NURSING PRACTICE IN THE COMMUNITY Pifth EditionPhilippine Copyright © 2009, 2004, 2003, 2002, 2000, 1997 by ARGONAUTA CORPORATION Marikina City and ARACELI S. MAGLAYA ROSALINDA G. CRUZ-EARNSHAW MA. BRIDGETTE T. LAO-NARIO MA. CORAZON S. MAGLAYA LUZ BARBARA L. PAMBID-DONES LUCILA B. RABUCO WINIFREDA O. UBAS-DE LEON ALL RIGHTS RESERVED A written permission of the editor and publisher must be secured if any part of this book is reproduced by any means and in any from whatsoever. Every authentic copy of this book bears a serial number and the signature of the editor or any one of the contributors. (Ars, ) Published and exclusively distributed by: ISBN 978-971- 91924-4-2 Argonauta Corporation No. 1 Makiling Street Marikina Village, Nangka Marikina City Tel. No. 91-61-60 Scanned with CamScannerCONTRIBUTORS Araceli S. Maglaya, RN, PhD Professor Centennial Professorial Chair College of Nursing University of the Philippines Manil Rosalinda G. Cruz-Earnshaw, RN, MIN, MPA Nurse Educator cumenical Christian College rarlac City, Former Faculty College of Nursing i of the Philippines Former Consultant Philippine Department of Health-Local Government Assistance and Monitoring Service and Essential National Health Research Luz Barbara L. Pambid-Dones, RN, MPH College of Nursing University of the Philippines Manila Ma. Corazon S. Maglaya, MD ‘Medical Consultant Smith Bell Group of Companies Resource Person “Doctors-On-Line” Program, DZAS Ma. Bridgette T. Lao-Nario, RN, MA Faculty Ai Pacific School of Nursing Second Careers in Nursing Program Aisa, California, USA ‘Telemetry Nurse Definitive Observation Unit Whittier Hospital Medical Center Azusa, California, USA Winifreda O. Ubas-de Leon, BSMT, MPH Professor (Revired) Department of Parasitology College of Publie Health University of the Philippines, Manila Lucila B. Rabuco, MSc Public Health (Nutrition), PHD Professor Centennial Professorial Chair Department of Nutrition College of Public Health University of the Philippines Manila Scanned with CamScannerPREFACE tion of the book Nursing Practice in the Community focuses ‘on theory-based practice methodologies using the competency-based framework. Theories whieh describe, explain and predict behavior of cliente (particularly families, groups and the community) provide backgrourid frameworks to guide readers on the bases for the selection of content and critieal thinking directions by phase of the nursing process. Within these purposes and background of the book, the cditor and contributing authors hope to enhance the teaching-learning empowering competencies of practitioners, teachers and students based on the uniqueness of every client and the health-bealing situation in every nurse-client relationship. Precision and coherence in concept elaboration and illustration hopefully achieve clarity in breaking down complex processes to describe the application of the nursing process by type of client, Particularly for clinical instructors and students challenged enough to pursue the breadth and depth of community health nurse practice, the Leory-based methodelogi presented in this book provide teaching-learning alternatives to prevent the likelihood of using “ready-made” nursing caré plans and client records to comply with course requirernents. ‘The fifth e ‘The book begins with a presentation of community health nursing (CHN) as context and practice using a four-client perspective: the individual, family, population group and community. Within the backdrop of social, political, cultural and economic determinantsofhealth and illness, the chapter discusses the health care delivery system, the national health situation and the components, processes and cthicolegal aspects of community health nursing practice. As a CHN practice option in many countries, ‘community-based case management is discussed towards the end of the chapter. Chapter 2 presents theory-based methods and tools on assessment in family health nursing practice. ‘The Assessment Data Base and The Typology of Nursing Problems in Family Nursing Practice are updated using precise concepts related with major family theories: The Systems Model, Interactional and Development Models and The Structural Functional Framework. Genograms, ecomap and family-life chronology are discussed as additional assessment tools with specific guides on construction and interpretation contained in Appendices B1 to B3. Chapter focuses on concepts, steps and intervention options in developing the family nursing care plan. A sample evaluation plan illustrates how to specify evaluation riteria/indicators, standards and types of methods and tools. Chapter 4 covers concepts, methods and tools related with the implementation and evaluation phases in family nursing practice. Two types of evaluation are discussed: formative and summative evaluation. Each type is presented to address specific components of family health nursing care based on evaluation criteria/indicators and standards. Challenges and directions include supervision of a case load of priority families by geographical assignment or catchment area and the case management approach in working with priority familics. Chapter 5 focuses on the nursing perspective of the partnership approach and the participatory action methodology explicitly illustrating the “Look-Think-Act” cyclical process using empirical data on the empowering experiences of families in a village in Abra Provines. Interdisciplinary teamwork and interagency collaboration are enhanced through competencies on partnership with diverse groups forming cross functional teams. Scanned with CamScannerChapter 6 presents the conceptsand methods of the work group approach in developing community competence, Chapter 7 describes the processes, methods and tools for assessing community health needs by type of community diagnosis. Application of demography, vital sta nd epidemiology as public health tools are illustrated by major concept or tool Chapter 8 discusses the approaches and steps involved in planning community health nursing programs and services. Community competence and community strength or empowerment as change outcomes are illustrated as examples of evaluation measures to pursue using the participatory approach. Chapter 9 presents the nursing interventions for community health and development. Within the perspectives of primary health care, health promotion and community competence, community health development sirategies include community organizing towards community participation in health, capacity-building through competency- based training, partnership and collaboration, advocacy and supervision. Caseload management is described as a process and an approach to systematically address the hgalth needs and problems of a number of clients under specific health programs or services, Chapter 10 presents assessment and management protocols for safe motherhoed and well-baby care. Chapter 11 describes nurse-managed maternal care in the community. Based on standards of prenatal care, home delivery and postpartum care, application of the nursing process in a nurse-managed care is presented Chapter 12 describes independent nursing practice using specific strategies, examples and experiences such as conducting developmental screening for preschoolers and maintaining a health promotion clinic to address client concerns like nutrition, comfort, mobility and sleep pattern. The components of nursing consultation together with other topies such as charging nursing professional fee, marketing services of the nursing clinic and establishing linkages and a referral system are discussed. Chapter 13 focuses on enhancing competencies on nutrition for wellness, presenting the functions and food sources of macronutrients (carbohydrates, proteins and fats) and micronutrients (vitamins and minerals). Methods and tools to assess nutritional status (eg. dietary and anthropometric methods, biophysical tests and clinical examination) are also described in tie chapter. Competencies on nutrition and wellness enhance the nurse’s confidence to assume an independent role or work in collaboration with the health team in addressing malnutrition as a health problem and risk factor of lifestyle diseases in many communities in the Philippines and in many parts of the world. Chapter 14 focuses on concepts, strategies and interventions to address malnutrition in early childhood based on common causes of undernutrition among Filipino children. Chapter 15 daseribes the life cycle and measures for prevention and control of parasites as causative agents of selected communicable diseases such as malaria, filariasis, schistosomiasis and intestinal parasitism. Chapter 16 describes assessment and management protocols to address selected common lifestyle-related health concerns and problems of adult clients. Scanned with CamScannerats the concepts and prineiples of nursing mana i i anagement ats the picolegal considerations are discussed. wement in the local Chapter 17 pres public health sys jecusses communit based participatory research t The nature, y atch to e : éy niue, process and. ouleomen or eee Ith wufyatrated using empirical data based in a Ss of family 1g research on malaria prevention Gnd GOnCol dnvotinn een 1 nity residents ofa village of Danglas Municipality, olving sixty-nine = » Abra Province, _ e. Finally, Chapter 38 di n vaith nursing preetice. community i empowerment multidiseiplina families as com “the fifth edition isa product of five years of exploring options based The Hffoners, clinical instructors, senior faculty San gudeoes Ge how eee rom ara ttnitate erikical thinking and analysis in community: featiliomee tn ee ang retical perepeetives provide the bases for thé ‘application of tha Sanne ee Theoreica! Tm using practice-based methodotogles. | Each {he nursing process opportunity for practitioners: ‘clinical instructors and students hapter provides an practice perspective from the vanrige point of participatory fo see the nursing race ing client's emspowsering potential. Y approach towards she book is dedicated to all families and nurses who are soure strength to enhance healing and attain wellness. turces of hope, wisdom and Araceli S. Maglaya Tagaytay City Scanned with CamScannerTABLE OF CONTENTS CHAPTER1 Community Health Nursing: Context and Practice Rosalinda G. Cruz-Earnshaw Community Health Nursing 16 Framework for Community Health Nursing 17 Clients of Community Health Nurses 27 © Individual 17 + Family is = Population group 18 Community 16 Health 19 * Factorsaffecting health 19 Health Care Delivery System 22 © Publichealth 22 Department of Health 23 Millennium Development Goals (MDGs) Health Sector Reform Agenda (HSRA) 24 FOURMula ONE for Health (F1) 24 National Objectives for Health (NOH) 25 Devolution of health services 25 ‘The National Health Situation 26 ‘Demographic profile 26 * Health profile 27 Primary Health Care and Health Promotion 39 © Primary health care 20 * Health promotion 22 Nursing Practice in the Community 33 © Nursing process 3 © Health education’ 32 * Management ang supervision 38 © Reseerch and evidence-based nursing practice Community Health Nursing in the Philippines 29 © Public health nursing 40 © Occupational health nurs: © School nursing 42 Community-Based Case Management 43 Ethicolegal Aspects of Community Health Nursing 42 The Philippines health care delivery system 2 a“ 2 Medium-term Philippine Development Plan (MTPDP) 24 Critical thinking in community health nursing 34 Program planning, implementation and evaluation 38 Scanned with CamScanner asCHAPTER 2 50 Assessment in Family Health Nursing Practice Araceli S. Maglaya Family Perspective in Community Health Nursing Practice 50 Family Nursing Practice: Theoretical Perspectives si Nursing Assessment: Operational Framework 54 Stops in Family Nursing Assessment 55 Data Collection $7 * Types of Data in Family Nursing Assessment 57 * Data-gathering Methods and Tools 57 Data Analysis 62 . Nursing Diagnoses: Family Nursing Problems 63 The Typology of Nursing Problems in Family Health Care 6a Conclusion 72 CHAPTER 3. 76 Developing the Family Nursing Care Plan Araceli 8. Maglaya The Farnily Nursing Care Plan 76 + Steys in Developing o Family Nursing Care Plan 75 + Prioritizing Health Conditions and Problems 77 + Factors Affecting Priority-Setting 79 * Scoring at * Formulation of Goals and Objectives of Care a1 Developing the Intervention Plan a3 © Analyze Realities and Possibilities based on Family's Lived Experience of Meaning and Concerns 6 + Focus on interventions to Help the Family Perform the Health Tasks 85 + Catalyze Behavior Change Through Motivation and Support 99 * Criteria for Selecting the Type of Nurse-Family Cantact m1 Developing the Evaluation Plan 92 Documentation 62 CHAPTER 4 Implementation and Evaluation in Family Nursing Practice ~ 7 Araceli 8. Maglaye Expert Caring: Methods and Possibilities 97 Competency-Based Teaching 98 + Leaming is an Intellectual and Emotional Process 99 + Learning is facilitated when experiences have meaning to the learner 101 + Learning is an individual Matter: Ensure Mastery of Competencies for Sustained Actions 102 Maximizing Caring Possibilities 203 Expertise through Reflective Practice 105 The Evaluation Phase 137 Challenges and Directions 107 Scanned with CamScannerCHAPTERS The Partnership Approach and the Participatory Action Methodology: The Nursing Perspective 110 Araceli S. Maglaya Human Care and Nursing Practice 120 Options for Change 111 Particigatory Action and Empowering Experiences of Families in Dangias, Abra 114 Enhancing Interdisciplinary and Interagency Cellaboration 113 The Essential Ingrediants of Partnership 116 * Belief in Egalitarian Relationship 116 * Open-mindedness 116 * Respect and Trust 17 + Commitment to Enhance each ather’s Capabilities for Partnership 117 Capabilities Necessary for Partnership 11s * Skills Necessary to Function as an Integrated Unit 118 Summary 17% CHAPTER 6 Developing Community Competence through the Work Group Approach 130 Araceli S. Maglaya Introduction 130 Community Competence 131 ‘The Work Group Model as Strategic Anproach to Community Competence 231 The Stages oF Group Development 137 + “The Stage of Orientation 132 The Stage of Conflict 133 The Stage of Cohesiveness 134 ‘The Work Group Stage 134 ‘The Termination Stage 135, + The Verious Stazes at Work 135 Interventions te Facilitate Group Growth 135, + Provide the Necessary Orientation, Structure and Direction 136 * Process, Negotiate and Resolve Conflicts to Member's Satisfaction 138 © Be Aware of the Effects of Own Behavior on the Group: Use the Self for Group Growth * Actas the Group's Completer/Resource Person 167 + Derive Oppartunities to Apply Learning on Another Situation 147 Work Group: Hub of Community Organization, Competence and Empowerment 47 CHAPTER 7 Assessing Community Health Needs 150 Luz Barbara P. Denes Introduction 150 The Community Diagnosis 250 + Ecologic Approach to Community Diagnosis 151 * Types of Community Diagnosis 152 + Comprehensive Community Diagnosis 152 + Problem-Oriented Community Diagnosis 155 Community Diegnosis: The Process 155 Scanned with CamScannerConducting Community Diagnosis 156 Steps 8 Cormining the Objectives 157 Defining the Study Population | 157 c petermining the Datato be Collected 158 = collecting the Data 358 t Seveloping the Instrument 161 © actual Data Gathering 368 = Data Collation 169 © Data Presentation 171 © pata analysis 174 y Peeatying the Community Health Nursing Problems 374 + Priority-setting 17 Application of Public Health Tools in Community Health Nursing 173 Demography 178 i = Sources of Demographic Data * Population Size 180 + Population Composition 182 + Population Distribution 183 Vital Statistics 184 Epidemiology 186 + The Multiple Causation Theory © Notural History of Disease 183 Levels of Prevention of Health Problems 188 Concept of Causality and Association 191 7 The Epidemiological Approach 392 Descriptive Epidemiology 392 Analytical Epidemiology 197 Interventional or Experimental Epidemiology 198 jeriology 198 286 = Evaluation & Conclusion 123, CHAPTER & Planning for Community Health Nursing Programs and Si Luz Barbara P. Dones Tt a aaa eet Introduction 202 ‘Whats Planning? 202 Approaches to Planning Health Programs 203 2) Participatory Flanning for Community Health 203 Planning for Health Promotion 204 The Planning Cycle 208, Situational Analysis 208, 5 Gos! and Objective sewing 212 Strategy and Activity-Setting 223 + Develaping an Evalun Conclusion 220 on Plan 21¢ Scanned with CamScannerCHAPTER 9 Nursing Interventions for Community Health and Development 223 Jar: Barbara P. Danes Introduction 223 Community Competence as Outcome of Community Health Nursing Interventions 223 Community Health Development Strategies 225 Health Promotion 226 Community Organizing towards Community Participation in Health 229 Capacity-Building through Competency-based Training 233 Partnership and Collaboration 236 Advocacy 237 Supervision 238 * Making ¢ Supervisory Plan 239 * Methods and Tools for Supervision 240 + Conducting a Supervisory Visit 200 * Case Study Illustrating the Application of the Steps in Supervisory Planning 242 Caseload Management 241 Conclusion 2a3 CHAPTER 10 Logic Trees for Safe Motherhood and Well-Baby Care 247 Ma. Corazon S. Maglaya and Araceli Maglaya Introduction 207 The Use of Logic Trees 247 Assessment Protoco! for Initial Pre-natal Check-up 248 Logic Tree Flowchart No. 28 250 Management Protocol for Initial Pre-natal Check-up 25 Assessment Protoco for Follow-up Pre-natal Chack-up 25s Logie Tree Flowchart No. 29257 Management Protocal for Follow-up Pre-natal Check-up 252 Assessment Protocol for Home Delivery 260 Logic Trae Flowchart No. 30 261, Management Protocol for Home Delivery 262 Assessment Protocol for Care of the Newborn Immediately after Birth 267 Logic Tree Flowchart No. 31 269 Management Protoco! for Care of the Newborn Immediately after Birth 270 Assessment Protocol for Postpartum Check-up 273, Logic Tree Flowchart No. 32. 274 Management Protocol for Postpartum Check-up . 275 Assessment Protoco) for Well Baby Checkup 260, Logic Tree Flowchart No. 33-A 26: Management Protocol for Well Baby Cheek-up 282 Assessment Protoco) tor Well Baby Checx-up, Patient is more than one month old 284 Logic Tree Flowchart No. 33-2 285 Management Protocol for Well Baby Check-up, Patient is more than one month old 286 Scanned with CamScannerCHAPTER 11 Nurse-Managed Maternal Care in the Community Maria Brigette T. Lao-Nario Introduction 258 Role of Maternal Care 289 Standards of Prenatai Care 290 Components of Pregnancy Care 292 * Antenats! Registration 293 Tetanus Toxoid Immunization 293 ‘+ Micronutrient Supplementatior + Vitamin A Supplementation 235 + Treatment of Diseases and Other Conditions 296 + Early Detection and Management of Complications ‘+ Family Planning Counseling 297 + STD/HIV/AIDS Prevention and Management 297 Standards in Home Delivery 297 Standards in Postpartum Visit 300 The Nursing Process in a Nurse-Managed Care 302 Nursing Assessment and Diagnoses 302 Determining Qutcomes of Care 203 Choosing Nursing Interventions sve Home Visit as an Intervention 304 CHAPTER 12 Demonstrating Independent Nursing Practice Ma. Brigette T. Lao-Nario Experiences in Setting up Independent Nursing Practice Metso Manila Develapmental Screening for Preschoolers Providing Consulting Services 213 The Health Promotion Nursing Clinic 216 Commonly Used Nursing Diagnoses 318 Establishing the Outcomes of Care 320 ‘The Nursing Consultation and its Components 320, Charging Clients @ Nursing Professional Fee 322 Marketing the Services of the Nursing Clinic 223 Establishing Linkages and a Referral System 323 CHAPTER 13 Enhancing Competencies on Nutrition for Wellness Lucila B. Rabuco Imreduction 326 Nutrition 326 Food 327 Nutrients 327 ° Macronutrients 227 + Micronutrients 229 Assessment of Nutritional status 333, * indirect methods 234 Macronutrient and Micronutrient Supplementation 208 ron Supplementation 254 of Pregnancy 296 aur ant Scanned with CamScanner 288 310 326© Direct methods 337 Common Nutritiona’ Problems of Public Health Importance 340 + Protein-Eneray Malnutrition (P.EM.) 240 Won Deficiency Anemia 341 Vitamin A Deficiency Disorders 342 lodine Deficiency Disorders 343 Overweight and obesity 344 Summary 344 CHAPTER 14 Appropriate Technology for the Prevention and Control of Malnutrition in Early Childhood 346 Araceli S. Maglaya Nutritional Status of Filipino Children: Consequences and Implications 346 Causes of Malnutrition Related tu Feeding Practices 347 + Non-breast-feeding or Farly Weaning 34 + Absence of or inadequate Complementary Feeding during Extended Periods of Breastfeeding or Dependence on Artificial Feeding 34% > Lack of or Inadequate Skill in Managing Diarrhea at Home a8 Interventions Using Appropriate Technology 3s + Family Competency-Bullding on Nutritional Status of Children and Options to Enhance Proper Nutrition 348 * Regular Complementary Feeding Using Protein Powders 349, = Increase Knowledge on the Daily Recommended Eneray and Nutrient Intakes (RENID for Infants and Toddlers 361 ‘+ Appropriate Home Management of Diarrhea 352 Summary 354 CHAPTER 15 Parasitology in Nursing Practice 356 Winifreda O. Ubas-de Leon Introduction 355 The Parasites 355 Directly-Transmitted Parasite 357 + Enterobius (Oxyuris) vermicularis 357 Soil-Transmitted Parasites 358 © Ascaris lumoricoides se © Trichuristrichlura sez © Hockworms 262 Food Transmitted Parasites 369 © Tacnia solium and Taenia saginata 369 © Paragonimus westermani 370 © Capillaria chilippinensis 371 © Heterophyid Flukes 371 Water-borne Protozoa 272 * Entamoeba histolytica 372 © Giardialambiis 273 © Cryptosporidium hominis 373 * Cyclospora cayatensis 377 Scanned with CamScanner© Blastocysts hominis 377 Vector-Borne Parasites 378 + Plesmodia 378 * Babesia spp 279 ‘+ Wuchereria bancrofti and Brugia malayl 380 Schistosoma japonicum 28a Conclusion 388, CHAPTER 16 Logic Tree for Common Adult Health Problems 388 ‘Ma. Corazon S. Magiaya and Araceli Maglaya Introduction a8 The LogicTiees a8 ‘Assessment Protocol for Problem on Cough, Colds or Difficulty of Breathing not Associated with Fover 389 Logic Tree Flowchart No. 7 392 Management Protocol for Problem on Cough, Colds or Difficulty of Breathing not Associated with Fever 392 Assessment Protocol for Problem on Skin Lesions 334 Logic Tree Flowchart No.9 395 Management Pratocal far Problem on Skin Lesions 398 Assessment Protocol far Prablem on Body Weakness 399 Logic Tree Flawehart No. 10 «00 Management Protocol for for Problem on Body Weekness 201 Ascessmant Protocol for Problem on Abéominal Pain, Epigastric 403 Logic tree Flowchart No. 11404 Management Protocol for for Problem on Abdominal Pain, Epigastric sos Assessment Protocol for Problem on Insomnia 407 Logie Tree Flowchart No.16 408 Management Protocol for Problem Insomnia 403 Assessment Protocol for Problem on Dizziness 412 Logic Tree Flowchart No. 24 413 Management Protocol for Problem Dizziness axa CHAPTER 17 “rsing Management in the Local Public Health System Rosalinda G. Cruz-Earnshaw ‘as Introcuction ais Management Functions «a9 fanagement in Public Health 421 The Local Public Health Organization 421 Context of the Lecal Public Health Organization 421 asa Manager and Supervisor 722 The pany * Planning 421 S Organizing 223 * stating as Leading (directing) 2s ean etling se ‘2l Considerations 429 Scanned with CamScannerCHAPTER 18 Enhancing Practice through Community-Based Participatory Research 432 ‘Araceli S. Maglaya Introduction 332 Community-Based Participatory Research 422 Enhancing Empowering Potential: The Human Response Perspective 433 Facilitating @ehavior Change thru Motivation-Support Interventions 435 Empowerment: Nature, Process and Qutcomes 436 Health in the Hands of the People 438 Behavior Change Over Time aax Community Leaders Update the Researcher at the University «39 Community-Based Research: Insights for Enhancing Nursing Practice a36 APPENDICES Al Community Health Nursing Practice Model as 2 Laws that Impact on People’s Health and CHN ane Aa Health Programs of the DOH sau B Family Assessment Tools sag 81 Constructing and interpreting a Genogram 49 82 Constructng the Family Ecomap 455 B3 Constructing the Family-Life Chronology 456 C1 Charting Nursing Care, Progress Notes and Client Responses/Outcomes C2 Family Service Progress Record 458 C3__ Instructions on the Use of the Family Service and Progress Record 361 D Selectinga Fruit Exercise 467 E Empowerment for Health Promotion/ Lifestyle Change 472 487 F Recommended Energy and Nutrient Intakes Per Day For Selected Population Groups 473 G Trends in Community Health and Community Health Nursing Practice 474 Scanned with CamScannerChapter 1 COMMUNITY HEALTH NURSING: CONTEXT AND PRACTICE Rosalinda G. Cruz-Earnshaw Community health nursing (CHN) is one of the two major fields of nursing in the Philippines; the other is hospital nursing. Some people use the terms community health nursing, and public health nursing interchangeably. However, the former is broader than the kitter; it includes public health nursing, eecupational health nursing, and school nursiag. COMMUNITY HEALTH NURSING Clark defines community health nursing us a “synthesis of nursing knowledge and practice and the science and practice of public health, implemented via a systematic use of the nursing process and other processes to promote health and prevent illness in population groups” (2008:5). The other processes include management, supervision, research, advocaey and political action. Annex Ai presents a model of community health nursing practice which illustrates the relationship between nursing practice as seience and art, core community health functions and essential community health services. ‘The following statements characterize CHN: (2) Promotion of health and prevention of disease are the goals of profession: y health nursing practice s comprehensive, general, cl nat epi There are different level: clientele-- individuals, families and population groups and the practitioner recog; the primacy of the population as a whole; (4) The nurse and the client have great control. in making decisions related to health care and they collaborate as equals; ‘The nurse reeognizes the impact of different factors an health and has a greater awareness of his/her clients’ lives and situations (Clark, 2008: 10-13). CEN is the totality of its philosophy and beliefs, principles, processes and standards. As one of the subsystems, it influenees and is influenced by the health care delivery ystem. CHN is practiced within a specific cconomie, political, socio-cultural and environmental context. The roles and functions of CHNs directly contribute to the health of their clients ‘The essence of nursing is the same even if pr: defined as the science and art of caring. Nursing as an art is reflected in the nurses interactions and communication with clients that are geared towards the improvement not just of their health but also their ability to deal with the determinants and consequences of their health problems. iced in different settings. Nursing According to Parse, the responsibility of nursing to society is to guide individuals and 16 en Scanned with CamScannerfamilies “in choosing possibilities in changing the health process which is zecomplished by intersubjective participation with people” (George, 2002:439). The art of nursing is demonstrated by nurses who can maintain the delicate balance between doing things for their clients and doing things with them, thus co-creating a better or more meaningful reality. The practice of community health nursing, therefore, entails active interaction and partnership between the nurse and the client. Such partnership recognizes the autonomy of both parties and the potential of each one in enciching their relationship. Nursing is also a se nee, which means that community health nurses should use practice-hased and evidenee-based methods and tools. They also need to enga generating evidence to support their practice through research, Quantitative research is needed fo describe or quantify variables of interest to community health nurses or to evaluate the effectiveness of existing practices, procedures or interventions. Qualitative research can be done to understand specific human response phenomena such as client-partners' lived experiences on poverty and adaptation. ‘The roles of CHNs are grouped by Clark (2008: 14-22) into client-oriented roles (caregiver, educator, counselor, referral resource, role model and case manager); dolivery-oriented roles (coordinator, collaborator and liaison); and, population oriented roles (case finder, leader, change agent, community mobilizer, coalition builder, policy advocate, social marketer and researcher).ln recent years, the case manager role in the community setting is gaining importance as an innovative strategy to provide high quality care in a-financially restricted environment. As the case management concepts of client independence, control, advocacy and coordination are already reflected in current nursing models and philosophies, nurses are considered the most appropriate professionals to fill the role of case managers(Knollmueller, 1989; Bergen, 1992). As a CHN practice option in many countries, community-based case management is discussed at length towards the cnd of this chapter. FRAMEWORK FOR COMMUNITY HEALTH NURSING ‘The practice of nursing, particularly in CHIN differs from one geographic area (country or region) to another. It is influenced by a number of factors primarily the seope of practice as defined by the nursing law, policies and standards of the Department of Health and organizations where CHNs work and the health needs and problems of the people. ‘The macro framework for CHN practice has four components: (1) the health care delivery system, with its CHN subsystem; (2) the clients (individual, family, population group and community); (3) health which is the goal of the health care delivery system CHCDS); and, (4) the economic, sociocultural, political and environmental factors that affect the HCDS, the practice of community health nursing, and the people's health. ‘These constitute the context of community health nursing practice in the Philippines This chapter elaborates on the different components of the framework, CLIENTS OF COMMUNITY HEALTH NURSES ‘There are different levels of clientele in community health nursing—the individual, family, population group and community, with the latter as the primary client. Individual v7 Scanned with CamScannerThe CHN deals with individuals—sick or well-- on a daily basis. Sinee the health problems of individuals are intertwined with those of the other members of the family and community, they are also considered as an “entry point” in working with these clients. Family From a systems perspective, a family is defined as a collection of people who are tegrated, interacting and interdependent (Hunt, 1997:126). Just like other systems, the parts (family members) interact with each other and the aetion of one affects the other members. The family hasa boundary which means that other people can recognize its members and those who are not. In fact a person may be identified primarily as a member of a particular family. many changes in the social context of the Filipino family and these ‘There have be sks and its capacity to remain as the may have modified how it performs its health ta primary source of support to its members. Population group ‘A population group is a group of people who share common characteristics, developmental stage or common exposure to particular environmental factors, and consequently common health problems, issues and concerns. Allender and Spradley (2001) identified population “aggregates” with developmental needs (such as: maternal, prenata] and newborn populations; infant, toddler and preschool populations; school- aged and adolescents; udults and working populations; and, older adult populations) and those that are vulnerable (rural clients, the poor, migrant workers, minority populations experiencing health disparities, those with mental health issues, thos living with addiction, those in correctional facilities and those in long-term care settings). Population groups are the usual targets or beneficiaries of social services and health programs. Community A community is a group of people sharing common geographic boundaries and/or common values and interests within a specific social system. This social system includes health systers, family system, economic system, educational system, religious system, welfare system, politica] system, recreational system, legal system and communication system (Allender and Spradley, p. 360). Behringer and Richards describe a community as “webs of people shaped by relationships, interdependence, mutual interests and patterns of interaction (Leonard, 2000:93). Althongh all communities are the same (according to the general systems theory one is nique because it functions within a specific sociocultural, political, economic and environmental contest. ‘They also vary in terms of community dynamics: participation, power and decision making structures end community collaboration efforts (Allender and Spradley, 362-364). A community is regarded as an orgunism with its own stages of development and it matures through time. Development is facilitated by some catalysts from within and outside the community. Anderson and McFarlane (Anderson, 2000:157) developed the community-as- client 18 Scanned with CamScannermodel which later on yas renamed to community-as-partner model. The two elements, of the model are: focus on the community as partner and the use of the nursing c story. The people sre affected by, and also influence sity—physical em on, safety and and government, health and social services, communieation, and recreation. process. At the core ofthe assessment wheel are the people of the community- s, values, belie HEALTH Health is a basic human right. On the 6" Global Conference on Health Promotion in 2005 the United Nations affirmed its recognition that the enjoyment of the highest standard of health is one of the fundamental rights of every human being (The Bangkok Charter for Health Promotion, 2005), Health which is viewed as a continuum, is considered as the goal of public health in general, and community health aursing, in particular. 11 is an important prerequisite {and consequence) of development. By promoting health and preventing disease, CHINs, therefore, contrite to the country’s economic and social development. ‘There are # number of definitions highlighting the different dimensions of health and basically focusing on the individual. ‘These should guide nurses in identifying areas for assessment and interventions. The most frequently cited is that of the WHO : "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1995). Dunn (1959, in Pender, 1987:21), on the other hand, emphasized high-level wellness which he defined as: “an integrated method of functioning which is oriented toward maximizing the potential which the individual is capable, It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning” Rene Dubos in his book Man Adapting (1965) defined health as “a quality of life, involving social, emotional, mental, spiritual and biological fitness on the part of the individual, which results from adaptations to the environment (Butler, 2001:2) Florence Nightingale looked into health and illness in relztion to the environment— ventilation, noise, light, cleanliness, diet and restful bed. She preseribed ways to improve health by manipulating the enviroment. Dorothea Orem, on the other hand, defined health as a “state characterized by soundness and wholeness of human structures and bodily and mental functions”(1985 in Pender, 23). Factors affecting health ‘There is a strong Jinx between a society's health and its economic development, whieh in turn is determined by its social and political structures and processes. The link between inequalities in income and wealth and inequalities in health is well-established (Wilkinson, 1996 in Naidoo and Wills, 2600:12), Culture and environment which impact on people's health are also affected by the country’s polities and economy. The different international conferenceson health promotion identified thedeterminants of, or prerequisites for health such as peace, food and shelter, clean water, education, adequate economic resources, a stable ecosystem, sustainable resources, social justice and equity and access to basic human rights. In her keynote address during the 5* Scanned with CamScanner 1920 International Conference on Health Promotion in 2000, the UN Secretary Gene pointed out that “many of the major determinants of better health lie outside the health system. Knowledge made availableto people. Clean environments. A to basie services. Fair societics, Fulfilled human rights. Good government. Enabling, people to make decisions relevant to their lives, and to act on them” (Proceedings of the 5" International Conference on Health Promotion, 2000). In 2005, the Bangkok Charter for Health Promotion identified “critical factors” that now influence health and these are: increasing inequalities within and between countries, new patterns of consumption and communication, commercialization, nvironmental change and urbanization. The other factors that influence health nd often adverse social, economic and demographic gj environments, family patterns, global identified by the Charter are rapid and ¢ ‘ changes that affcet the working conditions, learn and the culture and social fabric of communities. Poverty and health | ‘Poverty is an indication of the continuing social injustice and failure of a country’s developmen! efforts. It is a multidimensional construct that goes beyond income jneasurements. The United Nations(UN) Human Development Index(HDI) summarizes a composite index of life expectancy, adult literacy rate, combined prim::y, secondary and tertiary gross enrallment ratio and gross domestic product (GDP), among ethers: (MTPDP 2004-2010). The Philippines is the 90" among the 177 countries ranked by the United Nations Development Program in terms of human development (Philippine Star, 2/28/08) ‘The poverty incidence in the country was estimated at 34% in 2000, up from 3396 in 1997 (MTPDP 2004-2010). More than half of the total income flows to the richest 2096 ofthe population (MTPDP 1993-1998). According to the Social Weather Station (SWS), almost 16 of every 100 survey respondents claimed to have experienced involuntary hunger because they had nothing to eat in early 2008 (Mangahas, 2008). ‘he poor have poor health because they do not have the resourees to afford the basic requisites of health; they are not covered by health insurance; and they do not have the capacity to effectively transact or negotiate with the health care system which seems to be more resporisive to the needs of those with the necessary financial resources. Poverty, however, is a not a complete explanation for poor health. The poor are not 2 homogenous group. Martin and Henry point out that poverty is the only characteristic that the poor share for their cultural orientations, values, beliefs, practices and needs vary greatly (1991: 523). Culture and health Culture is, broadly speaking, a way of life; it is the totality of who we are as a people. Itis stable, which means that il endures over time and is passed on from one gencration to the next. As i is obviously an important influence on people's health, Culture includes many things such as beliefs, values and customs or practices ~how we socialize or interact with others, how we relax and spend our free time, the food that we eat or do not eat, how we prepare our food, how we treat and care for pregnant women, how we deliver babies and take care of newborns, how we cope with our problems, how and when we seck help, among many others Culture has positive effects on health. An example is the value that we Filipinos place ‘on close family ties and social relationships. Families, relatives and friends are a major source of financial, emotional, instrumental and social support, especially during crisis Scanned with CamScannersituations. These relationships contribute to our sense of emotional well-being, and mental health. Some people have beliefs and practices that adve difficult to isolate the effcets of culture bheeause of the and ignorinee, and the inadequacies of the be Ith. Tt is, however, fluences of poverty Ith care delivery system. Environment and health ‘The environment plays direct influence on the health of people. For example, it provides breeding sites for insect vectors of diseases like malaria, dengue and filatia hare still major healih problems in some parts of the country, An unsanitary onment is also major factor in the causation of d I diseases suich as cholera and typhoid fever. 11 is the breeding ground of ani ets that harbor and transin't microorganisms. Malaria, dengue and filrias: ill major problems in miiny parts of the country In the environment could be found toxic substances such as lead, mereury, asbestos, pesticides, tobaceo,solventsand PCBs. These could adversely affeet human reproduction, the brain and immune system and could esuse caneer (Needleman and Landrigan, 1994). Tobacco particularly is a major threat to health because it contains over 4000 chemicals (including hydrogen evanide, sulfur dioxide, carbon monoxide, ammonia, formaldehyde, arsenie, benzene, chromium, lead, nitrosamines, benzopyrene, nicotine, cadmium and carbon monoxides) many ef whieh are irritants, careinogens and motagens, toxins and substances that increase blood pressure, promote tumors, aftect the heart and brain, damage the lungs and cause kidney and reproduetive malfunctions (Framework Convention on Tobaceo Control Alliance, Philippines). ‘The increase of carbon dioxide, methane and nitrous oxide (among other gases) in the earth's atmosphere has depleted the ozone layer. The deterioration of the ecosystem has been implicated in the rapid increase of cancer cases and other health problems throughoutthe world. Specifically, theres arise in caneer-cansing ultraviolet radiation, surface air temperature and carbon dioxide. ‘The denudation of our forests has directly and indirectly resulted in many health problems, Rivers have dried up or are extremely polluted, thus depriving many people of their major source of dietary protein. The International Physicians for the Prevention of Nuelear War estimates that millions of cancer cases will result from the nuelear testing conducted in the past. The WHO also estimates about 20,000 deaths a year in the world due to pesticide poisoning alone (Philippine Breast Ca The so-called Fl Nifto and La Nifta phenomena which have been caused by insults to the environment have caused thousands of deaths due to disasters (Nash, 1998), The state of the world’s environment is the direct result of the interaction of a number of factors such as industrialization, government policies, poverty and an uncaring attitude towards the environment. Policies reflect the priorities of government and the value system of policy makers. ‘The health budget is the most conerete expression of the government's political will, Many Filipinos do not have full access to basic health goods and services beeause of the severely limited health care financing, In 1999, the amount spent for health was only 8.4% of the gross national produet, lower than WHO-recommended 5%. This 2 Scanned with CamScannertranslates to the fact that almost half of health expenditures is out-of-pocket; in other words, the “financial burden on individual families is heavy, leaving access to care highly inequitable” (NSCB, 2002). ‘The severely limited health budget is also the biggest hindrance to the full implementation of well-meaning policies such as national health insurance. ‘There are a number of laws that impact on people’s health directly (such as the salt fodization law and food fortification law) and indirectly such as those that affect their purchasing power (minimum wage, espanded value-added tax, energy law, etc.), family and social relationships (¢.g,, laws protecting women and children), environment, and on and employment opportunitie: access to educ ‘There ave also Jaws that affect the delivery of health services -- the Local Government Code, National [lealth Insurance Act and the professional practice ucts of the different professions (nursing, midwifery and medicine). HEALTH CARE DELIVERY SYSTEM Ahealth care delivery system is the totality of “societal services and activities designed to protector restore the health of individuals, families, groups and communities (Banta, 1986 in Cookfair, 1996:66). It includes both government and non-government health facilities (hospitals, clinics, diagnostic centers, health centers), programs, services and activities (preventive, promotive, curative and rehabilitative). Preventive health care is a major concern of the government-owned health centers while curative care is provided by hospitals, both government and private. ‘The health enre delivery system is affected by policies such as RA 9439 and RA 9502 (refer to Annex Az for a listing of laws that impact on people’ health and the health care delivery system) Public health Public health is generally regarded as a responsibility of government. One of the most quoted definitions of public health is that of Winslow (1920): ‘Public health is the science and art of preventing disease, prolonging life, and_ promoting health and efficiency through organized community effort; for the sanitation of the environment; the control of communicable infections; the education of the individual in personal hygiene; the organization of medical and nursing services for the early diagnosis and preventive treatment of disease; and, the development of the socia! machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity” (Hanlon and Pickett, 1979:4) Today public health could be defined in terms of its three core functions: assessment, policy development and assurance. Assessment is the regular collection and analysis of health data. These data aze used for program planning and policy development. Poticy development involves advocacy and political action to develop policies in various levels of decision making. Assuranceis makingsure that health services ate effective, available and accessible to the people (Institute of Medicine, 1988. in Clark, 2008:87-88). Related to the core functions of publie health there are ten essential health services (ASTDN in Lundy and Janes: 2001: 875) which ave: (1) monitoring health status to identify community health problems; (2) diagnosing and investigating health problems and hazards in the community; (3) informing, cducating and empowering people 22 Scanned with CamScannerabout health issues; (4) mobilizing community partnerships to identify and solve health problems; (5) developing policies and plans that support individual, family and community efforts; (6) enforcing laws and regulations that protect health and ensure safety; (7) linking, people to needed personal health services and ensuring the provision of health care that is otherwise unavailable; (8) ensuring competent public health and personal health care workforce; (9) evaluating effectiveness, aevessibility and quality of personal and population-based health services; and, (10) researching for new insights and innovative solutions to health problems. Public health nurses should participate in these essential health services. The Philippine health care delivery system ‘This section presents some of the major components of the Philippine health care delivery system that constitute the context of community health nursing—the Department of Health, Millennium Development Goals, Medium- Term Philippine Development Plan, Health Sector Reform Agenda, FOURmula One for Health, National Ohjcetives for Heaith and local health eare system (devolution of health services). Department of Health ‘The DOH leads in efforts to improve the health of Filipinos, in partnership with other government agencics, the private sector, NGOs and communities. With the exception of a few government agencies (such as the University of the Philippines and Armed Forces of the Philippines) and affluent cities (sueh as Manila, Makati and Quezon City) operating their own health facilities, the DOH remains to be the national government's biggest health (particularly curative) care provider. ‘The DOH used to have control and supervision over all barangay health stations, rural health units and hundreds of hospitals throughout the country (special and specialty hospitals, medical centers, and regional, provineial, distriet and municipal hospitals). ‘Today, only the regional hospitals, medical centers, special and specialty hospitals and a few re-nationalized provincial hospitals are directly under it. ‘The DOH exereises regulatory powers over health facilities and products. It takes the lead in the formulation of policies and standards related to health facilities, health products and health human resources. It provides LGUs the necessary support in managing thcir local health system. It also implements a number of health programs (Refer to Annex A3 for a listing of DOH health programs). ‘The DOH has undergone transformation to be more responsive to its post-devolution functions. One of the major changes at the Central Office is the creation of the Bureau of Local Health Development, which is concerned with local health systems clevelopment, health care financing programs, quality improvement programs, inter-sectoral (public~ private) coordination and local projects. Scanned with CamScanner 2324 Millennium Development Goals (MDGs) The concern to improve people's health is universal because there is a strong correlation between health and development. Poor health is a conscquenee and cause of poverty and underdevelopment. Poverty also breeds despair and turmoil. To address these problems, the United Nations spearheaded the formulation of the MDGs with the corresponding targets. These goals are: (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women: (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria and other diseases; (7) ensure environmental sustainability; and, (8) develop a global partnership for development. Medium-Term Philippine Development Plan (MTPDP) Chapter 12 of the Medium-Term Philippine Development Plan 2004-2010 spells out the priority strategies to meet the basic needs of the poor. The following health priorities were identified: (1) reduction of the cost of medicines; (2) expansion of health Fisurance particularly for indigents through premium subsidy; (3) strengthening qational and local health systems through the implementation of the Health Sector Reform Agenda: (4) improvement of health care management system; (5) improvement Of heal:h and productivity through Rand D; and, (6) establishment of drug treatment and rehabilitation centers and the expansion of existing ones. Specifically for public health, the plan provides for the strengthening of health promotion and discese prevention and control programs: (1) achieve and maintain Pig immunized children coverage to 95%: (2) achieve and maintain sputum positive ‘Te tase detection rate of 70% and eure rate of 85%: (3) widen the choice and reach of snning services and increase the prevalence rate of men and women/couples practicing responsible parenthood using either modern, natural or artificial methods to 60% by 2010; (4) contain HIV/AIDS prevalence to 1% or less for groups at high fuk for HIV infection: (5) reduce malaria morbidity rate by 50% from 48 cases per Joo.v0v population in 2002 ta 24 cases per 100,000 population by the year 2010; (6) impleinent micronutrient fortification of foods; and, (7) heighten advocacy for the provision of adolescent health services including sexuality education and counseling. Heolth Sector Reform Agenda (HSRA) Towards the end of the twentieth century, the DOH has come up with the HSRA 1999-2004 thet included the following reforms: (1) provide fiscal autonomy to government hospitals: (2) secure funding for priority public health programs; (3) promote the development of local health systems and ensure its effective performance; (4) strengthen the capacities of health regulatory agencies; and (5) expand the coverage of the National Health Insurance Program. FOURmula ONE for Health (F1) ‘The FOURmula ONE which is the implementation framework of the HSRA, has three goals: better health outcomes, more responsive health systems and equitable health care financing. The elements of the strategy are: health financing, health regulation, health service delivery and good governance. According to the Secretary of Health, Fis the guiding philosophy and strategic approach of the DOH (Foreword, NOH 2005:8). Scanned with CamScannerNational Objectives for Health (NOH) ‘The NOH 2005-010 is an important document that reflects the MDGs, MTPDP, Aand Fs. It includesa statement of vision, mission, principles, goalsand objectives, ‘ . targets, indicators and strategies to bring the health sector to its desired outcomes (http: //sww.doh.gov.ph/n0h). ‘The visiow of the NOH is “health forall Filipino: and quality of health care to improve the quality of life of all Filipinos, especi poor. The bet nd healthy nation: (2) en! the perfor al neces to quality essent ice of the health sector; (3) ens health care, and. (4) improving macro-economic and social conditions for better health gains. The goats ate: (1) beuer health out 2) more responsive health em: sid, (3) more equitable health care financing. The medium-term objeetives ter and sustained investments in health; (2) assure the quali ffordability of health goods (3) improve the accessibility and availability of basie and essential health eare for all: (3) Improve health eystems performance at the national and local levels, are to: (1) secure increased, be Devolution of health services One of the most significant laws that rudically changed the landscape of health care delivery in the country is 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 ystem of decentralization. Throughout the country, there are about 79 provinces,a1g cities, 1,496 municipalities, and 41, 943 barangays. (hétp://wunv.doh,gov ph/kp/ statistics /no_citics_prow). In 1993, health services were devolved or transferred from the Department of Health to the lveal government units -- all provincial, district and municipal hospitals to the provineial govecuments and the rural health units (RHUs) and barangay health stations (BHSs) to the municipal governments. In 1999 there were 2,381 RHUs and 4 BHSs (Bautista et a Each province, city and municipality has a Local Health Board (LIB). This body is a good venue for making the local health system more responsive to the needs of the people, It is mandated to propose ennual budgetary allocations for the operation and maintenance of health facilities and services within the municipality, city or province. At the provincial level, it is composed of the: governor (chair), provincial health officer (vice chair), chairman of the Committee on Health of the Sangguniang Panlalawigan, DOH representative and NGO representative. At the city and municipal level, the LHB is composed of the following: mayor (chair), munieipal health officer (vice chair), chair of the Committee on Health of the Sangguniang Bayan, DOH representative and NGO representative. At the municipal level, many public health nurses have been appointed as DOH representatives. This means that they have been retained by the DOH. Many of them, however, perform dual functions--those of a public health nurse and those of 8 DOH representative. Many of the local government units “cannot afford” to hire a Scanned with CamScanner26 form of support to low- lowed this set replacement, The DOH has, therefore, me municipalities The shift in the leadership 19 health care from the national government to the LGUs has resulted in both the improvement and deterioration of health care delivery. Some LGU have the political will and financial capability to support their own health care system while others do not. Some LGUs give their PINs SG 15 salaries in accordanee with RA 0173 while most do not. been established that an LGU’s financial capability, a dynamic and responsive omnmanity empowerment are the important ingredients of an It ha political leadership and effective local health system. Almost two decades after the devolution of health services, there is a need to look into Ith. It is also important to know how PHNs performed their its impact on peoples bh jabs, how they perceive their roles and how they view their professional development devolved set-up. THE NATIONAL HEALTH SITUATION s us an idea of the heaith situation n the The national health situation giv communities where nurses work. Because of the different conditions prev: these communities, their health picture expectedly varies. For example, 3 prevalent in the Mountsin Province while schistosomiasis is endemic local health situation. therefore, needs to be established for each province, city, and municipality ‘The next section gives a general demographic and health profile of Filipinos. It must be recognized, however, that the regional differences in many important socioeconomic and physieal factors are translated to differences in the regional health picture. Demographic profile ‘The Philippines ranked 12" in the world in terms of total population which million in August 2067 (http: //uncw’.census govsph) This is projected to incre 86%, 00 in 2O10 (National Objectives for Health, 2005:21). According to the President in her State of Nation Address in uly 2008, the country’s annual population growth rate is 2.04%, down from the 2.36% in the 1990s (The Philippine Star, 8/3/08). In 2004, the average life expectancy at birth was 72. 8 years for females and 67.5 years for males — up from the average of 61.6 years for hoth sexes in 1980, The country’s population is very young, with 21 years as the median age. The dependency ratio is 69 which means that 63 young dependents Co-14 years old) and 6 old dependents (65 years old and above) are being supported by 100 people aged 15-64. Thirty- seven percent (7%) of the total population are in the 0-14 age group while 3.8% are in the 65 and above age group (NOH, 2005). In 2000, there were about 255 people for every square kilometer of Philippine territory. Metra Manila has the highest population density and CAR has the lowest (NOH, 2005), ‘The population in the urban areas is increasing very rapidly. From the 37% of the total population in 1984 (UNICEF, 1986) the figure increased to 48% in 2004 (NOH 2005) Scanned with CamScannerHealth profile One of the issues reised about henlth statisties in the country is their aceura completeness and reliability. Different sources sometimes quote different figures. The intention of including some statisties in this chapter is to give a general picture of the epidemiological patterns and trends in the health of Filipinos. Births and deaths ‘The erude birth rate (CBR) in 2600 was 23.1 per 1000 population while the erude death rate (CDR) was 4.8 per 1000 population. Based on these figures, the rate of natural increase in the country’s populotion for the same year was 18.3 (23.1 minus 4.8) for every 1000 population (NOH, 2005). Despite the decline in the fertility of women, the total fertility rate (TFR) in the Philippines remains high (3.1 births per woman in 2004, according to the ADB) compared to the neighboring Southoast Asian countries. Rural women have more children than urban women, Unedueated women also have more children than those who are with college education, Those in the 25-29 age group have the highest fertility rate (NOH 2005). Between 1998 and 2003, the infant mortality rate (IMR) was 29/2000 live births, which is within the WHO global goal for IMR of less than 50/1000 live births. This figure went down te 26/1000 live births in 2004. The child mortality rate (CMR) between 1998 and 2003 was 12/1000 live births (NOH 2005). The maternal mortality rate (MMR) was 2/1000 live births (ADB, 2006)-There are more deaths among males than females, This explains the “feminization” of old age. Causes of morbidity and mortality ‘The following are the leading causes of mortality among Filipinos: (1) heart disease; (2) vascular system disease; (3) malignant neoplasms; (4) accidents (5) pneumonia; (6) TB, all forms: (7) ill-defined and unknown cause of mortality(8) chro respira the perinatal period (Philippine Health § highly preventable. ry disease; (9) diabetes mellitus; and, (10) certain conditions originating in fatistics 2004). Most of these dise sare Despite the improvements in the field of public health, many of the common causes of morbidity ean be prevented easily by improving environmental sanitation and personal hygiene and through health education. In 2004, the leading causes of morbidity were: (2) acute lower respiratory tract infection (RTI) and pneumonia; (2) bronchitis and bronchiolitis: (3) acute wat wthea; (4) influenza; (5) hypertension; (6) TB respiratory: (7) chickenpox; (8) diseases of the heart; (9) malaria; and, (10) dengue fever (PHS 2004). Infants and children ‘The leading causes of infant mortality in 2004 were: (1) bacterial sepsis of newborn: (2) respiratory distress of newborn; (3) pneumonia ; (4) disorders related to short gestation and low birth weight not elsewhere classified; (5) congenital pneumonias; . (6) congenital malformation of the heart; (7) neonatal aspiration syndrome; (8) other congenital malformation; (9) intrauterine hypoxia and birth asphysda; (10) diarrhea and gastroenteritis of presumed infectious origin (PHS 2004). Malnutrition is very common amongehildren, particularly protein-energy malnutrition. In 2001, 31% children underg years old were underweight (ADB, 2006) The Philippines i ‘one of the highest blindness rates in the world. It is estimated that 17 children | become permanently blind everyday and lack of Vitamin A is the primary cause of a7 eee Scanned with CamScannerch results in mental and growth «J above, and in pregnant and retardation is common lactating, mothers (Nati us health c 3 Fil An emerging serie that almost 1 in 2007) Maternal mortality Maternal mortality is a major indir the WHO as the death ef a woman tw 2 days of termination of pregnaney irrespective uf the durution and the site of the pregnancy from any cause reluted to, or aggravated by the pregnancy or its management, but not from acridentai or incidenta! causes. The maternal mortality rate in 2000 was 2/1000 live births (ADB, 2006). th status, It is defined by or of a woman le proanant or within 12004 were: (1) other complications related delivery and puerperium: (2) hypertension nd puerperium: (3) postpartum hemorrhage; (4) and, (5) hemorrhage in carly pregnancy (2004 “The leading catises of maternal mortality urse of laber to pregnancy oceurringin th complicating pregnancy. childbirth pregnancy with abortive outcome; Philippine Health Statistics). Maternal mortality should be viewed within the greater context of women’s health. Analysis of women’s poor health and maternal mortality should consider the overall Iand cconomie environment, The woman who dies from pregnaney- telated causes is more likely to be poor, with low educational status, a multipar and anemic More likely she comes from an area where th natal services are inacerssihle. transport facilities are poor; supply of blood for transfusion is inadequat ailable; and adequately skilled help in sital drugs, supplies and equipment are not a labor and delivery is not available Elderly Probably the most commonly documented problems of older people are those cording to the DOH, the elderly suffer from the “double burden” of 6 tive and communicable diseases. ‘The leading eau i amony older people pre influenza, pneumonia and TB. The leading cause are cardiovascular diseases, pneumonia, malignant neoplasms, TB, COPD, di mellitus, gastroint ents and injuries, nephritis, nephrotic and nephrosis and septicemia (PHS 2000 in NOH 2005). related ty their health. Ac of mort jabetes ndrome of nutritional deficiency disorders among older people is hi emia, qs and riboflavin, 12%. There are more older women (6%) than older mea (155) who are underweight (National Health Objectives, 144). According to the Food and Nutrition Research Institute (20a1:21) the prevalence of chronic energy deficiency is higher in females than in males, and the severity increases The prevalen: 45%: thiatni with age In 1995 there were 345,000 senior citizens (9.2%) with some type of disability. Low vision was the most common especially among elderly women (44.1% as compared to 49.7% among elderly men), The other types of disability that alder people suffer from were deafness (partial and total), poor hearing, blindness (partial and total) and paralysis (NSO, 28 SS Scanned with CamScannerLifestyle-related diseases ed significantly. While infectious nain to he the main causes of morbidity, cardiovascular diseases, diabetes nd ebronic respiratory diseases, the so-called lifestyl auses of deaths. WHO estimates that 60% of all deaths to ebroniv disc: hty percent (40%) of these occur in low- and middle-income countries like the Philippines (WHO, 2005). By 2020, it is estimated that 73% of total deaths will be attributed to the major non-communieable diseases (World Health Assembly, 2004). re due People's lifestyle (particularly their unhealthy diet, sedentary work and lack of exercise) has been identified to be the major reason why they die from the diseases which used to be associated with developed countri Cardiov: cardiovaset ths. Nine Filipinos die of very hour. Diabetes mellitus, which is regarded as “the biggest health e: phe the world has ever seen” (Castillo, 2003) is found in 4 out of 100 Filipinos. Not surprisingly, more diabetics are found in urban areas (6.8%) than in rural areas (2.5%) (FNRI). cer is the most dreaded of all diseases beeause of its very high ease fatality rate and the long suffering that. patients exporienee. The leading cancer sites among males are: lung, liver, colon/rectum, prostate, leukemia, stomach, nasopharynx, non-Hodgkin's lymphoma, oral cavity and larynx. Among females, these are: breast, cervix, colon/ rectum, lung, ovary, thyroid, leukemia, liver, uterus and stomach. (Philippine Cancer 08). In addition to lifestyle, a major factor in the causation of malignant ‘ms is the drastic change in the physical environment and greater exposure of Iychlorinated biphenyls or PCs), radiation and other Needleman and Landrigan, 1994). Infectious and communicable diseases Although the number of deaths from infectious diseases has decreased, many of ve Still major public health problems in the country Cholera and typhoid fever mmon oceurrence in many parts of the country. The number of paralytic h poisoning (more commonly known as red tide) continues to increase because of the degradation of the country’s bodies of water. In the past few y ws, there were infectious diseases that have emerged such as the scary sever ndrome (SARS). SARS has highlighted the fact that asm foctious diseases is facilitated by the inereasing physical mobility of people and ease in traveling, from one country to another. There is a steady increase, though relatively slow, in the number of HIV Ab seropositive ses in the country—2,454 cases from January 1982 to February 2006. HIV/AIDS is no longer just associated with homosexuality, About one-third of the cases were OFWs (seafarers, domestic helpers, entertainers and health workers). About three-quarters (74%) were males. The mode of transmission is primarily (93%) through sexual intercourse (DOH, 2006). The increase in other sexually transmitted diseases (STDs) such as syphilis and gonorrhea is due to unhampered prostitution in many areas of the country. Prostitution has always been identified as a consequence of poverty. STDs (and the newly emerging diseases) further burden the health care system which at the moment could not cope adequately with the leading causes of morbidity and mortality. Scanned with CamScanner 29Tuberculosis which was the number one cause of mortality about 50 years ago continue to be a major killer of Filipinos. TD prevalence in 2003 was 458 per 100,000 population (ADB, 2006) and this problem is made worse by the resistant strains of the TB microorganisms. Unfortunately, TB will not significantly decline over the next two decades (ADB, 2004). Leprosy, 100, is still a public health concern in some parts of the country. Schistosomiasis continues to affect hundreds of barangays in 24 endemie provinces Rabies incidence in the Philippines is one of the highest in the world. It is estimated that about 12% of the population are chronic carriers of hepatitis B (DOH). ‘The significance of this figure lies on the very close association between hepatitis B and Three fatal and debilitating diseases—malaria, filariasis and dengue fever are brought about by the vector mosquito. Malaria is endemic in most provinces in the country. Filariasis, on the other hand, is endemic in the Bicol Region and some provinces in Region 16 and ARMM. In the past few years, there has becn a significant increase in the incidence of dengue fever (DOH). Mental illness Mental illness is the third most common form of disability, after visual and hearing impuirments, according to a disability survey by the National Statistics Office in 2000, ‘Almost 2 deaths (1.8) per 100,000 population resulted from suicide and self-inflicted injuries. In another survey in 2004, 0.7% of the households included have a family member with mental disability. The ineidence of mental illness is reportedly highest among older age groups. Other vulnerable groups are drug users and these who could ith stresses of daily living (NOH 2005). not cope PRIMARY HEALTH CARE AND HEALTH PROMOTION ‘The practice of community health nursing is guided by the philosophy, goals and strategies of primary healih care and health promotion. In their search for more effective strategies and interventions, community health nurses should also learn from the lessons of Alma-Ata and the different charters of health promotion. A major lesson from all of them is that meaningful improvements in the socioeconomic determinants of health are required to have significant improvements in people's health. Primary health care In 1978, representatives from 134 countries whoattended the International Conference on Primary Health Care in Alma-Ata, USSR signed the Declaration on Primary Health Care (PIIC) because they believed that the global health situation was unjust. There a wide gap in the health of underdeveloped and developed countries and even within countries. Community health nurses subscribe to the beliefs articulated in the Declaration, specifically: (1) The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world perice; (2) The people have the right and duty to participate individually and collectively in the planning and implementation of their health care; (3) PHC premised on the spirit of social justice; and, (4) PHC is an integral part of the country’s health system and of the overall social and economic development of the community (WHO/UNICEF 1978:2-4). 30 a Scanned with CamScannerPHC was viewed as the approach that could improve the health situation thr the world. It was defined as ” | health care based on practical, scientifically made universally accessible to individuals and ty through their full participation and at a cost that the community can afford to maintain at every stage of their development in the spirit of self reliance and self determination” (WHO/UNICEF p. 16). sound and socially acceptable methods and technology ‘The essential elements of PHC include: education about pres including methods of prevention and control; promotion of a and proper nutrition; immunization against the major infectious diseases; provision of safe water and basic sanitation; maternal and child health care, including family planning; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and, provision of essential drugs. Although these were identified decades ago, these are still reflective of the needs of most people in the world, particularly in developing countries. ing health problems, te food supply Realizing that health and illness are multi-causal and could be addressed only by an tegrated effort, the CHN works with other health workers and those from other government agencies and non-government organizations (NGOs). Multisectoral linkage ensures that the different facets of health problems are addressed. (These concepts are elaborated in other chapters of this book.) Appropriate technology is used in addressing people's problems for many reasons. _ Herbal medicines and acupressure which have been proven to be effective, have the advantage of safety, acceptability and affordability. Three decades after the International Conference on Primary Health Care, access to basic health services has not significantly improved for certain segments of the country's population. Why? The answer lies on the political commitment to primary health ‘care which “implies more than formal support from the government and community leaders... For developing countries in particular, it implies the transfer of a greater share of health resources to the under-served majority of the population. At the same time, there is a need to increase the national health budget until the total population has access to essential health care..." (WHO/UNICEF 1978, in Werner and Sanders, p. 18) In addition, many people (health workers and communities) have not fully understood the essence of community participation and have not developed the necessary competencies to participate more effectively. Nurses should do their share in making basic health services available and accessible through advocacy and proper management of health programs and services. Community participation should be ensured in all the phases of the nursing process and other community health nursing processes. Nurses must be competent on the use of participatory approach to engage clients/community partners to look, think and act in order to address illness realities and barriers to quality health care, by enhancing the competence of clicnt-purtners to understand, analyze and carry out options to address hopelessness, apathy and helplessness, they can sustain their motivation to change the current reality in order to out health and health care in their hands (Maglaya, 2008). The participatory approach is described in Chapter 5 and pursued with specific examples in Chapter 18 as participatory action research on family empowerment for malaria prevention and control in a barangay in Abra Province. Scanned with CamScanner 31