, 2007

World Health Organization. Increasing Immunization Coverage at the Health Facility

Level. Geneva: World Health Organization. WHO/V&B/02.27. 2003.

World Health Organization (WHO). Immunization in Practice: A Practical Guide for

Health Staff. Geneva, Switzerland: WHO, 2015.

World Health Organization. Training for Mid-level Managers (MLM). Module 1 to

Module 8. Geneva, Switzerland: WHO, 2008.

https://www.scribd.com/doc/121426326/THE-PHILIPPINE-HEALTH-CARE-
DELIVERY-SYSTEM

92
 COURSE GUIDE
COURSE: Mid 212/ Primary Health Care I

COURSE DESCRIPTION:

Concepts and principles in the provision of basic services of health promotion/maintenance

and disease prevention at the individual and family level.

The course module is a product of collaborative efforts of Midwifery Instructors of College of

Nursing and Allied Sciences of Eastern Samar State University system designed for self-
learning of students who are taking up Primary Health Care 1 this semester amidst COVID-
19 pandemic. This module is subdivided into parts, to wit:

I. The Philippine Health Care Delivery System

II. Primary Health Care
III. Community Health Process
IV. Health Care Process as Applied to the Family
V. Clinic Activities: Immunization

COURSE LEARNING OUTCOMES:

1. The student will demonstrate beginning skills in providing basic health care in terms of
health promotion, maintenance and disease prevention at the individual and family
level guided by the health care process.
2. The students will have developed the needed competencies in the provision of basic
health services for health promotion and disease prevention at individual and family
levels.

93
 COURSE POLICIES:

1. To ensure successful completion of this course, students are expected to accomplish the
assigned tasks prescribed in the Student’s Worksheet and pass the major examinations.
2. All students are expected to behave with academic honesty. It is not academically honest to
misrepresent another person’s work as your own, to take credit for someone else’s words
or ideas, to obtain advanced information on confidential test materials, or to act in a way
that might harm another students’ chances for academic success. These students will
automatically have a grade of 5.0 after three (3) offenses of academic dishonesty.
3. Assignments/presentations and other related requirements should be accomplished on the
set deadline. Late requirements will be deducted accordingly.
4. All students are expected to take Major Exams (Mid-term/Finals) on the specified schedule.
In general, no make-up test or re-test will be given except when circumstances warrant
but with valid supporting documents presented.
5. All students are expected to strictly observe the proper standards in handling the module,
any form of damage on the said materials will be a demerit on the students’ performance
rating.

GRADING SYSTEM

60% - Class Activities (academic related tasks such as lesson exercises/learning activities,
written and oral presentations, etc.)

40% - Major Examinations (Midterm, and Final Examination)

100%

94
 .

QUALITY POLICY

We commit to provide quality instruction, research, extension, and

production grounded on excellence, accountability and service as we
move towards exceeding stakeholders' satisfaction in compliance with
relevant requirements and well-defined continual improvement
measures.

"De kalidad nga edukasyon, Kinabuhi na mainuswagon"

95
96
97