Chn Concepts

COMMUNITY HEALTH AND DEVELOPMENT What Community Development Is? Excerpts from the book Health Care Practice in the Community By Erlinda Palaganas, R.N. Ph.D.

FRAMEWORK FOR CHN PRACTICE INDIVIDUAL Family Population Group Community HEALTH CARE DELIVERY SYSTEM COMMUNITY HEALTH NURSING PRACTICE . Philosophy/beliefs . Principles Primary Health Care Ethicolegal aspects . Processes Critical thinking Nursing Process Program Planning, Implementation, and Evaluation. Management and supervision Research Quality Assurance Advocacy and political Action . Roles and Function ECONOMIC, SOCIOCULTURAL, POLITICAL AND ENVIRONMENTAL FACTORS HEALTH

PRINCIPLES: Primary Health Care Ethicolegal aspects

CONCEPT: PRIMARY HEALTH CARE HISTORY OF PRIMARY HEALTH CARE May 1977- The 30th World Health Assembly adopted resolution WHA 30:43. This resolution 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 12, 1978- International Conference on Primary Health Care was held in this year at Alma Ata. USSR The conference came up with what is known popularly as the Alma Ata Declaration, which represents a global ideal, a new vision about how to achieve world health. The Declaration stated that primary health care is the key to attaining the health-for-all goal. 1979- The World Health Assembly launched the Global Strategy for Health for all. October 19, 1979- The President of the Philippines issued Letter of Instruction 949 which mandated the Ministry of Health to adopt Primary Health Care as an approach towards design, development, and implementation of programs, which focus health development at the community level.

DEFINITION OF PRIMARY HEALTH CARE The Alma Ata Conference defines Primary Health Care as 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 the, through their full participation and at a cost that community and country cam afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms as integral part of both the country’s health system, of which it is the central function and the main focus, and of the overall social and economic development of the community.

GLOBAL GOAL OF PRIMARY HEALTH CARE The global goal as stated in the Alma Ata Declaration is Health for All by the year 2000 through self-reliance. The Health for All goals does not mean however that nobody will be sick or disabled anymore. Nor does it mean that health care professionals will provide care for everybody in the country or the world for all their existing ailments. What it means is that health begins at home, in schools and in the work place.

PRIMARY HEALTH CARE PRINCIPLES AND STRATEGIES 1. Accessibility, Availability, Affordability and Acceptability of Health Services. Strategies: a. Health services delivered where the people are b. Use of indigenous/resident volunteer health worker as a health care provider with a ratio of one community health worker per 10-20 households. c. Use of traditional (herbal) medicine with essential drugs. 2. Provision of quality, basic and essential health services Strategies: a. Training design and curriculum based on community needs and priorities b. Attitudes, knowledge and skills developed are on promotive, preventive, curative and rehabilitative health care. c. Regular monitoring and periodic evaluation of community health worker performance by the community and health staff.

3. Community Participation Strategies: a. Awareness-building and consciousness raising on health and health- related issues. b. Planning, implementation, monitoring and evaluation done through small group meetings (10-20 households cluster) c. Selection of community health workers by the community. d. Formation of health committees/ e. Establishment of a community health organization at the parish or municipal level. f. Mass health campaigns and mobilization to combat health problems. 4. Self-Reliance Strategies: Community generates support (cash, labor) for health programs a. Use of local resources (human, financial, material) b. Training of community in leadership and management skills. c. Incorporation of income generating projects, cooperatives and small scale industries.

5. Recognition of the interrelationship of health and development Strategies: a. Convergence of health, food, nutrition, water, sanitation and population services. b. Integration of PHC into national, regional, provincial, municipal and barangay development plans. c. Coordination of activities with economic planning, education, agriculture, industry, housing, public works, communication and social services. d. Establishment of an effective health referral system. 6. Social Mobilization Strategies: a. Establishment of an effective health referral system b. Multi-sectoral and interdisciplinary linkage c. Information, education, communication support using multi media. d. Collaboration between government and non-governmental organizations 7. Decentralization Strategies: a. Reallocation of budgetary resources b. Reorientation of health professionals on PHC c. Advocacy for political will and support from the national leadership down to the barangay level.

ESSENTIAL HEALTH SERVICES IN PRIMARY HEALTH CARE The Alma Ata report on PHC outlined eight essential elements to be emphasized in PHC. These shall comprise the initial and continuing care at the point of entry into health system. The list of essential elements is a modification of the basic health services of earlier times. To facilitate easy recall of these, the acronym ELEMENTS is used to present these. 1. Education for health 2. Locally Endemic Diseases Control Malaria, Leprosy, Leptospirosis 3. Expanded Program of Immunization Poliomyelitis, measles, tetanus, diphtheria and other deadly but preventable diseases. 4. Maternal and Child Health including responsible parenthood protection of mother and child against illness and other risks. 5. Essential drugs Proper utilization and acquisition of drugs Generic Act of the Philippines Campaign 6. Nutrition 7. Treatment of Communicable and Non-Communicable Diseases. 8. Safe water and sanitation.

ETHICOLEGAL ASPECTS OF NURSING PRACTICE IN THE COMMUNITY Guided by a number of legal and ethical principles centered on the welfare of clients and protection of their rights. Professional practice is legal if the practitioner works in accordance with the law. Ethical practice is characterized by three major principle: Respect for Autonomy – the ability to decide: adequate information, intellectual competence; power to act ypon your decision, and respect for the individual autonomy of others. - self determination Beneficence – acts of mercy and charity, to apply measures for the benefit of the sick. - maximize the good, minimize harm Justice – fairness, “ equals must be treated equally and un-equals must be treated unequally. - example: distributive justice, compensatory justice - Bases for Client’s rights and their rights have professional responsibility.

Other Universal Ethical Principles are: 4.Veracity – in association with truth, disclose factual information so that patient can exercise personal autonomy 5.Nonmaleficence – not to inflict evil or harm, someway similar to Beneficence 6.Confidentiality – privacy, important aspect of trust that patients place to health professionals 7. Role Fidelity – practice as team

Some Applications: Right to be informed about condition and treatments, interventions to be done. Right to accurate or adequate information to make an informed decision. Example: to decide or to refuse treatment. Right to safe and quality care. Example: update client on latest development of health care Right to privacy Etc FINALLY……Do Not only deliver health services but Humanize the Health Care Delivery System.

Other IMPORTANT CONCEPTS: C H N is composed of three major concepts: COMMUNITY (CLIENT) HEALTH (GOAL) NURSING (MEANS) HEALTH PUBLIC HEALTH PRIMARY HEALTH CARE RIGHT TO, AND RESPONSIBILITY FOR HEALTH

RIGHT TO, AND RESPONSIBILITY FOR HEALTH HEALTH is a basic human right (Universal Declaration of Human Rights Article 1, Philippine Constitution and By Laws; Article 13, section 11 “ The state shall adopt an integrated and comprehensive approach to health development which shall endeavor to make essential goods, health and other social services available to all people at affordable cost. WHO (1995) “ Governments have a responsibility for the health of their people by providing adequate health and social measures. Congressional Commission on Health (1993). Health as a Fundamental Right, Health deserves to a top national priority. The state, individuals, families and communities share the responsibility for health and as responsibility of all sectors..

POCESSES IN C H N PRACTICE 1.Critical Thinking – Rational examination of ideas, inferences, assumptions, principles, arguments, conclusions, issues, statements, beliefs and action. Critical thinking in all of daily living Discriminate among the uses and misuses of language in nursing Identify and formulate nursing problems Analyze meaning of terms in relation to their indication, cause or purpose. Analyze arguments, issues and conclusions Examine nursing assumptions Report data and clues accurately

1.Critical Thinking Make and check inferences based on data, make it sure plausible Formulate and clarify beliefs Verify, corroborate and justify claims, beliefs, conclusions, decisions and actions Give relevant reasons for belief and conclusions Formulate and clarify value judgments Seek reasons, criteria and principles that effectively justify value judgments and Evaluate the soundness of conclusions

2. Nursing Process – the means by which nurses address the health needs and problems of their clients. It is a logical and systematic way of processing information gathered from different sources and translating intentions into meaningful actions or interventions. FOUR PHASES: ASSESSMENT, PLANNING, IMPLEMENTATION AND EVALUATION

3. Management and Supervision – Management activities depend on the size and level of autonomy of health center Example: Organizes nursing service, manages the RHU in the absence of the Physician. :Supervises the Rural Health Midwives. :many more.

4. Research in Community Health Purposes: 1. improve our understanding of clients and their specific context 2. provide date needed for program and policy development and evaluation 3. improve the delivery of health services and implementation 4. improve cost-effectiveness of programs 5. project a good image of nurses

5. Quality Assurance Characteristics: appropriate health services are available and accessible health care is effective, desired outcomes for the clients are obtained health service is equitable; given to most needy health interventions are safe and are based on professional and agency standards good interpersonal relation, based on mutual respect proper coordination among health workers and a working referral system efficiency and economy in the provision of services.

.Quality Assurance – Process of ensuring that clients receive the agreed-upon level of care through setting up of standards, monitoring and evaluation practices. Example: The Sentrong Sigla Movement or Centers for Vitality. 6.Standards - desired level of performance against actual practice is compared. What should be ? 7. Advocacy and Political Action – An act of pleading for or giving verbal support for a cause - To speak up for the clients’ rights - Speaking up and meeting with politicians and hand in our issues, our positions, demands and many. - For policy making or legislations.

Health : A “ state of complete physical, mental and social well being and not merely the absence of disease or infirmity” (WHO, 1946/1948) : emphasis not the prevailing physical and mental conditions of the people and the community. : recognizes the multifaceted nature of health and that health involves different dimensions, it considers the political, economic and social/cultural dimensions that affect the living conditions and quality of life

2 Basic Components of a Concept of Health ( Kass) 1. well workingness - identifies the physical ability of components of the body to function. 2. wholeness – simultaneous functioning of the different components of the ability to self-heal. Health : is the ability of the person to adapt to continuing physical, social and personal change ( Dubos, Candus, Thrall) Health : a state in which the organism is “functioning effectively, fulfilling needs, successfully responding to the requirement or demands of the environment, whether external or internal, and pursuing its biological destiny, including growth and reproduction. ( Engel)

Disease – “that which is malfunctioning or maladaptation of biologic of biologic and psychophysiologic processes in the individual” - may occur at any biological level i.e. the cell, the organ, system, and the body. - Incapacity to perform one’s roles. Illness – “the threat of incapacity of the person to fulfill personal expectations or perform social role or task” refers more to the experiential/ behavioral level nonphysical and nonphysiological incapacity as personal, interpersonal and cultural responses to disease or discomfort

Three Structural Domains of Health Care Professional – utilizes biomedicine and which is primarily interested in the recognition and treatment of disease (curing) and generating technological intervention. 2. Popular – family and social networks 3. Folk – non professional healers or the traditional healing. Both popular and folk or traditional healing are principally concerned with illness that is treating the human experience of disease.

Community Health Nursing -one of the two major fields of Nursing in the Philippines - the other is Hospital Nursing Definitions of CHN By Ruth B. Freeman: It refers to a “a service rendered by professional nurse with communities, groups, families, individuals at home, in health centers, in clinics, in school, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation.

By Jacobson Is a learned practice discipline with ultimate goal of contributing, as individuals and in collaboration with others, to the promotion of the client’s optimum level of functioning through teaching and delivery of care. By American Nurses Association CHN practice promotes and preserves the health of populations by integrating the skills and knowledge relevant to both nursing and public health.

COMMUNITY HEALTH NURSING - is broader than public health nursing because it encompasses “nursing practice in a wide variety of community services and consumer advocate areas, and in a variety of roles, at times including independent practice. - is the synthesis of nursing practice and public health practice. 2 Major Fields of Nursing in the Philippines 1. Community Health Nursing School health nursing Occupational health nursing 2. Hospital Nursing or Institutional Nursing

PUBLIC HEALTH NURSING - (WHO) is a special field of nursing that combines skills in public health nursing, public health, and some phases of social assistance and function as part of the total public health program for the: promotion of health, improvement of condition in social and physical environment, rehabilitation, prevention of illness and disability.

Public Health (By Dr. C.E. Winslow) The Science and Art of : (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency though organized community effort for a. the sanitation of the environment, b. the control of communicable disease, c. the education of individuals in personal hygiene, d. the organization of medical and nursing services for the early diagnosis preventive treatment of disease and e. the development of social machinery to insure a standard of living adequate for the maintenance of health, so organizing there benefits as to enable every citizen to realize his birth right of health and longevity.

Key phrase: “through community effort” Ex: Government efforts (legislation, support from taxes, etc.), private efforts or funds, multidisciplinary public health efforts. Mission of Public Health – SOCIAL JUSTICE …….which entitles all persons to basic necessities: adequate income and health protection, accepts collective burdens to make such possible.

COMMUNITY HEALTH NURSING - its basic knowledge and skills are anchored on Nursing Theories and Concepts from the science of the public health such as: 1. Importance of the greatest good for the greater number (ethics) 2. Assess health needs, plan, implement, and evaluate the impact of health services on population or groups (nursing process) 3. Priority of health promotion and disease prevention strategies over curative

4. Tools for measuring and analyzing community health problem (Biostatistics, Demography, Epidemiology) 5. Application of principle of management and organization 6. Its practice and enhanced by bodies of knowledge of other academic discipline (sociology, psychology, anthropology, economics, political science) Philosophy of CHN : Worth and Dignity of Man (Person) By: Margaret Shetland.

Highlight/ Concept of C H N Goal of Professional Practice-> Promotion of health and Preservation of life Nature of Practice-> Comprehensive, general, continual, not episodic Knowledge Base-> Nursing and Public Health Levels of Clientele-> individual, families, groups (aggregate), community, sick or well in daily basis, health tasks, children, elderly, youth Practitioner’s recognition-> Primacy of population as a whole Greater control for both nurse and client in health care decision Collaboration between nurse and clients as equals Recognition of the impact of different factors of their client lives and situation Goal of CHN “ To raise the level of health of the citizenry” ► to help the community and families to cope until discontinuities of health and threats; a way to maximize potential for high level wellness and promote reciprocally supportive relationship between people and their physical and social environment.

PRINCIPLES OF CHN 1.Based on recognized needs of communities, families, groups and individual 2.Full understanding of objectives and policies of the agency 3.Family is the unit of services 4.Available to all regardless of sex, status, political beliefs and others. 5.Health teaching a primary responsibility of community health nurse. 6.The nurse works as a member of the team 7.Periodic evaluation of Community Health Nursing Services 8.Opportunities continuing education and professional growth 9.Make use of available community health resources 10.Utilizes existing active organized groups

11.Provide educative supervision 12.Accurate Recording and Reporting SUB-SPECIALTIES OF CHN 1.Occupational Health Nursing health care services for workers and worker population promotion, protection and restoration of worker’s health in the context of a safe and healthy work environment. aim: to cope with actual and potential stresses for optimum level of physical and psychological functioning determined by: Government Policies and Standards (DOLE, DOH, SSS, Phil. Health) are Professional Standards (OHNAP, PNA).

2.School Health Nursing to promote health of school children and prevent health problem that hinders learning and performance of their developmental task. Health on important requisite in education determined by: age, developmental stage, health problems, genetic consideration; policies and standards of DECS/DepEd, DOH, and the nursing professions; socio-economic realities in the schools and LGU’s.

Clients of the Community Health Nurse 1.Individual - sick or well - on a daily basis - who consult at the health center and receives services a. prenatal b. well-baby follow up c. morbidity d. chronic illness: diabetes, hypertension e. clients seen during home follow up f. school consultation g. workplace visit- conference h. other community based activities

2. Family Rationale: (Maglaya & Bailon) 1.Natural and fundamental unit of society; important social institution 2.Generates, prevents, tolerates and connect healthy problems within its members 3.Health problems of family members are interlocking 4.The most frequent focus of health decisions and actions in personal care. 5.An effective and available channel for much of the community nursing effort. 6.Service of the most solid support to its members specially the young, elderly and less-fortunate.

Family Health Nursing - A level of community nursing practices directed on the family as the unit of care, with the Health as the Goal and Nursing as the medium, Channel or Provider of Care Nurses Role and Functions: assist family cope effectively with health problem by increasing in capacity to perform with health task and to render family independent with continues guidance of the nurse till no longer needed. Roles of the Nurse: 1.Health Monitor 2.Provider of Care 3.Coordinator of family service 4.Facilitator 5.Teacher 6.Counselor

Family Case Load - number and kind of families a nurse handles at any given time (prioritizing on problematic families: low income/ poor, with illness, pregnant, children, elderly) Family Health Tasks are basis for effective coping and family nursing problem statement 3. Population Group or Aggregate - who share common characteristics, developmental stage, common exposure to environmental factor which results to common health to to to common health problems a. children e. prisoners b. women f. farmers c. factory worker g. elderly d. commercial sex workers

Leading ailments of school children a. dental carries g. otitis media b. parasitism h. tinea flava c. colds i. PEM d. Pediculosis j. EOR & Blindness e. URTI k. enlarged glands f. CEDC- Children in Especially Difficult Circumstances Ex: neglected, street children, impaired with disability, drug users, working children, cultural minorities & IPs Elderly/Senior Citizen – 4.5 million a. influenza g. COPD b.T.B. h. ischemic heart disease c. Bronchitis i. Respiratory Disease d. Pneumonia j. Asthma e. CVD k. Physical disabilities f. Senility

Women- Nearly 60% of the Phil. population Domestic violence & VAW Uncontrolled Pregnancies & Abortion Contraceptives Use & FP Anemia Etc…. 4. Community @ A group of people sharing a common geographic boundaries and/ or common values and interest. It functions within a particular sociocultural context with varying physical environment, coping and behaving. (Maglaya 2003, Nsg. Practice in Community) @ A social group of people interacting with each other, determined by geographic boundaries, living together to attain certain and common goals and sharing the same interests (Untalan 2005, COPAR)

@ Refers to groups composed of individuals, families, organizations, or business that share a common language, common values, a common history, or common purpose. ( Aleria Narda 2003, Community Health and Wellness Needs Asst.) @ Communities= Fellowship B. Characteristics (Maglaya ) 1.Defined by its geographic boundaries with certain identifiable characteristics. Ex. 2.Urban Poor Communities, Indigenous People, Peasant, etc… 3.Made up of institutions organized into social systems linked in a complex network having formal, informal power structure and communication system.

4.Common or shared interest that binds together 5.Has area with fluid boundaries which a problem can be identified and solved. 6.Has a population aggregate concept. “ Aggregate”- people may or may not belong to a certain community but together to achieve one goal. -who share some common aspect, such as age, economic status, cultural background, gender, races, area of residence, chronic illness, etc. (Swanson & Albert)

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