COMMUNITY HEALTH NURSING II

What will be the mainstream knowledge that forms the basis of practice in community health nursing?

COMMUNITY HEALTH NURSING

- As promotion of health, prevention of illness, care of the sick at home and rehabilitation (Ruth B.
Freeman)
- “the synthesis of nursing practice and public health practice applied to promoting and
preserving the health of the specialty area that encompasses subspecialties that include public
health nursing, school nursing, occupational health nursing, and other developing fields of
practice, such as home health, hospice care, and independent nurse (ANA, 1980)

WHAT IS COMMUNITY HEALTH NURSING?

WORLD HEALTH ORGANIZATION (WHO)

 Special field of nursing that combines skills of nursing public health...

 Function as part of total public health programs for:
o Promotion of health
o Improvement of condition
o Rehabilitation of illness and disability

DR. RUTH B. FREEMAN

 CHN is a unique blend of nursing and public health practice aimed at developing and enhancing
health capabilities of people. It is involved in entire spectrum of health services for the
community.

PUBLIC HEALTH is the science and art of (1) preventing disease (2) prolonging life, and (3) promoting
health and efficiency through organized community effort. (C.E. WINSLOW)

The Philosophy of Community Health Nursing is based on the Worth and Dignity of man (DR. MARGARET
SHETLAND)

PRINCIPLES OF CHN

1. Focus on the community as a unit of care. The nurse’s responsibility is to the community as a
whole.
2. Give priority to community needs. The community health nurse has to “marry” skills in the
nursing process with population-focused skills.
o Determine health needs
3. Work with the community as an equal partner of the health team.
o Team approach is most evident in community health work, and, frequently, the nurse
serve as the liaison officer of the health team.
 4. Emphasis is given on strategies to promote optimal health and prevent disease and disability.
Treatment is necessary component of programs that control prevalent communicable diseases,
but treatment is by itself a measure to control the spread of the disease to others.
5. Promote a healthful physical and psychosocial environment.
o The health team designs strategies to concentrate on the environmental determinants
of health (WHO, 2011).
6. Reach out to all who may benefit from the specific service. The community health nurse realizes
that members of the community who need a particular service are the least likely to actively
seek for appropriate help.
7. Promote optimum use of resources. Limited health resources is best used for strategies that will
produce long-term effects, taking ethical principles into consideration.
8. Collaborate with others working in the community.
o Health is a product of multiple determinants.
o For this reason, the nurse has to work with variety of sectors, including the community
itself, in resolving issues that affect health.
o NOTE: Community health efforts have to be coordinated

FEATURES OF COMMUNITY HEALTH NURSING PRACTICE

POPULATION-FOCUSED NURSING

 Concentrates on specific groups of people and focuses on health promotion and disease
prevention, regardless of geographical location.
 Moreover, population-focused practice:
o Focuses on entire population
o Based on assessment of the populations’ health status
 Considers the broad determinants of health,
 Emphasizes all levels of prevention,
 Intervenes with communities, systems, individuals, and families

GOAL...

 The goal of population-focused nursing is to promote healthy communities.

 A population focus involves concern for those who do, and for those who do not, receive health
services
o Involves scientific approach

CONCEPT OF COMMUNITY

TYPES OF COMMUNITY

GEOPOLITICAL

 Defined or formed by both natural and man-made boundaries and include barangays,
municipalities, cities, provinces, regions, and nations.
  Geopolitical communities may ----- called territorial

PHENOMENOLOGICAL

 Relational interactive groups, in which the place or setting is more abstract, and people share a
group perspective or identity based on cultures, values, history, interests, and goals.
 A community of solution

CHARACTERISTICS OF HEALTH COMMUNITY

 A shared sense of being a community based on history and values.

 A general feeling of empowerment and control over matters that affect the community as a
whole.
 Existing structures that allow subgroups within the community to participate in decision making
in community matters.
 The ability to cope with change, solve problems, and manage conflicts within the community
through acceptable means.
 Open channel of communication and cooperation among the members of the community.
 Equitable and efficient use of community resources, with the view towards sustaining natural
resources.

COMPONENTS OF COMMUNITY

 THE CORE - Represents the people that make up the community

DETERMINANTS OF HEALTH AND DISEASE

Factors affecting community

 Health care access

 Economic conditions
 Social and environmental issues
 Cultural practices

Note: Health nurse needs to understand the determinants of health and recognize the interaction of the
factors that lead to disease, death and disability.
EIGHT SUBSYSTEMS OF THE COMMUNITY

Housing

 What type of housing facilities are there in the community?

 Are there enough housing facilities?
 Housing laws and regulations

Education

 Include laws, regulations, facilities, activities affecting education, ratio of health educators to
learners

Fire and Safety

 Fire protection facilities and fire prevention activities, distribution of these facilities.

Politics and Government

 Political structure present in the community, decision-making process/pattern, leadership style

observed

Health

 Health facilities and activities, distribution, utilization, ratio of providers to clientele served;
priorities in health programs developed

Communication

 Systems, types of communication existing, forms of communication, be it formal or informal

Economics

 Occupation, types of economic activities, income

Recreation
  Recreational activities/facilities; types, consumers, appropriateness to consumers.

DETERMINANTS OF HEALTH

 Income and social status – higher income and social status are linked to better health. The
greater the gap between the richest and poorest people, the greater the differences in health
 Education – low education levels are linked with poor health, more stress and lower self
confidence
 Physical environment – safe water and clean air, healthy workplaces, safe houses, communities
and roads all contribute to good health
 Employment and working conditions – people in employment are healthier, particularly those
who have control over -----
 Social support networks – greater support from families, friends and communities is linked to
better health
 Culture – customs and traditions and the beliefs of the family and community all affect health
 Genetics – inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing illnesses
 Personal behavior and coping skills – balanced eating, keeping active, smoking, drinking, and
how we deal with life’s stresses and challenges all affect health
 Health services – access and use of services that prevent and treat disease influences health
 Gender – men and women suffer from different -----

FACTORS AFFECTING HEALTH OF THE COMMUNITY

PEOPLE

Population variables that affect the health of the community include:

 Size
 Density
 Composition
 Rate of growth or decline
 Cultural characteristics
  Mobility
 Social class
 Educational level

LOCATION

 The health of the community is affected by both natural and man-made variables related to
location
 Natural factors consist of geographic features, climate, flora, and fauna

SOCIAL SYSTEM

 Is the patterned series of interrelationships existing between individuals, groups, and

institutions and forming a coherent whole.
 Social system components that affect health include:
o Family
o Economic
o Educational
o Communication
o Political
o Legal
o Religious
o Recreational
o Health systems

ROLES AND ACTIVITIES OF COMMUNITY HEALTH NURSE

Clinician/Direct care provider

 Ensure that health services are provided, not just to individuals and families but also to groups
and population
 Involves certain emphasis different from basic nursing, i.e.-holism, health promotion, and skills
expansion
 Expanded skills
o Physical care skills, skills in observation, listening, communication and ----

Educator

 Health teaching is a part of good nursing practice and one of the major functions of a
community health nurse
 The educator role is especially useful in promoting the public’s health for at least two reasons.
 The educator role:
o Has the potential for finding greater receptivity and providing higher yield results
o Is significant because wider audience can be reached

Advocate
  The issue of client’s rights is important in health care today. Every patient or client has the right
to receive just equal and humane treatment.
 Community health nurse often must act as advocate for clients pleading the cause or acting on
behalf of the client group.

Managerial role

 As a manager the nurse exercises administrative direction towards the accomplishment of

specified goals

Activities includes:

 Oversee client care

 Supervise ancillary staff
 Do case management
 Manage caseloads run clinics or conduct community health needs assessment projects

Case management

 Systematic process by which the nurse:

o Assesses clients’ needs
o Plans for and co-ordinates services
o Monitors and evaluates progress to ensure that clients multiple service needs are met

Collaborator

 Work with many people including clients, other nurses, physicians, social workers and
community leaders, therapist, nutritionist, occupational therapists, epidemiologists, legislators,
etc. as a member of health team.

Leader

As a leader:

 Nurse directs
 Influences or persuades others to effect change that will positively affect people’s health
 Primary function is to effect change; thus, the community health nurse becomes agent of
change

Research role

Community health nurses:

 Engage in systematic investigation, collection and analysis of data for the purpose of solving
problems and enhancing community health practice.
 Search and/or to investigate
 Discover
 Interpret facts
RESPONSIBILITIES OF THE COMMUNITY HEALTH NURSE

 Participates in the development of an overall health plan, its implementation, and evaluation for
communities.
 Provides quality nursing services to the four levels of clientele
 Maintains coordination/linkages with other health members, NGO/government agencies in the
provision of public health services
 Initiates in the conducts researches relevant to CHN services to improve provision of health care
 Initiates and provides opportunities for professional growth and continuing education for staff
development.
COMMUNITY DIAGNOSIS
We diagnose the community

The Community Diagnosis process

 “a means of examining aggregate and social statistics in addition to the knowledge of the local
situations, in order to determine the health needs of the community”
 Is called as community assessment or situational analysis
 Process used to determine the health status of the community and the factors responsible for it.
 Quanti and quali
 The purpose of community diagnosis is to define existing problems, determine available
resources and set priorities for planning, implementing and evaluating health action, by and for
the community.
 Termed as community organizers ang mag diagnose sa community

Importance of Community Diagnosis

 It helps to find the common problems or diseases, which may be easily preventable in the
community
 It is a tool to disclose the hidden problems that are not visible but affect community
 To access the group of underprivileged people
 It helps to find the real problems of the community people which might not have perceived by
them as problems
 It helps to impart knowledge and attitudes to turnover people’s problems towards the light of
solution

Types of Community Diagnosis

1. Comprehensive
 Aims to obtain general information about the community or a certain population group
2. Problem-oriented
 Type of assessment that responds to a particular need

ELEMENTS OF COMPREHENSIVE COMMUNITY DIAGNOSIS

 Demographic variables
 Socio-economic and cultural variables
 Health and illness patterns
 Health resources
 Political/leadership patterns
A. Demographic Variables

A comprehensive community diagnosis should show the size, composition, and geographical distribution
of the population, as indicated by the following:

1. Total population and geographical distribution, including urban-rural index and population
2. Age and sex composition
3. Selected vital indicators such as growth rate, crude birth rate, crude death rate, and life
expectancy at birth.
4. Patterns of migration
5. Population's projections
6. Population groups with special needs, indigenous people, internal refugees, and other socially
dislocated groups.
B. Socio-Economic and Cultural Variables
1. Social Indicators
a. Communication network (whether formal or informal channels) necessary for disseminating
health information or facilitating referral of clients to the health care system
b. Transportation system, including road networks, necessary for the accessibility of health care
c. Educational level that may be indicative of poverty and may reflect on the health perception and
health utilization pattern of the community
d. Housing conditions that may suggest health hazards (congestions and exposure to harmful
elements) and safety hazards (fire)
2. Economic Indicators
a. Poverty level/income
b. Unemployment and underemployment rates
c. Proportion of the total economically active population that are salaried and wage earners
d. Types of industry present in the community
e. Occupation common in the community
f. Land ownership
g. Recreational facilities
3. Environmental Indicators
a. Physical/Geographical/Topographical characteristics of the community
o Land areas that contribute to vector problems
o Terrain characteristics that contribute to accidents or pose geohazard zones
o Land usage in industry
o Climate/season
b. Water Supply
o Percentage of population with access to safe, adequate water supply
o Source/s of water supply for drinking other activities
c. Water disposal
o Percent of population reached by the daily garbage collection systems
o Percent of population with safe excreta disposal system
o Types of waste disposal and garbage disposal system
d. Air, water, and land population
o industries within the community that are hazardous to health
o air and water pollution index
4. Cultural Factors
a. variables that may " break up" the people into groups within the community
o ethnicity, social class, language, religion, race, political orientation
b. cultural beliefs and practices that affect health
c. concepts about health and illness
 d. other factors that may directly or indirectly affect the health status of the community.
C. Health and Illness Patterns

If the nurse has access to recent and reliable secondary data, then those could be used; otherwise,
nurse will have to gather the following:

1. Leading causes of morbidity

2. Leading causes of mortality
3. Leading causes of infant mortality
4. Leading causes of maternal mortality
5. Leading causes of hospital admission
D. Health Resources

Refers to manpower, institutional and material resources provided not only by the state, but also those
that are contributed by the private sector and other non-government organizations.

1. Manpower resources
o Categories of health manpower available
o Geographical distribution of health manpower
o Manpower population ratio
o Distribution of health manpower according to health facilities (hospital, rural health units.)
o Distribution of health manpower according to type of organization (Government, non-
government, private)
o Quality of health manpower
o Existing manpower development/policies
2. Material Resources
o Health budget and expenditure
o Sources of health funding
o Categories of health institutions available in the community
o Hospital-bed population ratio
o Categories of health services available
E. Political/Leadership Patterns

Reflect the action potential of the state and its people to address the health needs and problems of the
community. It mirrors the sensitivity of the government to the people's struggle for a better life.

a. Power structures in the community (formal or informal) include leadership patterns, community
organizations, and government structures among others.
b. Attitudes of the people toward authority
c. Conditions/events/issues that cause social conflict/upheavals or that lead to social bonding or
unification.
d. Practices/ approaches that are effective in settling issues and concerns within the community.

Sources of Data for Community Diagnosis

1. Primary Data
  source would be the community people through surveys, interviews, focused group discussion,
observations, and through the actual minutes of community meetings.
2. Secondary Data
 sources would be organizational records of the program, health center records, and other public
records.

Characteristics of indicators

 Should be valid
 Should be reliable
 Should be sensitive
 Should be specific
 Should be feasible
 Should be relevant

Steps in conducting community diagnosis

1. Planning
 Determine the objectives
 Define the study population
 Prepare the community
 Choose the methodology and instrument of community diagnosis
 Setting the targets
2. Implementation
 Actual data gathering
 Collation/organization of data
 Presentation/organization of data
 Analysis of data
 Identification of community health nursing problems
 Priority – setting of community health nursing problems
A. PLANNING
1. Determine the objectives — nurse decides on the depth and scope of the data to be gathered,
regardless of the type of community diagnosis to be conducted, the nurse must determine the
occurrence and distribution of selected environmental, socio economic, and behavioral
conditions important to disease prevention and wellness promotions. (Statement of Objectives
should be SMART)
2. Define the study population — nurse identifies the population group, based on the objectives of
the study; the study population may be the entire community population or be focused on a
population group, such as women in the reproductive age group or the infants.
3. Prepare the community — courtesy call for meetings are a must to enable the nurse to
formulate the community diagnosis objectives with the key leaders of the community; the
following initial data are gathered through the key leaders:
o Spot map of the entire community
o Initial secondary data e.g., total number of households per area, total population per area, list of
traditional healers, list of CHW's
 4. Choose the methodology and instrument of Community Diagnosis — primary data may be
gathered through surveys, interviews, community meetings, and observations, while secondary
data may be gathered through the review of program and public records.
5. Setting the Targets — involves constructing a timetable of activities, taking into considerations
the sample size and the number of personnel that will work.

Three Levels of Data Gathering

1. Community People — household heads, traditional, non-traditional leaders, 30% of the total
population of households for the survey sample spread out proportionally would be ideal;
representation increases or decreases proportionally depending on the size of the area, ideally
10 % of traditional leaders.
2. Community health workers — ideally 20% of all enlisted CHW's as of the previous year
3. Program Staff

Instrument may be the following:

 Survey questionnaire
 Observation Checklist
 Interview Guide

Note: The nurse should meet the data gatherers to discuss and analyze the instrument to be used. They
may be asked to role-play an interview scene so that they can place themselves in an actual interview
situation.

B. IMPLEMENTATION
1. Actual data gathering
 the nurse supervises the data collections by checking the filled-out instruments for
completeness, accuracy, and reliability of the information collected. Data gathered should cover
the following:
 Community Dimensions secondarily related to health
a. Demographic data
b. Economic characteristics
c. Social indications
d. Political characteristics
e. Cultural characteristics
f. Environmental indicators
 Community Dimensions directly related to health
a. General health indicators — Birth, death, morbidity, mortality rates
b. Maternal and child health care — family planning, midwifery services, child care
c. Immunization status of children
d. Food and Nutrition — daily food budget, daily food intake, knowledge of basic food groups
e. Illness and Injury — type of sickness, medical personnel attending to the sick, where the sick go
for consultations and treatment, types and sources of medicine, dental care, mental health,
accidents, causes of death.
f. Water and environment — water supply, and storage, food storage, sanitation (Excreta,
garbage, waste water disposal, pets, and vermin control.)
 g. Endemic diseases
h. Essential drugs
i. Health education
j. Health resources — government/private, health manpower, health centers, health services.
k. Perception of health problems — concepts of health, perceived health problem, solutions to
health problem.
2. Collation/Organization of Data
 there are 2 types of data that may be generated
o Numerical data — data that can be counted
o Descriptive data- description of observable characteristics of different factors.
3. Presentations/Organization of data
- data collected may be presented as:
- Statistical tables
- Graphs
- Descriptive data — Examples: geographic data, history of a village, health beliefs
4. Analysis of data
- aims to establish trends and patterns in terms of health needs and problems of the community.
It allows comparison of obtained data with standard values
5. Identification of community health nursing problems
 make a list of the health problems and categorized them as:
 Health Status Problem — may be describe in terms of increased or decreased morbidity,
mortality, or fertility. E.g., 40% of the school aged children have ascariasis
 Health Resources Problem — they may be described in terms of lack of or absence of
manpower, money, materials, or institutions necessary to solve the health problems. E.g., 25%
of the BHW's lack skills in vital sign taking
 Health Related Problems — they may be described in terms of existence of social, economic,
environmental, and political factors that aggravate the illness inducing situations in the
community. E.g., 30% of the households dump the garbage in the river
6. Priority-Setting of Community Health Nursing Problems
- Nature of the Problem
- Magnitude of the Problem
- Modifiability of the problem
- Preventive Potential
- Social Concern

Schemes in stating community diagnosis (NANDA)

Shuster and Goeppinger (2004)

Three-part statement

 The health risk or specific problem to which the community is exposed

 The specific aggregate or community with whom the nurse will be working to deal with the risk
or problem
  Related factors that influence how the community will respond to the health risk or problem;
defining characx of the problem

Health risk: risk of maternal complications

Specific aggregate: Tomas Monteverde Agdao

Related factors: inaccessibility of skilled birth attendance

OMAHA SYSTEM

 Applications for Community Health Nursing

 This is the oldest of the nursing classifications and was developed in the 1970’s by Karen Martin
 It was designed for nurses in community and public health services
 Is a research-based, comprehensive practice and documentation standardized taxonomy
designed to describe client care

Components:

 Problem classification scheme (client assessment)

 Intervention scheme (care plan and services)
 Problem rating scale for outcomes (client change/evaluation)

Problem classification scheme (client assessment)

- Provides a structure, terms, and system of cues and clues for a standardized assessment of
individuals, families, and communities.
- It includes 40 problems or diagnoses
- Modifiers for the diagnoses identify the problem as either individual or family problem and as
either a health promotion, potential, or actual problem
- There are also s/s specific to each problem
Identified problem are classified in 4 levels

1. The first and most general level of classification is composed of 4 domains (environmental,
psychosocial, physiological, health related behaviors)
2. The second level consists of problems or areas of concern under the four domains
 Domains and problems of the problem classification scheme
 Environmental domain: (Income, Sanitation, Residence, Neighborhood/Workplace safety)
 Psychosocial domain: (Communication with community resources, Social contact, Role change,
Interpersonal relationship, Spirituality, Grief, Mental health, Sexuality, Caretaking/parenting,
Neglect, Abuse, Growth and development)
 Physiological domain: (Hearing, Vision, Speech and language, Oral health, Cognition, Pain,
Consciousness, Skin, Neuro-musculo-skeletal function, Respiration, Circulation, Digestion-
hydration, Bowel function, Urinary function, Reproductive function, Pregnancy, Postpartum,
Communicable/infectious condition)
 Health-related behaviors domain: (Nutrition, Sleep and rest patterns, Physical activity, Personal
care, Substance use, Family planning, Health care supervision, Medication regimen)

3. The third level, the problem or area of concern is classified according to two sets of qualifiers
 (The area of concern is categorized into health promotion, potential problem, or actual
problem)
 (The level of clientele – individual, family community)
4. The fourth and most specific level is made up of clusters of s/s that describe actual problems
Intervention scheme

- Describe and communicate multidisciplinary practice, practice to prevent illness,

improve/restore health, decrease deterioration, and/or provide comfort before death.

FOUR INTERVENTION CATEGORIES:

Teaching, guidance, and counseling

 Activities designed to provide information and materials, encourage action and responsibility for
self-care and coping, and assist the individual/family/community to make decisions and solve
problems

Treatments and procedures

 Technical activities such as wound care, specimen collection, resistive exercises, and medication
prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms of the
individual/family/community

Case management

 Activities such as coordination, advocacy, and referral that facilitate service delivery, improve
communication among health and human service providers, promote assertiveness, and guide
the individual/family/community toward use of appropriate resources
Surveillance

 Activities such as detection, measurement, critical analysis, and monitoring intended to identify
the individual/family/community’s status in relation to a given condition or phenomenon
 Monitoring

Problem rating scale for outcomes

 Knowledge
 Behavior
 Status
PLANNING COMMUNITY HEALTH INTERVENTIONS

Priority Setting

 This step provides the nurse and the health team with a logical means of establishing priority
among the identified health concerns

CRITERIA IN DECIDING COMMUNITY HEALTH CONCERN FOR INTERVENTIONS

 Significance of the problem

 Community Awareness
 Ability to reduce risk
 Cost of reducing risk
 Ability to identify the target population
 Availability of resources
1. SIGNIFICANCE OF THE PROBLEM
 Is based on the number of people in the community affected by the problem or condition.
 Disease condition/Potential problem
2. COMMUNITY AWARENESS
 Related to the priority that the community gives to the health concern
3. ABILITY TO REDUCE RISK
 Is related to the availability of expertise among the health team and the community itself.
4. COST OF REDUCING RISK
 The nurse has to consider economic, social, and ethical requisites and consequences of planned
action
5. ABILITY TO IDENTIFY THE TARGET POPULATION
 Matter of availability of data sources such as FHSIS, census, survey reports, and/or case finding
or screening tools
 FHSIS – field health services information system – agency na may data ng community
6. AVAILABILITY OF RESOURCES
 To intervene in the reduction of risk entails technological, financial, and other material
resources of the community, nurse and the health agency.

CRITERION

1. From a scale of 1 to 10, 1 being the lowest, the members give each criterion a weight based on
their perception of its degree of importance in solving the problem. “How important is
significance of the problem to it’s solution”
2. From a scale of 1 to 10, 1 being the lowest, each member rates the criteria in terms of the
likelihood of the group being able to influence or change the situation. “Can the group influence
the significance of this problem”
3. Collate the weights (from step 1) and ratings (from step 2) made by the members of the group
4. Compute the total priority score of the problem by multiplying collated weight and rating of
each criterion.
5. The priority score of the problem is calculated by adding the products obtained in step 4.

“How important is the criterion in solving the problem?” - 1st table

“Can the group influence the situation in relation to the criteria” - 2nd table

3rd table

COMMUNITY DIAGNOSIS: STEPS IN IMPLEMENTATION PHASE

Priority-setting
  Nature of the condition/problem presented
o Classified as health status, health resources or health related problems
 Magnitude of the problem
o Severity of the problem which can be measured in terms of the proportion of the
population affected by the problem
 Modifiability of the problem
o Probability of reducing, controlling or eradicating the problem
 Preventive potential
o Probability of controlling or reducing the effects posed by the problem
 Social concern
o Perception of the population or the community as they are affected by the problem and
their readiness to act on the problem, may survey tool to evaluate

COMMUNITY HEALTH NURSING PROBLEMS

 Health status problems – may be described in terms of increased or decreased morbidity,

mortality or fertility. Illnesses, death, actual problem
 Health resource problems – they may be described in terms of lack of or absence of manpower,
money, materials, or institutions necessary to solve the problem. Ex. skills
 Health-related problems – may be described in terms of existence of social, economic,
environmental, and political factors that aggravate the illness-producing situations in the
community. Ex. Improper garbage disposal

STEPS IN PRIORITIZING PROBLEM

 Score each problem according to each criteria

  Divide the score by the highest possible score
 Multiply the answer by the weight of the criteria
 Add the final score for each criterion to get the total score for the problem. The highest possible
score is 10, while the lowest possible score is 1
 The problem with the highest total score is given high priority by the nurse.

FORMULATING GOALS AND OBJECTIVES

Goals

 Broad and not constrained by time and resources, states the ultimate desired end point of all
activities, directed towards solving health status problems

Objectives

 Stated in specific, measurable terms, client-centered, and outcome-focused, concerned with

resolutions of the health problems itself. An adequate statement of objective specifies both the
criteria as well as the standards of evaluation

DECIDING ON COMMUNITY INTERVENTIONS

 The process of developing the plan, the group takes into consideration the demographic,
psychological, social, cultural, and economic characteristics of the target population on one
hand and the available health resources on the other hand.

IMPLEMENTING THE COMMUNITY HEALTH INTERVENTIONS

 Entails coordination of the plan with the community and the other members of the health team
COMMUNITY ORGANIZING
 is a process of educating and mobilizing members of the community to enable them to resolve
community problems
 Process consists of steps or activities that instill and reinforce the people’s self confidence on
their own collective strengths and capabilities (Manalili,1990)
 It entails harnessing and developing the community’s capacities to recognize a community
problem, identify and implement solutions, and monitor and evaluate the efforts in resolving
the problem.
 Is a values-based process, tracing its roots to three basic values: HUMAN RIGHTS, SOCIAL
JUSTICE, SOCIAL RESPONSIBILITY

CORE PRINCIPLES IN COMMUNITY ORGANIZING

1. Community Organizing is People-centered

 with emphasis on the development of human resources necessitating education
2. Community Organizing is Participative
 Is evident in the involvement of many people in the community activities.
3. Community Organizing is Developmental
 Should be directed towards changing current undesirable conditions
4. Community Organizing is Process-oriented
 Organizers need to diligently and patiently follow the community organizing process to
achieve its goals.
5. Community organizing is Democratic
 It is a process that allows the majority of people to recognize and critically analyze their
difficulties and articulate their aspirations

GENERAL PHASES OF COMMUNITY ORGANIZING

I. PREPARATORY PHASE

A. Area Selection

 Do the community members feel the need to work together to overcome a specific health
problem?
 Are there concerned groups and organizations that the nurse can possibly worked with?
 What will be the counterpart of the community in terms of community support, commitment,
and human resources
 D O P E Community

B. Community Profiling

 A comprehensive description of the needs of a population that is defined, or defines itself, as a

community, carried out the active involvement of the community itself.
 identifying of a contact person- usually a community leader, regardless of social or political
status
Community Profile

 An overview of the demographic characteristics and the existing community and health –related
services and facilities; this will serve as the initial data base and provide the basis for planning
and programming of organizing activities, including appropriate organizing approaches.

C. Entry in the Community and Integration with the People

Integration

 Process of living with the people, understanding their problems, undergoing their hardships, and
sharing their hopes and aspirations to help build mutual trust and cooperation

Guidelines

 Recognize the role and position of local authorities

 Adapt a lifestyle in keeping with that of the community
 Choose a modest dwelling which the people, especially the economically disadvantaged; will not
hesitate to enter.
 Avoid raising the expectations of the people; be clear with your objectives and limitations
 Participate directly in economic production
 Make house calls and seek out people where they usually gather.
 Participate in some social activities
II. ORGANIZATIONAL PHASE

A. Social Preparation - integration paves the way for the nurse to be introduced to the community; this
signal the START of the social preparation phase wherein the nurse deepens and strengthens her ties
with the people.

B. Spotting and Developing Potential Leaders

Characteristics:

 Leaders should not be able to identify with, understand, and articulate effectively the problems
that beset the community.
 They should have a wide influence among booth the rich and the poor.
 They should be willing to work for the desired change.

C. Core Group Formation

CORE GROUP – the core group consists of the identified leaders tasked to lay down the foundation for a
strong people’s organization; ideally, it should represent the different sectors in the community

D. Setting Up the Community Organization

Guidelines:

 When all the sectoral organizations are already formed, the people are now ready for a
community wide organization
  The nurse must ensure that the members have maximum participation and control of the
organizational activities.
 Organizational structure must be simple to facilitate consultation and decision making
 Working committees must be created to look into the different concerns of the organization and
the community.
III. EDUCATION AND TRAINING PHASE

PURPOSE: To strengthen the organization and develop its capability to attend to the community’s basic
health care needs.

A. Conduct of Community Diagnosis

B. Training of Community Health Workers
C. Health Services Provision and Mobilization
D. Leadership Formation Activities
IV. INTERSECTORAL COLLABORATION PHASE

NETWORKING – a relationship among organizations that consists of exchanging information.

COORDINATION – a relationship in which organizations modify their activities in order to provide better
service to the target beneficiary.

COOPERATION – a relationship in which organizations share information and resources and make
adjustments in their respective agendas to accommodate the other organization’s agenda.

COLLABORATION – the level of organizational partnership in which organizations help each other
enhance their capacities in performing their tasks, as well as in the provision of services

COALITION or MULTI SECTOR COLLABORATION – level of relationship where organizations and citizens
form a partnership where all parties give priority to the good of the community.

ADVOCACY WORK – involves:

 Informing the people about the rightness of the cause

 Thoroughly discussing with the people the nature of the alternatives, their content, and possible
consequences
 Supporting the peoples right to make a choice and to act on their choice
 Influencing public opinion
V. PHASE OUT

 Turns over the work and develops a plan for monitoring and subsequent follow-up of the
organizations activities
COMMUNITY ORGANIZING PARTICIPATORY ACTION RESEARCH

COPAR

 Is a community development approach that allows the community (PARTICIPATORY) to

systematically analyze the situation (RESEARCH), plan a solution, and implement
projects/programs (ACTION) utilizing the process of community organizing.
 A research project done by the community that leads to actions that improve conditions in the
community.
 a social development approach that aims to:
o Transform -> participatory and politically responsive community

Importance of COPAR

 tool for community development and people empowerment

 prepares people/client to eventually take over the management of a development program(s) in
the future
 It maximizes community participation and involvement
 Community resources are mobilized for community services
 Offers alternative solutions to health problems that may not require modern medical
intervention

Principles of COPAR
 1. People, especially the oppressed, exploited and deprived sectors are open to change, have the
capacity to change and are able to bring about CHANGE.
2. Should be based on the interests of the poorest sectors of the society
3. Should lead to a self-reliant community and society

PROCESS/METHODS USE IN COPAR

A Progressive Cycle of ACTION –REFLECTION –ACTION

 which begins in small, local and concrete issues identified by the people and the evaluation and
reflection of and on the action taken by them

CONSCIOUSNESS-RAISING

 Through experiential learning is central to the COPAR process because it places emphasis on
learning that emerges from concrete action and which enriches succeeding action.

COPAR is Participatory and Mass-Based

 Because it is primarily directed towards and biased in favor of the poor, the powerless and the
oppressed

COPAR is Group Centered

 And not leader centered. Leaders are identified, emerged and are tested through action rather
than appointed or selected by some external force or entity.

Critical Steps/Critical Activities in COPAR

Critical Steps

 Integration
 Social Investigation
 Tentative program planning
 Groundwork
 Meeting
 Role Play
 Mobilization or action
 Evaluation
 Reflection
 Organization

PHASES OF COPAR

I. PRE-ENTRY PHASE
 The initial phase of the organizing process where the community organizer looks for
communities to serve/help.

RECOMMENDED ACTIVITIES

 Statement of objectives, realization of CIP

  Laying out the site criteria
 Site selection
 Develop survey tools
 Meeting and courtesy call to the local government unit of the selected site
 Courtesy call to the barangay level
 Meeting with the “will be” foster parents of the health care students
 Setting the target date of immersion, Exposure and Departure

Criteria for Site Selection

 The area must be Economical.

 Must have a relative Concentration of poor families
 Must have a population of Ten thousand and above
 As much as possible no Hospital but with RHU and BHS
 Accessibility of transportation must be considered
 No Strong resistance from the community
 Peace and order problem must be considered
 Rural community will be a top priority
 Preferably With adjacent barangays
 (S-H-A-R-P-C-E-W-T)

OCULAR SURVEY

1. Community meet the ‘GIDA” criterion of DOH (hard to reach, unserved or underserved, and
economically depressed. GIDA - geographically isolated and disadvantaged areas
2. Members of the community perceive the need for assistance
3. Community show signs of willingness or hostility towards the organizer
4. No obvious threat to the safety of community organizer
5. Identify other individuals or group or agencies working in the area
6. Is the partnership among all potential stakeholders possible and feasible?
II. ENTRY PHASE

IMMERSION (other term of entry phase)

 Sensitization of the people on the critical events in their life, motivating them to share their
concerns and eventually mobilizing them to make collective action on these.
 This phase signals the actual entry of the CO/Community Worker into the community
 Sometimes called as SOCIAL PREPARATION PHASE

Recommended Activities

 Inform/ Update local government leader/ barangay officials of the selected site
 meeting with the foster parents
 appreciating the environment
 meeting with community officials and residents
 general assembly
  Actual survey
 Analysis of data
 Core group formation ex. group of senior citizens, grp of teens, grp of kababaihan
 Self-awareness and leadership training/ Action planning

Community Integration

 “PAKIKIPAMUHAY” is the phase when the CO may usually live in the community in an effort to
understand the community better and imbibe community life.
 Establishing Rapport

INTEGRATION STYLES

 “Now you see, now you don’t”

 “Boarder” Style
 “Elitist” Style

PEOPLE–CENTERED APPROACH

Techniques

 Pagbabahay-bahay / Occasional home visits

 “Huntahan” / Informal conversations
 Participation in production process
 Participation in social activities

SOCIAL ANALYSIS

 The process of gathering, collating, and analyzing data to gain extensive understanding of
community conditions, help in the identification of problems of the community, and determine
the root causes of this problems
 Social investigation, community study, community analysis, or community needs assessment.
 This steps requires a comprehensive analysis of the following factors: Demographic data, socio
cultural, economic, environmental, health patterns data, and health resources.

Data for the social investigation should contain the following:

1. Physical/Geographic data
2. Demographic Data
3. Economic Conditions
4. Mortality and Morbidity Data
5. Food supply and Nutrition
6. Cultural patterns, common cultural beliefs, and health practices
7. Health services and facilities
8. Education
9. Community leadership and organizations
10. Development agencies
11. Community problems and needs as articulated by the people.
IDENTIFYING POTENTIAL LEADERS

Desirable Characteristics

1. They represent the target group community

2. They possess or display leadership qualities
3. They have the trust and confidence of the community
4. They express belief in the need to change the current undesirable situation in the community

CORE GROUP FORMATION

 Functioning core group is the focal point of community organizing

 This requires a series of training sessions to “transfer the technology” of community organizing,
enabling the core, group to take charge of the subsequent organizing process.

 General assembly
 Actual survey
 Analysis of data
 Core group formation
 Self-awareness and leadership training/Action planning
III. ORGANIZATION-BUILDING PHASE/Community Organization

 This phase entails the formation of more formal structures and the inclusion of more formal
procedures of planning, implementing, and evaluating community wide activities.
 This phase also involves the conduct of trainings to develop the KSA of leaders in managing the
health program.

COMMUNITY ORGANIZATION

Characteristics

 An organization name and structure

 A set of officers recognized by the members of the community
 Constitution and bylaws stating the vision, mission, and goals (VMG), rules and regulations of
the organization, and duties and responsibilities of its officers and members

ACTIVITIES DURING ORGANIZATION BUILDING

 1. Preparing the community for Organization building
2. Organizing the CHO
3. Training and Education for the CHO
4. Setting up the CHO

Recommended Activities

 meeting with officials

 identifying problems
 spreading awareness and soliciting solution or suggestions
 analysis of the presented solution
 planning of the activities
 Organizing the people to build their own organization (election of officers)
 Registration of the organization (legality purposes)
 Link with LGU’s or NGO’s for financial & technical assistance
 Evaluation
IV. SUSTENANCE AND STRENGTHENING PHASE

 Occurs when the community organization has already been established and the community
members are already actively participating in community-wide undertakings.

RECOMMENDED ACTIVITIES

 Meeting with the organizational leaders

 Evaluation of the programs
 Re-implementation of the programs
 Education and training
 Networking & linking
 Conducting mobilization on health and development concerns
 Implementation of livelihood projects
 Developing secondary leaders
V. MOBILIZATION PHASE

 Refers to implementation of the community’s planned projects and programs.

Important Considerations

1. Allow the community to determine the pace and scope of project implementation.
2. The process is as important as the output
3. Regular monitoring and continuing community formation program are essential.

Strategies

 Education and Training

 Networking and Linkages
 Community mobilization on health and development concerns
 Development of secondline leaders
EVALUATION

 Is a systematic, critical analysis of the current state of the organization and /or projects
compared to desired or planned goals or objectives.
 It should be done periodically during mobilization to allow revision of the strategies.
 2 areas of evaluation Program based Evaluation, Organizational Evaluation

Areas of Evaluation

Program Based

 Were the goals and objectives of the program achieved?

 What strategies were implemented? What worked? What did not?
 What is the overall impact of the project on the community?
 How were the resources of the organization and community utilized?

Organizational

 Were the vision, mission, and goals of the organization achieved?

 How are the organizational policies being implemented?
 What is the level of participation in the affairs of the community organization?
 How were the resources of the organization utilized and managed?
 What type of interpersonal relationship is shared among the members of the organization,
among the leaders and the members of the community?

Recommended Activities

 meeting with the organizational leaders

 evaluation of the programs
 re-implementation of the programs
 education and training
 networking & linking
 conducting mobilization on health and development concerns
 implementation of livelihood projects
 developing secondary leaders
VI. Phase Out/EXIT and EXPANSION PHASE
 the phase when the health care workers leave the community to be independent

Recommended Activities:

 leaving the immersion site

 Documentation

Exit/Expansion Phase

 “the best entry plan is EXIT Plan”

 The time of EXIT should be mutually determined by the organizer and the community during a
meeting for monitoring and evaluation
Indications of Readiness

 Attainment of the set goals of the community organizing efforts,

 Demonstration of the capacity of the people’s organization to lead the community in dealing
with common problems, and
 People empowerment as manifested by collective involvement in decision making and
community action on matters that impact their lives

PAR vs TRADITIONAL RESEARCH

PAR TRADITIONAL RESEARCH

 People as researchers and as active  People as objects of research
collaborators of change and development  Researcher is an outsider
 Veers away from dependence on outside  Researcher has preconceived theoretical
researchers frameworks and biases
 PAR tries to come up with the real desire,
aspiration, and problems of the
community

IDEAL COPAR
PARTNERSHIP & COLLABORATION

AIM: to get the people to work together in order to address problems or concerns that affect them

WAYS UTILIZED IN P&C:

A. Networking

 Described as the relationship among organizations that consists of exchanging information

about each other’s goals & objectives, services or facilities.

Benefits:

 The org will become aware of each other’s worth & capabilities & how each can contribute to
the accomplishment of the network’s goals & objectives
 Requires small amount of time yet has great potential in terms of joint action

B. Coordination

 Described as a relationship where the org modify their activities in order to provide better
service to the target beneficiary

C. Cooperation

 Described as a relationship where organizations share information & resources and make
adjustments in one’s own agenda to accommodate the other org’s agenda

D. Collaboration
  Is the level of org relationship where organizations help each other enchance their capabilities in
performing their tasks as well as in the provision of services

E. Coalition or Multi-sector Collaboration

 Is the level of relationship where organizations and citizens form a partnership

 MIDTERM – CHN II
COMMUNITY HEALTH ASSESSMENT TOOLS

COMPREHENSIVE NEEDS ASSESSMENT PROBLEM-ORIENTED ASSESSMENT

 Information about the entire community  Focused on particular aspect of health.
using a systematic process where data is Collect information with a certain
collected regarding all aspects of the community problem in mind, and then
community to identify actual and proceeds to gather information from the
potential problems aggregate vulnerable to the problem.

Tools for Community Assessment

DATA sources are grouped into: PRIMARY and SECONDARY data

PRIMARY DATA

Are data that have not been gathered before and are collected by the nurse through:

 Observation
 Survey
 Interview
 Community forum
 Focus group discussion

SECONDARY DATA

Data are taken from existing data sources

 Vital registries
 Health records and reports
 Disease registries
 Publications

"Data are just summaries of thousands of stories-tell a few of those stories to help make the data
meaningful." - Chip and Dan Health

PRIMARY DATA

Observation

- done through ocular or windshield survey

- gives the nurse the chance to observe people as well as take note of environmental conditions
and existing community facilities.

WALKING through a community allows the nurse to talk with people to find out their perceptions of
health and health services.

Environmental Conditions Community resources

 Terrain  Health facilities
  General conditions of homes and housing  Barangay halls
density  Schools
 Cleanliness  Places of worship, open spaces (plaza,
 Presence and type of vegetation basketball court, etc.)
 Presence of street animals like cat

Survey

- Is made up of a series of questions for systematic collection of information from a sample

individuals or families in a community, and may be written or oral.
- For comprehensive needs assessment, data are collected about a random sample of the
population

Purposive sampling

- Indicated in a problem-oriented assessment where the sample population consists of the

population susceptible to the problem being studied.

Uses

 Determining community attitudes, knowledge, health behaviors, and perceptions of health and
health services.
 Used by the nurse in identifying patterns of utilization of health services.
 An opportunity for making the members of the community more aware of community problems
and their effects and more conscious of their capacity to influence decision making about health
policies and plans.

Informant Interview

- Purposeful talks with either key informants or ordinary members of the community.
- Key informants consist of formal and informal community leaders or persons of position and
influence.

Community Forum

Focus Group
SECONDARY DATA

Registry of Vital Events

Act 3753 (Civil registration law, Philippine legislature), enacted in 1930, establish the civil registry system
in the Philippines and requires the registration of vital events, such as:

 Births
 Marriages
 Deaths

The NSO serves as the central repository of civil registries and the NSO Administrator and the Civil
Registrar General of the Philippines.

The birth and death registries are of particular importance to the nurse, since they are the sources of
fertility and mortality data.

In facility-based births, the facility administrator shall be responsible for the registration of the event.

The physician, nurse, midwife, or anybody who attended the delivery has the responsibility for
registering births that occur outside a facility. Either parent may also register the birth.

Presidential Decree 856 (Sanitation Code- Office of the President, Republic of the Philippines, 1975)
requires a death certificate before burial of the deceased.

The Physician who last attended the deceased shall be responsible for preparing the death certificate,
certifying the cause of death, and forwarding the death certificate to the health officer within 48 hours.

If death occurred without medical attention, the nearest relative or any person who has knowledge of
the death shall report to the health officer within 48 hours.

Registration of death shall be made within 30 days from the occurrence of death at the Local Civil
Registry Office of the city or municipality where the birth occurred. Fetal deaths are registered following
the same process (NSO, 2010).

Health Records and Reports

As specified by the Executive Order No. 352, the Field Health Service Information System (FHSIS) is the
official recording and reporting system of the DOH and is used by the NSCB to generate health statistics.
FHSIS

 Essential tool in monitoring the health status of a population at different levels.

 Basis for
o priority setting by local governments
o planning and decision making at different levels
o monitoring and evaluating health program implementation
 Provides a standardized, facility-level database for more in-depth studies (DOH-IMS, 2011).
 FHSIS is composed of recording and reporting tools.

Recording Tools

1. Individual Treatment Record (ITR)

 is the building block of the FHSIS

 Records contain the dates, names, address of the patient, presenting symptoms or complain of
the patient on consultation and the diagnosis (if available), treatment and date of treatment.
 Maintained at the facility on all patients seen

2. Target Client Lists (TCLs)

 is the second building block of the FHSIS

Purposes:

a. To plan and carry out patient care and service delivery.

b. To facilitate monitoring and supervision of the service delivery activities.
c. To report services delivered, thus reducing the need to refer back to the IT Rs to accomplish
reporting.
d. To provide a clinic-level database that can be access for further study.

The following are the TCLs maintained in RHUs and health center:

 TCL for Prenatal Care

 TCL for Postpartum Care
 TCL of under 1 year old children (immunization & nutritional status)
 TCL for family planning
 TCL for Sick children (IMCI cases)
 NTP TB register
 National Leprosy control program central registration form

Disease Registries and Census Data

Disease Registries

 Is a listing of person diagnosed with a specific type of disease in a defined population.

 Data collected through disease registries serve as basis for monitoring, decision making, and
program management (DOH, 2011).

Census Data
  Periodic governmental enumeration of the population.
 Batas Pambansa Blg. 72 provides for a national census of population and other related data in
the Philippines every 10 years. (Batasang Pambansa, 1980)
 During a census, people maybe assigned to a locality by de jure or de facto method
 De jure assignment – based on the legally establish place of residents of people. Kahit wala ka,
icount gihapon
 De facto – is according to the actual physical location of people. Di ka macount if wala ka doon
 (NSCB, 2012)

“The census population consist of Filipino nationals, to include those residing in and out of the
Philippines, and nationals of other countries having their usual residents in the Philippines” – NSO, 2008
METHODS TO PRESENT COMMUNITY DATA
PURPOSES:

 Inform existing health and health related conditions

 Appreciate the significance and relevance of health information to their lives
 Solicit broader support and participation
 Validate findings
 Allow wider perspective in the analysis of data
 Provide basis for better decision making

PICTURIAL FORM

1. MAPS

 Can be used to show differences or similarities across geographic area

2. GRAPHS

 A diagram showing the relation between variable quantities, typically of two variables, each
measured along one of a pair of axes at right angles.

GRAPHS FOR PRESENTING COMMUNITY DATA

A. BAR GRAPH

 To compare values across different categories of data

B. LINE GRAPH

 To have a visual image of trends in data over time or age

C. PIE CHART

 To show percentage distribution or composition of a variable, such as population or household

D. SCATTER PLOT/DIAGRAM

 To show colleration between two variables

 The values of both variables in subjects are plotted in a graph with an x-axis & y-axis
COMMUNITY MENTAL HEALTH NURSING
DIFFERENT FIELDS OF NURSING

1. School Nursing
2. Occupational Health Nursing
3. Community Mental Health Nursing

MENTAL HEALTH

 Mental Health is an integral part of every individual.

 A state of social well-being in which every individual realizes his or her own potential (self-
image), can cope with the normal stresses of life (resiliency), can work productively and fruitfully
(productivity and creativity), and is able to make a contribution to her or his community (sense
of purpose) WHO (1999)

Mental Health is determined by the interplay of different factors such as:

1. Socioeconomic
2. Genetics
3. Poverty
4. Low level of education
5. Poor living conditions

Note: Hopelessness increase vulnerability to mental illness IGNACIO ET. AL, 2000

Behavioral problems like substance abuse, violence, and abuse of women and children and health
problems such as HIV/AIDS are also linked with mental illnesses. Department of Health-WHO, 2012

Mental health problems have four facets as a public health burden (WHO, 2001) These are:

1. defined burden
2. undefined burden
3. hidden burden
4. future burden

FACETS:

1. Defined or direct burden - burden affecting persons with mental disorders such as cost of
treatment, quality of life, and disability
2. Undefined or indirect burden - burden relating to the impact of mental health problems to
others such as family members or the community who care for the patient.
3. Hidden burden - stigma and violations of human rights to persons affected with mental health
problems.
4. Future or health burden - burden resulting from the aging population or increasing social
problems such as the development of complications or other medical illnesses or death.

Conditions that can lead to mental illness:

 Stressful life events like death of a loved one, financial problems, marital conflict, and violence.
  Difficult family background; for example, a history of neglect and violence may result in an
unhappy childhood.
 Brain diseases like mental retardation and brain infections, aids, head injuries, epilepsy, and
stroke.
 Heredity may be a factor; however, this is also influenced by environmental factors
 Medical problems like kidney and liver failure, or medicines taken can alter processes.

DEINSTITUTIONALIZATION

 Home care management for mentally ill patient in the Philippines.

o promotive and preventive levels in this aspect of health rather than pursue the curative
and rehabilitative care.
 Acute cases- managed by the NATIONAL CENTER FOR MENTAL HEALTH OR HOSPITALS WITH
PSYCHIATRIC FACILITIES

NATIONAL MENTAL HEALTH PROGRAM

 VISION: Better quality of life through total health care for all Filipinos
 MISSION: A rational and unified response to mental health
 GOAL: Quality mental health care

Source: DOH, 2013

THEORETICAL MODELS/APPROACHES
Theoretical Models/Approaches

 Health Belief Model (HBM)

 Milio's Framework for Prevention
 Nola Pender's Health Promotion
 Lawrence Green's (PRECEDE-PROCEED Model)

HEALTH BELIEF MODEL

 Developed in the 1950 by social psychologist Hockbaum, Rosenstock et.al

 The health belief model is a social psychological health behavior change model developed to
explain and predict health-related behaviors, particularly in regard to the uptake of health
services.
 Theory of health behavior
 basis for much of the practice of health education and health promotion
 HBM may be applied by the nurse to assist clients in making necessary behavior modifications
precisely by making them conscious of the need for such modifications.

PREMISE of HBM

Individuals will take action off, to screen for, or to control an ill health condition if:

1. They regard themselves as susceptible to the condition

2. They believe it to have potentially serious consequences
3. They believe a course of action can reduce the susceptibility and seriousness
4. They believe the costs of the action are outweighed by its benefits

Key concepts and definitions of the Health Belief Model

 Perceived susceptibility
- One's belief regarding the chance of getting a given condition
- Perceived severity
- One's belief regarding the seriousness of a given condition
- Perceived benefits
- One's belief in the ability of an advised action to reduce the health risk or seriousness of a given
condition
 Perceived barriers
 One's belief regarding the tangible and psychological costs of an advised action
 Cues to action
 Strategies or conditions in one's environment that activate readiness to take action
 Self-efficacy
- One's confidence in one's ability to take action to reduce health risks
  Perceived susceptibility
 How likely it is that I will get a flu?
 Perceived Severity
- How-bad would it be if I did?
- Perceived Benefits
- What do I gain by getting the shot?
- Cues to Action
- Is it Available, What's the cost?
- Self Efficacy
- I am confident that I can be healthy.

When a person believes he or she is susceptible to a health problem with severe consequences, the
person will more likely conclude that the benefits outweighed the barriers

Limitation of HBM
  It does not account for a person's attitudes, beliefs, or other individual determinants that dictate
a person's acceptance of a health behavior.
 It does not take into account behaviors that are habitual and thus may inform the decision-
making process to accept a recommended action (e.g., smoking).
 It does not take into account behaviors that are performed for non-health related reasons such
as social acceptability
 It does not account for environmental or economic factors that may prohibit or promote the
recommended action.
 It assumes that everyone has access to equal amounts of information on the illness or disease.
 It assumes that cues to action are widely prevalent in encouraging people to act and that
"health" actions are the main goal in the decision-making process.

MILIO'S FRAMEWORK FOR PREVENTION

 Nancy Milio
 Includes concepts of community - oriented, population -focused care
 Basic treatise was that behavioral patterns of the population and individuals who make up
populations are a result of habitual selection from limited choices.
 Challenged the common notion that a main determinant for unhealthful behavioral choice is
lack of knowledge
 Milio's framework described a sometimes neglected role of a community health nursing to
examine the determinants of community's health and attempt to influence those
determinants through public policy

6 PROPOSITIONS OF MILIO'S THEORY

1. Population health deficits result from lndividuals and families living in poverty have
deprivation and or excess of critical health poorer health status compared with middle- and
resources. upper-class individuals and families.
2. Behaviors of populations results from selection Positive and negative lifestyle choices are
limited choices; these arise from actual and strongly dependent on culture, socioeconomic
perceived options available as well as beliefs and status, and educational level.
expectations resulting from socialization,
education, and experience.
3. Organizational decisions and policies dictate Health insurance coverage and availability are
many of the options available to individuals and largely determined and financed by the
populations and influence choices. government through the NHIC and private
insurance.
4. Individual choices related to health promotion Choices and behaviors of individuals are strongly
or health damaging behaviors are influenced by influenced by desires, values, and beliefs.
efforts to maximize valued resources.
5. Alteration in patterns of behavior resulting Some behaviors such as tobacco use have
from decision making of a significant number of become difficult to maintain in many settings or
people in a population can result in social change. situations in response to organizational and
public policy mandates.
6. Without concurrent availability of alternative Addressing persistent health problems is
 health promoting options for investment of hindered because most people are very aware of
personal resources, health education will be what causes the problem, but are reluctant to
largely ineffective in changing behavior patterns. make lifestyle changes to prevent or reverse the
condition. Often, "new" information or resources
can assist in attracting attention and directing
positive behavior change.

PENDER’S HEALTH PROMOTION MODEL (HPM)

 NOLA J. PENDER (1982; revised, 1996) was designed to be a "complementary counterpart to

models of health protection."
 It defines health as a positive dynamic state not merely the absence of disease. Health
promotion is directed at increasing a client's level of well being.
 The health promotion model describes the multi dimensional nature of persons as they interact
within their environment to pursue health.

The model focuses on following three areas:

1. Individual characteristics and experiences

2. Behavior-specific cognitions and affect
3. Behavioral Outcomes

Pender's Health Promotion Level

1. Individual Characteristics and Experiences

 Each person's unique characteristics and experiences affect his or her actions. Their effect
depends on the behavior in question.

2. Behavior-specific Cognitions and Affect

 These variables are considered to be very significant in behavior motivation. They are a "core"
for intervention because they may be modified through nursing actions. Assessment of
interventions measuring the change in these variables.

3. Prior related Behavior

 Prior behaviors influence subsequent behavior through: perceived self-efficacy, benefits,

barriers, and affects related to that activity. Habit is also a strong indicator of future behavior.

4. Personal Factors

 Biological factors such as age, body mass index, strength and agility; psychological factors
include self-esteem, self motivation, and perceived self status; socio-cultural factors include
race, ethnicity, acculturation, education, and socioeconomic status.

5. Perceived Benefit of Action

 The perceived benefits of a behavior are strong motivators of that behavior. These motivate
behavior through intrinsic and extrinsic benefits. Intrinsic benefits include increased energy and
 decrease appetite. Extrinsic benefits include social reward such as compliments and monetary
rewards.

6. Perceived Barriers to Action

 Barriers are perceived unavailability, inconvenience, expense, difficulty, or time regarding health
behaviors

7. Perceived Self-efficacy

 Self-efficacy is one's belief that he or she is capable of carrying out health behavior. If one has
high self-efficacy regarding a behavior, one is more likely to engage in that behavior than if one
has low self-efficacy

8. Activity-related Affect

 The feelings associated with a behavior will likely affect whether an individual will repeat or
maintain the behavior.

9. Interpersonal Influences

 In the HPM, these are feelings or thoughts regarding the beliefs or attitudes of others. Primary
influences are family, peers, and health care providers.

10. Situational Influences

 These are perceived options available, demand characteristics, and aesthetic features of the
environment where the behavior will take place.

11. Commitment to a plan of action

 These are alternate behaviors that one considers as possible optional behaviors immediately
prior to engaging in the intended, planned behavior. One has little control over competing
demands, but one has great control over competing preferences

12. Health promoting behavior

 This is the goal or outcome of the HPM. The aim of health promoting behavior is the attainment
of positive health outcomes.
PRECEDE-PROCEED MODEL

- Provide a model for community assessment, health, education, planning, and evaluation
- In this framework, health behavior is regarded as being influenced by both individual and
environmental factors, and hence has two distinct parts
- Dr. Lawrence W. Green
- It provides a comprehensive structure for assessing health and quality of life needs, and for
designing, implementing, and evaluating health promotion and other public health programs to
meet those needs

First Educational Diagnosis

 Predisposing
 Reinforcing and
 Enabling
 Constructs in
 Educational Diagnosis and
 Evaluation

PRECEDE

 Predisposing factors - refer to people's characteristics that motivate them toward health related
behavior.
 Enabling factors - conditions in people and the environment that facilitate or impede health-
related behavior.

PRECEDE provides the structure for planning a targeted and focused public health program.
PROCEED provides the structure for implementing and evaluating the public health program.

REINFORCING

 factors refer to the feedback given by support persons or groups resulting from the performance
of the health related behavior
COMMUNITY FACTORS

 Social assessment: Determine the social problems and needs of a given population and identify
desired results.
 Epidemiological assessment: Identify the health determinants of the identified problems and
set priorities and goals.
 Ecological assessment: Analyze behavioral and environmental determinants that predispose,
reinforce, and enable the behaviors and lifestyles are identified.
 Identify administrative and policy factors that influence implementation and match appropriate
interventions that encourage desired and expected changes.
 Implementation of interventions.

PROCEED

 Policy
 Regulatory
 Organizational
 Construct in
 Educational and
 Environmental
 Development

IDENTIFICATION OF DESIRED OUTCOMES AND PROGRAM IMPLEMENTATION:

 Implementation: Design intervention, assess availability of resources, and implement program.

 Process Evaluation: Determine if program is reaching the targeted population and achieving
desired goals.
 Impact Evaluation: Evaluate the change in behavior.
 Outcome Evaluation: Identify if there is a decrease in the incidence or prevalence of the
identified negative behavior or an increase in identified positive behavior.

The PRECEDE-PROCEED planning model consists of five planning phases, one implementation phase, and
3 evaluation phases

PRECEDE phases PROCEED phases

Phase 1 – social diagnosis Phase 6 – implementation
Phase 2 – epidemiological, diagnosis Phase 7 – process evaluation
Phase 3 – behavioral and environmental Phase 8 – impact evaluation
diagnosis
Phase 4 – educational diagnosis Phase 9 – outcome evaluation
Phase 5 – administrative & policy diagnosis
HEALTH STATISTICS AND EPIDEMIOLOGY
EPIDEMIOLOGY AND THE NURSE

What is Epidemiology?

Epidemiology

 Originated from the Greek words epi, meaning “upon", demos, meaning "people” and logos,
meaning "study"
 Study of the distribution and determinants of health-related states or events in specified
populations, and the applications of this study to the prevention and control of health problems
 This field of study makes use of concepts and methods from numerous other fields such as:
biology, sociology, demography, geography, environmental science and policy analysis and most
notably from statistics.

AIMS of EPIDEMIOLOGY

 DESCRIBE the health status of the community

 EXPLAIN the etiology of the disease
 PREDICT the frequency and distribution of the disease
 CONTROL diseases in populations

Epidemiological Principles

1. Diseases don’t occur at random

2. Diseases have causal and preventive factors which can be identified
3. Diseases and health have distribution
4. Focuses on population rather than individual persons

Definition of Terms

Study Includes surveillance, observation, hypothesis testing, analytic research,

experiments
Distribution Analysis by time, places, classes of people affected
Determinants All biological, chemical, physical, social, cultural, economic, genetic and
behavioral factors that influence health
Health-related states or Diseases, causes of death, behaviors (tobacco use) positive health states,
events reactions to preventing regimens and provision and use of health services
Specified population Identifiable characteristics (eg: occupational groups)
Application to aim of public health to promote, protect, and restore good health
prevention and control

PATTERNS OF DISEASE OCCURRENCE

1. Epidemic – a situation wherein the proportion of the susceptible are high compared to the
proportion of the immunes. Usually characterized by a situation with high incidence of new
cases of a specific disease in excess of the expected
 2. Endemic – a situation wherein there is a habitual presence of a disease in a given geographic
location accounting for the low number of both immunes and susceptible. The causative factor
of the diseases is constantly available or present in the area
3. Sporadic – A situation wherein a disease occurs every now and then, affecting only a small
number of people relative to the total population
4. Pandemic – Global or worldwide occurrence of a disease
5. Outbreak – Occurrence of cases of disease in excess of what would normally be expected in a
defined community, geographical area or season

PRACTICAL APPLICATIONS OF EPIDEMIOLOGY

 Assessment of the health status of the community or community diagnosis

 Elucidation of the natural history of disease
 Determination of disease causation
 Prevention and control of disease
 Monitoring and evaluation of health interventions
 Provision of evidence for policy formulation

STAGES IN NATURAL HISTORY OF DISEASE AND LEVELS OF PREVENTION

 Stage susceptibility
 Stage of subclinical disease
 Stage of clinical disease
 Resolution stage

Stage of Susceptibility

- "Prepathogenesis stage"
- Person is not yet sick
- May be exposed to the risk factors of the disease (e.g. multiple sex partners of cervical cancer)
- Primary level of prevention is applied to avoid the development of the disease
- (e.g. Health education and Immunization)

Stage of Subclinical Disease

- Person is still healthy

- No clinical manifestations are present
- Pathologic changes occurred
- Secondary level of prevention can detect the early stage
- (e.g. PAP Smear)
- Prompt treatment can be initiated to avoid progression of the disease

Stage of Clinical Disease

- Patient manifests recognizable signs and symptoms (e.g. vaginal bleeding)

- Tertiary levels of prevention are applicable to limit disability and restore functional capability
- (e.g. Support groups for cancer survivors help maintain the emotional and mental well-being of
the cancer patient that renders functional members of society)
Resolution Stage

This will lead to either:

 Patient recovers completely from the disease

 Disease becomes a chronic case
 Patient dies from the disease

Triangle Model of Disease Causation

 Epidemiologic triad
 Uses one of two schematic presentations

The triad consists of:

 an external agent
 a susceptible host
 an environment that brings the host and agent together.

Agent, host, and environmental factors interrelate in a variety of complex ways to produce disease.

Different diseases require different balances and interactions of these three components.

Development of appropriate, practical, and effective public health measures to control or prevent
disease usually requires assessment of all three components and their interactions.
  Agent originally referred to an infectious microorganism or pathogen: a virus, bacterium,
parasite, or other microbe.
 Host refers to the human who can get the disease.
 Environment refers to extrinsic factors that affect the agent and the opportunity for exposure.

As long as balance is maintained or is titled in favor of the host (due to good nutritional status and high
levels of immunity) = Disease does not occur

However, when the balance is tilted in favor of the agent (through virulence, pathogenicity of the agent)
= Disease eventually occurs

The environment such as climate can also tilt the balance in favor of the agent. (e.g. rainy season)

Outbreak INVESTIGATION

The occurrence of cases of disease in excess of what would normally be expected in a defined
community, geographical area or season (WHO)

Criteria:

 A previously known disease

 Has never occurred in the area where the lone case is observed
 Has been absent from the population for a long time

Impending Outbreaks can be detected through:

 Surveillance systems
 Perceptive Clinicians
 Infection control nurses
 Laboratory workers (who reports an unusual disease)

Surveillance Systems

- Sentinel Surveillance
- Accelerated Disease Control
- National Active
- National Passive

Sentinel Surveillance

 Used when high-quality data are needed about a particular disease that cannot be obtained
through a passive system.
 Selected reporting units with high probability of seeing cases of the disease in question, good
laboratory facilities and experienced well-qualified staff, identify and notify on certain diseases.
 The data collected in a sentinel system can be used to signal trends, identify outbreaks and
monitor the burden of disease in a country.

Accelerated Disease Control

o National Active
 o Involves visiting health facilities, talking to health-care providers and reviewing medical records
to identify suspected cases of disease under surveillance
o National Passive
o A passive system that relies on the cooperation of the health-care providers, laboratories,
hospitals, health facilities and private practitioners to report the occurrence of vaccine-
preventable disease.

Steps in Outbreak Investigation

1. Operationally define what constitutes a case.

2. Based on the operational definition, identify the cases.
3. Based on the number of cases identified, verify the existence of an outbreak.
4. Establish the descriptive epidemiologic features of the cases.
5. Record the clinical manifestations of cases.
6. Based on the clinical manifestations, incubation period, available laboratory findings and other
information gathered, formulate a hypothesis regarding the probable etiologic agent, the
sources of infection, the mode of transmission, and the best approach for controlling the
outbreak.
7. Test the hypotheses by collecting relevant specimens from the patients and from the
environment.
8. Based on the results of the investigation, implement prevention and control measures to
prevent recurrence of a similar outbreak.
9. Disseminated the findings of the investigation through media and other forms to inform the
public.
ADOLESCENT REPRODUCTIVE HEALTH
 Adolescence is a period of life during which individuals reach sexual maturity
 It is the period of transition from childhood to adulthood and it is often characterized by
biological and psychosocial changes as well as sexual experimentation

Most Common Problems of Adolescence: Teenage Pregnancy

Teenage Pregnancy

 Is pregnancy in a female under the age of 20. Pregnancy can occur with sexual intercourse after
the start of ovulation, which can be before the first menstrual period but usually occurs after the
onset of periods.
 Adolescent pregnancy is a worldwide issue, although it is more prevalent in poorer and
marginalized groups

WHAT CAUSES TEENAGE PREGNANCY?

 Lack of information about sexual and reproductive health and rights

 Inadequate access to services tailored to young people
 Family, community and social pressure to marry
 Sexual violence
 Child, early and forced marriage, which can be both a cause and a consequence
 Lack of education or dropping out of school

HOW DOES TEENAGE PREGNANCY AFFECT GIRLS?

 Mother and child death

 Death among girls aged 15 to 19
 Health risks and problems
 Experience stigma, rejection, and threats of violence from their parents and peers
 Domestic violence

Other complications of Adolescence:

 Depression
 Suicide
 Drug addiction
 Alcoholism

Services of DOH to address Adolescent Health Reproduction

ADOLESCENT HEALTH AND DEVELOPMENT PROGRAM (AHDP)

Mr. Vincent D. Ingen, Nurse III - Program Coordinator

Republic Act (RA) 10354, the Responsible Parenthood and Reproductive Health (RPRH) Act of 2012
The Adolescent Health and Development Program of the Department of Health - Center for Health
Development - Cordillera Administrative Region (DOH-CHD-CAR) is solidly anchored on policies meant
to address adolescent's health concerns.

Vision: A region with well informed, empowered, responsible and healthy adolescents who contribute
meaningfully to their communities

Mission: To ensure that adolescents have equitable access to quality comprehensive health care and
culturally-responsive services in an adolescent-friendly environment

Goal: To empower adolescents for informed decision-making to improve their health and wellbeing

PROGRAM STRATEGIES

 Provision of Capability Building Activities to frontline health workers and other health partners
 Demand Generation Activities
 Provision of Information and Education Campaign Materials
 Certification for Level 1, Level II, and Level III Adolescent-Friendly Health Facility (AFHF)
Standards
 Coaching and Mentoring
 Research and Development
 Monitoring and Evaluation

2019 ACTIVITIES

 Conduct of Workshop to Develop a Local Adolescent Health and Development Program of

Benguet
 Conduct of Training on Adolescent Job Aid Manual for Adolescent Health Service Providers to
improve access to quality adolescent friendly services
 Conduct of "Usapang Pangkalusugan ng mga Kabataan"
 Conduct of Monitoring of Adolescent Friendly Health Facilities
 Reproduction/distribution of IEC materials on the prevention of teen pregnancy
FAMILY PLANNING (DEPARTMENT OF HEALTH)
WHAT IS FAMILY?

 "A family is a group of two or more persons related by birth, marriage, or adoption who live
together; all such related persons are considered as members of one family"
 "The family is widely known as the basic unit of the society”

WHAT IS FAMILY PLANNING?

 Is having the desired number of children

 when you want to have them by using safe and effective modern methods
 Proper birth spacing

VISION OF DEPARTMENT OF HEALTH

 “For Filipino women and men achieve their desired family size and fulfill the reproductive health
and rights for all through universal access to quality family planning information and services”

MISSION OF DEPARTMENT OF HEALTH

 “The National Family Planning Program is committed to provide responsive policy direction and
ensure access of Filipinos to medically safe, legal, non-abortifacient, effective, and culturally
acceptable modern family planning (FP) methods.”

OBJECTIVES OF DEPARTMENT OF HEALTH

1. To increase modern Contraceptive Prevalence Rate (mCPR) among all women from 24.9% in
2017 to 30% by 2022
2. To reduce the unmet need for modern family planning from 10.8% in 2017 to 8% by 2022

POPULATION

 111,500,195 – current population of Philippines

 109, 581, 078 – estimated population at year 2020
 1.41% total world population

TEENAGE PREGNANCY

 PH ranked 13 or 30???
 7% Increase in birth among girls aged 15 and below
 To 62,510 From 62,341 2019 data of Filipino minors giving birth in 2018
 In 2019, 2,411 gave birth, or almost seven every day –¾ increase from 2000

OUTSIDE LUZON

 Northern Mindanao with 4,747 cases

 Central Visayas with 4,541
 Davao Region with 4,551

SEXUALLY TRANSMITTED DISEASE

  From DOH statistics
 Total of: 81,169 HIV and AIDS cases reported from January 1984 to October 2020
 94% (76,216) were male
 6% (4,953) female

GUIDING PRINCIPLES OF THE FAMILY PLANNING

 Respect for the sanctity of life

 Respect for human rights
 The freedom of choice and voluntary decision
 Respect for the rights of clients to determine their desired family size

FAMILY PLANNING PROGRAM METHODS

PERMANENT METHODS

TUBAL LIGATION

 the fallopian tubes are cut, tied or blocked to permanently prevent pregnancy

VASECTOMY

 surgical procedure for male sterilization or permanent contraception

TEMPORARY METHODS

BIRTH CONTROL PILLS

 Effective 99% - pills

 a daily pill that contains hormones to change the way the body works and prevent pregnancy
INTRAUTERINE DEVICE

 Is a small plastic T-shaped device used for birth control

 Effective 99%

INJECTABLES

 It is an injection, or shot, that contains progestin

MALE CONDOM

 a thin sheath placed over the erect penis

FERTILITY AWARENESS-BASED METHOD

BILLINGS OVULATION METHOD

 careful observation of mucus patterns during your menstrual cycle

BASAL BODY TEMPERATURE

 method of natural family planning that requires only the purchase of a very accurate
thermometer

SYMPTOTHERMAL METHOD

 observing various fertility indicators, such as core body temperature and cervical mucus

STANDARD DAYS METHOD

 is a calendar-based method that identifies a fixed fertile window in the woman's cycle
 White beads: pregnancy is most likely
 Brown beads: pregnancy is very unlikely
 Dark brown bead tells you If your cycle shorter than 26 days
 Movable rubber ring
 Red bead: first day of your period
LACTATION AMMENORHEA METHOD

 a woman relies on exclusive breastfeeding after birth to prevent pregnancy

 Taas levels of prolactin
 Applicable only for exclusive breastfeeding (up to 6months)
 Within 6 mos, if nagbalik na ang menstruation, di na effective ang LAM

STRATEGIES OF NATIONAL FAMILY PLANNING PROGRAM

STRATEGIES

 FP Outreach Mission
 FP in hospitals
 House-to-house visits - Usapan session

BENEFITS OF FAMILY PLANNING PROGRAM

BENEFITS

 Improving maternal health and child survival

 Reducing the number of abortions overall, especially unsafe abortion
 Preventing sexually transmitted infections
 Empowering women
 Promoting social and economic development and security.
 Protecting the environment
PRE-NATAL CARE
Maternal and Child Care Programs

 OBJECTIVE: To improve the well-being of mothers and children through the delivery of
comprehensive maternal and child related services through the utilization of Primary Health
Care Approach (3A: accessible, affordable, available)

Safe Motherhood

 Ensures that all women receive the care they need to be safe and healthy through pregnancy &
childbirth
 PHILOSOPHY: No woman should die or be harmed by pregnancy or childbirth-related causes
 Target Clients: Pregnant Women

SERVICES:

 Antenatal care and counseling

 Skilled attendants with necessary equipment
 Postpartum and newborn care
 Family planning, birth spacing information and services throughout reproductive lifespan
 Community education on safe motherhood
 Political and financial commitments

PRE-NATAL CARE

 Care of women before delivery

PURPOSES:

 Establish baseline data

 early assessment and detection
 early prevention, monitoring and treatment of Rh factors
 ensuring safe delivery
 getting an appropriate advice on proper care

Services:

 Data Gathering (Demographic, Obstetrical, Medical Health)

 Physical Exam (weight, height, BMI, vital signs)
 Pelvic Examination (IE – health center, TVS - hospital, Pap Smear - detect STI)
 Leopold's Maneuver
 Fetal heart tone monitoring
o Normal: 120 - 160 bpm
o 8th week – use Doppler (kasi if earlier maliit pa ang tiyan mahirap pa I-detect)
o 20th week - use stethoscope kay visible na ang fundus
 Laboratory Examinations (CBC, UA, Blood typing, Cystic Fibrosis (a congenital defect), Evidence
of previous exposure to varicella, rubeola, mumps or rubella)
 Giving of Fe supplements, folic acid, vit. A, elemental lodine
  TT immunization
 Counseling

Pre-natal Schedule Visit

 Every Thursday prenatal care day

 1st – 7th month – MONTHLY
 8th month – TWICE A MONTH
 9th month - WEEKLY

Initial Pre-Natal Visit

 Obtain Data
1. Obstetrical Data
 Menarche
 Gynecological History
 AOG
o by weeks (LMP)
o Mc donald's Method (months)
 Bartholomew's rule (palpate fundus)
o 12 weeks - near symphysis pubis
o 16 weeks - between umbilicus & symphysis pubis
o 20 weeks - near umbilicus
o 36 weeks - xyphoid process
o 40 weeks - 4 cm below xyphoid process
 GPA-TPAL
 Expected Date of Confinement/Delivery
o Naegel's rule: (-3 +7 +1) using LMP

2. Medical Health History

 Immunizations
 Hospitalizations
 Past Surgery
 Diseases (Hypertension, DM)
 Leopold's Maneuver
 Common and systematic way to determine fetal position of fetus
 Preferably performed after 24 weeks

4 DISTINCT MANEUVERS

 FIRST: Fundal Grip

  SECOND: Umbilical Grip
 THIRD: Pawlick's Grip
 FOURTH: Pelvic Grip

1. The superior surface of the fundus is palpated to determine consistency, shape, mobility
2. Both sides of the uterus are palpated to determine the direction the fetal back is facing
3. Determines the part of the fetus at the inlet and its mobility
4. Determines the fetal attitude and degree of fetal extension into the pelvis

Tetanus Toxoid Immunization

 To protect pregnant women against tetanus and prevent neonatal tetanus (newborn)

VACCINE MINIMUM AGE INTERVAL PERCENT DURATION OF PROTECTION

PROTECTED
TT1 As early as possible during ---- -----
 pregnancy
TT2 At least 4 weeks later after 80% Infants born to mother will be
the first dose (TT1) protected from neonatal tetanus
Gives 3 years protection for the
mothers
TT3 At least 6 months after the 90% Gives at least 5 years protection for
2nd dose the mothers
TT4 At least 1 year after TT3 99% Gives at least 10 years protection
for the mothers
TT5 At least 1 year after TT4 99% Gives lifelong protection for the
mother against tetanus

Counselling

1. Self-care: Follow the basics

2. Don't smoke, drink alcohol or take drugs.
3. Get enough rest.
4. Eat a healthy diet. (Add 300 calories to daily intake + protein intake)
5. Well-balanced diet (+ fresh fruits, grains, vegetables)
6. Take prescribed vitamins/minerals, folic acid-to prevent birth defects like spina bifida, iron-to
prevent anemia, calcium. Vitamin A (di dapat too much kay naay complications; follow doc’s
prescription)
7. Over-the-counter medications are generally considered off limits due to their potential risk/effects
on the fetus.
UNDER FIVE CARE PROGRAM
Under Five Care Program is a package of child health-related services focused to the 0-59 months old
children to assure their wellness and survival. There are several services included in this program which
include:

 Expanded Program on Immunization

 Integrated Management of Childhood illnesses
 Newborn Screening
 Nutrition Program
o Micronutrient Supplementation
o Vitamin A
o Food Fortification Program
 Oral Health Program

Expanded Program on Immunization

 It was established in 1976 to ensure that infants/children and mothers have access to routinely
recommended infant/childhood vaccines.
 6 preventable vaccines (EPI) - BCG, OPV, IPV, pentavalent, MMR, hepa b (monovalent)

Integrated Management of Childhood Illnesses

 It is an integrated approach to child health that focuses on the well-being of the whole child. It
was developed to allow high-quality treatment with limited resources.
 Prevent illnesses for young children
Newborn Screening

 A public health program aimed at early identification of infants who are affected by certain
genetic/metabolic/infectious conditions in the Philippines.

Nutrition Program

 The target clients are from 0-71 months old children, pregnant and lactating mothers. The
objective of this program is to decrease the prevalence of malnutrition among children and
pregnant/lactating mothers

Micronutrient Supplementation

 It is the provision of pharmaceutically prepared vitamins and minerals for treatment of specific
micronutrient deficiency.

Vitamin A

 It is used for treating vitamin A deficiency and also used to reduce complications of diseases
such as malaria, HIV, measles and diarrhea in children with vitamin A deficiency.

Food Fortification Program

 The addition of nutrients to processed food or food products at levels above what is naturally
present in the food. Based on typical Filipino’s daily needs as measured using the most recent
recommended dietary allowances (RDA).

ORAL HEALTH PROGRAM

 In 2007, the Department of Health formulated the Guidelines in the Implementation of Oral
Health Program for Public Health Services (AO 2007-007).
 To reduce the prevalence rate of dental caries to 85% and periodontal disease by 60%

*continuation sa baba after micronutrient program*

NEWBORN SCREENING PROGRAM
Newborn Screening

 is an essential public health strategy that enables the early detection and management of
several congenita disorders.
 It has been an integral part of routine newborn care in most developed countries for five
decades, either as a health directive or mandated by law. In the Philippines, it is a service
available since 1996.

Vision (according to DOH)

 “Every Filipino child will be born healthy and well, with an inherent right to life, endowed with
human dignity and reaching her/his potential with the right opportunities and accessible
resources.”

Mission (according to DOH)

 “To ensure that all Filipino children will have access to and avail of total quality care for the
optimal growth and development of their full potential.”

Goal (according to DOH)

 “By 2030, all Filipino newborns are screened and properly managed for common and rare
congenital disorders to reduce preventable deaths of newborns.”

What is Newborn Care Package?

 is a PhilHealth benefit package for essential health services of the newborn during the first few
days of life.
 It covers essential newborn care, newborn screening and hearing screening tests.

I. Essential Newborn Care

 Involves the following health practices to newborn care which have been proven to improve the
health outcomes of the baby:
a. Immediate drying of the baby;
b. Early skin to skin contact;
c. Timely cord clamping;
d. Non-separation of mother/baby for early breast-feeding initiation;
e. Eye prophylaxis and Vitamin K administration;
f. Weighing of the baby;
g. First dose of hepatitis B Vaccine; and
h. First dose of BCG Vaccine.
 Eye prophylaxis-ointment
II. Newborn Screening Test
 is a blood test done on the newborn after 24 to 72 hours after birth.
 Early detection and management of congenital diseases
III. Newborn Hearing Screening Test
  is a test done on the newborn to detect congenital hearing loss.

Disorders most commonly screened:

1. Phenylketonuria (PKU)
 is a metabolic disorder of phenylalanine that is detected by newborn screening.
 by 3 to 6 months of age, infants with untreated PKU begin to show symptoms of intellectual and
developmental disability. These disabilities can become severe if the Phe remains at high levels.
2. Galactosemia
 means being unable to use galactose.
 infants with untreated galactosemia can die of a serious blood infection or of liver failure. those
that may survive usually have intellectual or developmental disability, other damage to the brain
and nervous system.
 Galactose builds up in the blood
3. Maple Syrup Urine Disease
 is an inherited disorder in which the body is unable to process certain protein building blocks or
amino acids properly.
 the disorder gets its name from the distinctive sweet odor of affected infants' urine.
 Poor feeding, lack of energy, delayed development
 Lead to seizures comma and death -untreated

How is newborn screening done?

 It usually starts with a blood test, followed by a hearing test and other possible tests.
 A hospital staff fills out a newborn screening card with an infant's vital information.
 Part of the card consists of special absorbent paper used to collect the blood sample.
 Heel stick test is done, which is a small puncture in the baby's heel and squeeze out a few drops
of blood. They put the absorbent part of the card in contact with the blood drop.
 Lastly, the card is sent to a laboratory where the blood is tested for the various conditions as
part of the newborn screening panel.

What is the meaning of the newborn screening result?

 A negative screen means that newborn screening result is normal.

 A positive screen means that the newborn must be brought back to his/her health practitioner
for further testing and management.
 72 hours bago mugawas ang result (depende sa hospital)
MICRONUTRIENT SUPPLEMENTATION PROGRAM
Definition of Terms:

 Nutrition - is the sum of all the interactions between an organism and the food it consumes.
 Nutrients - are organic and inorganic substances found in foods that are required for body
functioning.
 Essential Nutrients - are nutrients that are required for normal functioning of the body, but that
cannot be made by the body at all or cannot be made in sufficient amounts for good health.

Nutrients can be divided into two categories...

MACRONUTRIENT MICRONUTRIENT
 Carbohydrate, protein, and fat are  Vitamins and minerals
macronutrients  Are those vitamins and minerals that are
 They make up the bulk of your diet. required in small amounts (e.g., milligrams or
 large amounts needed for energy micrograms) to metabolize the energy-
providing nutrients.

MICRONUTRIENTS

 micro- is an ancient Greek word which meant “small."

 Vitamins are organic compounds made by plants and animals which can be broken down by
heat, acid or air.
 Minerals are inorganic, exist in soil or water and cannot be broken down.
 The micronutrient content of each food is different, so it's best to eat a variety of foods to get
enough vitamins and minerals.
 Vitamins and minerals are vital for growth, immune function, brain development and many
other important functions.
 A, D, E, K, folic acid, Iron, Calcium (vitamins)

Health Benefits of Micronutrients

 Consuming an adequate amount of the different vitamins and minerals is key to optimal health
and may even help fight disease.
o Certain vitamins and minerals can act as antioxidants. Antioxidants may protect against
cell damage that has been associated with certain diseases.
o Certain minerals may also play a role in preventing and fighting disease.

Micronutrient Deficiency

 Micronutrient deficiency (MND) is a lack of essential vitamins and minerals required in small
amounts by the body for proper growth and development. Most healthy adults can get an
adequate amount of micronutrients from a balanced diet, but there are some common nutrient
deficiencies that affect certain populations.

Vitamin A A nutrient important to vision, growth, cell division, reproduction and

immunity. Vitamin A also has antioxidant properties.
Iodine Iodine is an essential component of the thyroid hormones thyroxine (T4) and
 triiodothyronine (T3)
Iron Iron is part of hemoglobin, a protein which carries oxygen from our lungs
throughout our bodies. It helps our muscles store and use oxygen.
Iron deficiency - common in preschool children, menstruating women, vegans
Zinc Helps your immune system and metabolism function. Zinc is also important to
wound healing and your sense of taste and smell.
Deficiency – growth retardation, loss of appetite, impaired immune function
Folate Folate is the natural form of vitamin B9, water-soluble and naturally found in
many foods.
Folate deficiency – no enough count of RBC, probably acquire anemia

MICRONUTRIENT SUPPLEMENTS

 The safest and most effective way to get adequate vitamin and mineral intake appears to be
from food sources.
 Provision of pharmaceutically prepared supplements

Micronutrient Supplementation Program

 High prevalence of malnutrition common to young children

VISION

 Empowered healthy and well-nourished Filipino families

MISSION

 DOH and partners to align their strategic actions and exert collective and unified efforts to
create a supportive environment for a sustainable and improved nutrition development

GOAL

 To reduce prevalence of micronutrient deficiencies (Vitamin A, Iron and Iodine) below public
health significance

Policies and Laws

Administrative Order No. 2010-0010

 Revised Policy on Micronutrient Supplementation to support achievement of 2015 MDG Targets

to reduce under-five and maternal deaths and micronutrient needs of other population groups
 Aims to guide health workers in administering micronutrient supplements

GUIDELINES AND PROCEDURES FOR MICRONUTRIENT SUPPLEMENTATION

a. Vitamin A

Targets and Dose

Universal Supplementation of Vitamin A

  Involves the administration of supplemental doses every six months to all infants and children
aged 6 months to 71 months.
 Done during regular services in all health facilities including but not limited to the
implementation of:
- Integrated Management of Childhood illnesses
- Immunization activities,
- Growth Monitoring Promotion
- Garantisadong Pambata

Table A1: High dose universal-distribution schedule for the prevention of Vitamin A Deficiency

TARGETS PREPARATION DOSE/DURATION

Infants (6-12 months) 100,000 I.U. 1 dose only
Children 12 months and older 200,000 I.U. 1 capsule every 6 months

Treatment for Xeropthalmia

 Xerophthalmia is a serious consequence of vitamin A deficiency that requires immediate

treatment. It includes night blindness, Bitot's spots, corneal xerosis, corneal ulceration and
keratomalacia.
 Nyctalopia/night blindness - inability to see well at night or in poor light

Table A2: Treatment for Xeropthalmia

 TARGETS PREPARATION DOSE/DURATION
Infants (6-12 months) 100,000 1.U. 1 dose given immediately upon
diagnosis, 1 capsule given the
Children 12 months and older 200,000 1.U. next day & 1 capsule 2 weeks
after

SAFETY OF VITAMIN A

 Vitamin A is known to be safe and effective even for those who do not exhibit vitamin A
deficiency
 With high-dose capsule, some side effects may occur such as headache, nausea and vomiting.
Disappear within 24 hours even without treatment
 Vitamin A in big doses is also safe even if given in an interval of 4 weeks.
b. Iron

INFANTS 6-11 MONTHS OF AGE

 Infants need a relatively high iron intake because they are growing very rapidly. Infants are
normally born with plenty of iron.
 Low-birth weight infants are born with fewer iron supply and are at high risk of iron deficiency
ever if exclusively breastfed.
 Supplementation starts at two (2) months of age.
 Supports proper neurological development in infant (iron)
 Infants are normally born with plenty of iron, but ang iron milk contents daw insufficient na

Table B1: Iron supplementation to Infants 6-11 Months of Age

TARGETS PREPARATION DOSE/DURATION

Low birth Weight Drops: 15mg elemental iron / 0.3 ml once a day to start at two
0.6ml months of age until 6 months
when complementary foods are
given.
Infants 6-11 months Drops containing 15mg. 0.6 ml once a day for 3 month
Elemental iron/0.6 ml.

SAFETY OF IRON

 There is no risk of toxicity to iron/folate supplements when taken at the prescribed dose.
 Intake of iron also produces minor undesirable gastrointestinal side effects in some individuals
such as epigastric discomfort, nausea, vomiting, constipation, and diarrhea.
 The dose of iron may be reduced and gradually increased until the full dose is reached and is
well tolerated.
 Best time to take 1 hour before or 2 hours after meals
c. Iodine

CHILDREN OF SCHOOL AGE

 Children of school age are also a priority for iodine supplementation.

 There is also risk in developing hypothyroidism.
  It is also among this population group that the intake of iodine sources from food could be very
poor.
 Increase demand for iodine bc of growth spurts

Table C1: Iodine Supplementation to Children of School Age

TARGETS PREPARATION DOSE/DURATION

Children of School Age Iodized oil capsule with 200 mg. 1 capsule for 1 year
Iodine

SAFETY OF IODIZED OIL CAPSULE

 There has been no report of side effects due to intake of oral iodized oil.
 There are clinical conditions that may worsen with the intake of iodized oil capsule. They are: (1)
toxic goiter (2) untreated tuberculosis (3) recent hemorrhage.
 The iodized oil capsule should not be given to individuals with the above clinical condition
 Avoid iodize oil hyper/ hypothyroidism

Types of Service:

PhilHealth Benefit Package

 Maternity Care Benefit Package (MCP)

 Primary Care Benefit Package

Trainings

 Orientation on the Updated MOP on Micronutrient Supplementation

Implementation Support Materials

 Job Aids for Health Workers on Micronutrient Supplementation

PARTNER ORGANIZATIONS

List of Local Advocacy Partners

National/Government

 Philippine Information Agency

 Presidential Communications Operations Office

Local/Youth/CSOs/NGOs
  PHILCAN
 Scaling UP Nutrition Movement

International Partners

 WHO
 UNICEF
 KOICA
 Vitamin Angels
 Nutrition International
ORAL HEALTH PROGRAM
 In 2007, the Department of Health formulated the Guidelines in the Implementation of Oral
Health Program for Public Health Services (AO 2007-007).
 To reduce the prevalence rate of dental caries to 85% and periodontal disease by 60% - 2 most
common oral problem

GOAL: “Attainment of improved quality of life through promotion of oral health and quality oral health
care."

Objective: Annual rate reduction of 5% reduction of 2 most common oral health problem

WHAT IS ORAL HEALTH?

 Oral health is one of the key indicators of overall health, well-being and quality of life.
 Oral diseases are on the rise in most low- and middle-income nations, increased urbanization
and changes in living conditions.
o Healthy mouth –able to speak eat socialize without discomfort or embarrassment
o Due insufficient fluoride exposure, sa water and toothpaste
 The most common oral health illnesses of Filipinos are dental caries (tooth decay) and
periodontal diseases (gum diseases) wherein 87.4% Filipinos suffer from dental caries while
48.3% suffer from gum diseases.

DENTAL CARIES (TOOTH DECAY)

 Toothache, spontaneous pain or pain that occurs without any apparent cause .
 Tooth sensitivity
 Mild to sharp pain when eating or drinking something sweet, hot or cold . Visible holes or pits in
the teeth
 Brown, black or white staining on any surface of a tooth
 Pain when biting down

PERIODONTAL (GUM) DISEASES

 Swollen or puffy gums

 Bright red, dusky red or purplish gums
 Gums that feel tender when touched
 Gums that bleed easily . Pink-tinged toothbrush after brushing
 Spitting out blood when brushing or flossing your teeth
 Bad breath
 Pus between the teeth and gums
 Loose teeth or loss of teeth
 Painful chewing
  New spaces developing between the teeth
 Gums that pull away from the teeth (recede), making the teeth look longer than normal
 A change in the way the teeth fit together when biting

PARTNER INSTITUTIONS OF THE DOH

POLICIES AND LAWS THAT SUPPORT THE PROGRAM

 Republic Act 3814

o An Act Creating the Bureau of Dental Health Services (As Amended by RA 5211)
 Republic Act 9484
o The Philippine Dental Act of 2007
 AO 101 s 2003
o National Policy on Oral Health
 AO 2007 – 0007
o Guidelines in the Implementation of Oral Health Program for Public Health Service.

FEBRUARY - NATIONAL ORAL HEALTH MONTH

SERVICES OF DOH
Neonatal and infants under 1 year old

 Dental check-up as soon as the first tooth erupts

 Health instructions on infant oral health care and advise on exclusive breastfeeding
 Magerupt ang tooth 6-9 months commonly

Children 12-71 months old

 Dental check-up as soon as the first tooth appears and every 6 months thereafter
 Supervised tooth brushing drills
 Oral Urgent Treatment (OUT)
o Removal of unsavable teeth
o Referral of complicated cases
o Treatment of post extraction complications
o Drainage of localized oral abscess
o Application of Atraumatic Restorative Treatment (ART)

Mother (Pregnant Women)

 Oral Examination
 Oral Prophylaxis (scaling)
 Permanent fillings
 Gum treatment
 Health instruction

School Children (6-12 years old)

 Oral Examination
 Supervising tooth brushing drills
 Topical fluoride therapy
 Pits and Fissure Sealant Application
 Oral Prophylaxis
 Permanent Fillings

Adolescent and Youth (10-24 years old)

 Oral Examination
 Health promotion and education on oral hygiene, and adverse effect on consumption of sweets
and sugary beverages, tobacco and alcohol

Other Adults (25-29 years old)

 Oral Examination
 Emergency dental treatment
 Health instruction and advice
 Referrals

Older Person (60 years old and above)

 Oral Examination
 Extraction of unsavable tooth
 Gum treatment
 Relief of pain
 Health instruction and advice
MALARIA CONTROL AND ELIMINATION PROGRAM
Malaria

Malaria is a serious and sometimes fatal disease caused by a parasite that commonly infects a certain
type of mosquito which feeds on humans. People who get malaria are typically very sick with high
fevers, shaking chills, and flu-like illness (DOH, 2018).

Different types of the genus Plasmodium

Falciparum highest incidence rate

Zoonotic malaria

Signs and Symptoms of Malaria

"FLU-LIKE SYMPTOMS"

Pathogenesis of Malaria
Terms:

 Sporozoites
 merozoites

Transmission can be through:

 infected mosquito bites

 From mother to unborn child
 Through blood transfusions
 By sharing needles used to inject drugs

Treatment/Prevention

 Antimalarial drugs
 Bed nets, protective clothing, insect repellant

MALARIA CONTROL AND ELIMINATION PROGRAM

DOH take on Malaria:

The Philippines carried a high burden of malaria disease in the past but with the unrelenting efforts of
the National Malaria Control and Elimination Program, cases and deaths have been reduced
significantly, and the country is now inching towards elimination. Hence, this program aims to eliminate
malaria by adopting a health system focused approach to achieve universal coverage with quality-
assured malaria diagnosis and treatment, strengthen governance and human resources, maintain the
financial support needed, and ensure timely and accurate information management.

VISION

A Malaria–Free Philippines by 2030

MISSION

Further accelerate malaria control and transition towards elimination

OBJECTIVES

Objective 1 (Universal Access) – To ensure universal access to reliable diagnosis, highly effective and
appropriate treatment and preventive measures
Objective 2 (Governance and Human Resources) – To strengthen governance and human resources
capacity at all levels to manage and implement malaria interventions
Objective 3 (Health Financing) – To secure government and non-government financing to sustain malaria
control and elimination efforts at all levels
Objective 4 (Health Information and Regulation) – To ensure quality malaria services, timely detection of
infection and immediate response, and information and evidence to guide malaria elimination

PROGRAM COMPONENTS

1. Program Management and Health System -

2. Diagnosis and Treatment
3. Vector Control
4. Advocacy and Social Mobilization
5. Surveillance, Outbreak Preparedness and Response
6. Monitoring and Evaluation
7. Partnerships
8. Assessment of Other Factors - assessment of the possible contribution of factors such as
government health expenditure, poverty, forest cover, etc.

PARTNERS AND INSTITUION

 World Health Organization (WHO)

 Filipinas Shell Foundation Inc. (PSFI)
 Asian Collaborative Training Network for Malaria (ACT Malaria)
 National Commission on Indigenous Peoples (NCIP)
 Bureau of Quarantine (BOQ)
 University of the Philippines-Philippine General Hospital (UP PGH)
 Research Institute for Tropical Medicine (RITM)
 Asia Pacific Malaria Elimination Network (APMEN)

1966: Republic Act 4832: Malaria Eradication Law; an act creating the malaria eradication service and
providing funds for the duration of the campaign.
1973: cut-off from the support of USAID and WHO
1982: EO 851, ordered the decentralization and integration of malaria control in “the general health
services”
1983: “Malaria Eradication” to “Malaria control”
1986: EO 119: change in the bureaucracy of the Philippine government – revising the system of the
Department of Health
1987: Department Circular No. 167 s. 1987: Semi-vertical Malaria programme1991: RA 7160 “Local
Government Code”
2009: AO 2009-0001 “Revised Policy and Guidelines on the Diagnosis and Treatment of Malaria”
2009:AO 2009-0024 “Reconstitution of the Country Coordinating Mechanism in Support of the Global
Fund to Fight Against AIDS, Tuberculosis and Malaria Grants in the Philippines”
2012: AO 2012-0026 “Guidelines in the Conduct of Border Operation”
2013: AO 2013-0007 “Guidelines on Establishment of Elimination Hub”
2013: AO 2013-0023 “Guidelines on Establishment of Collaborating Centers”
2014: AO 2014-0004: PhilMIS: Reporting and Recording of malaria cases

STRATEGIES, ACTION POINTS, AND TIMELINE

1. Early Detection and Prompt Treatment through a strengthened case-finding mode;

2. Foci investigation and Classification as a means to determine need for interventions;
3. Annual Stratification using Foci Classification;
4. Strengthened recording and reporting;
5. Use of Primaquine as a transmission-blocking agent;
6. Use of Artesunate ampoules and suppositories;
7. Expanded RDT and sustained microscopy services;
8. LLIN as continued cornerstone of vector control
9. IRS in border areas and as outbreak response mechanism;
10. Quality assurance monitoring to cover all aspects of malaria service delivery;
11. Structured capability-building of local health system staff; and
12. Adaption of specified IEC strategies and other social mobilization approaches for identified risk
groups

PROGRAM ACCOMPLISHMENTS/STATUS

SUB-NATIONAL INITIATIVES WITH 42 PROVINCES DECLARED MALARIA - FREE OUT OF 81 PROVINCES,

ONLY 7 PROVINCES REMAINS WITH LOCAL TRANSMISSION SIGNIFICANT REDUCTION OF CASES AND
DEATHS THAT in 2010; 19,217 cases were detected with 33 deaths and a downward trend leading to
3,998 cases with 4 deaths in 2017. These figures denote 83% decrease in cases from 2010 to 2017

Palawan highest incidence rate of malaria; 90% of the cases

CALENDAR OF ACTIVITIES

 World Malaria Day, 25 April 2018

 Entomology Meeting, 16-17 May 2018
 Malaria Technical Working Group Meeting (quarterly or as need arises)
 OLMIS Meeting, 5 June 2018
 Entomology Refresher Course 23-28 July 2018
 Curriculum Refinement Workshop, 30 July to 3 Aug 2018
 Philippine Coordinating Committee Meeting (monthly)
 Mindanao Cluster Meeting (Cluster I, 8-9 August 2018; Cluster II, 28-29 August 2018)
 Integrated Vector Management Control, 13-17 August 2018
 External Competency Assessment 13-17 August 2018
DENGUE CONTROL PROGRAM

Dengue

 “break bone fever”

 Viral infection characterized by acute onset of high fever (2-7 days)
 Spread to people through a bite of an infected Aedes mosquito
 Found in most tropical and subtropical regions are at greatest risks
 Indian Subcontinent
 Southeast Asia
 Southern China
 Taiwan
 Pacific Islands
 Carribean (except Cuba & Cayaman)
 Pwede mag last to 14 days

 Endemic 2019 dengue 400,000+, 22,000 death

Statistics

Globally: approx. up to 400 M get infected; 100 M get sick & 40, 000 die from severe dengue

Philippines: As of July 3, 2021, there were 32, 555 cases reported with 119 deaths

Types
a. Dengue without warning signs
 “Grade I Classification”
 Signs & Symptoms:
o (+) flu-like symptoms – headache, muscle and/or joint pain, cough, colds, fever of up to
38 - 40C.
o Skin petechiae - broken capillaries during torniquet test
o (+) Tourniquet test

b. Dengue with warning signs

 “Grade II Classification”
 Signs & Symptoms:
o Manifestations of Grade I plus
o Spontaneous bleeding
o gum bleeding, ephistaxis;
o one of serious types: melena, vaginal bleeding, hematemesis & intracranial bleeding
c. Severe Dengue
 “Dengue Hemorrhagic Fever”
 Fatal form of the disease
 “Grade III Classification”
 Signs & Symptoms:
o Manifestations of Grade II + beginning signs of circulatory failure that might lead to
shock (Gr. IV)
o Abdominal pain
o Persistent vomiting
o Marked change in temperature
o Change in mental status (irritation, confusion or obtundation)
o Early signs of shock (cold & clammy skin, rapid weak pulse, narrowing of pulse

WHO:

 Fever or recent history of fever lasting 2-7 days

 Any hemorrhagic manifestations
 Thrombocytopenia count of <100, 000/ mm3
 Evidence of increased vascular permeability
= Dengue Shock Syndrome

Causative Agents

*Dengue Virus 1, 2, 3, 4 (DENV-1, 2, so on)

 Members of the genus Flavivirus, family Flaviviridae

 One serotype of DENV provides immunity to that type for life, yet provides no long-term
immunity to other types

*Chikungunya virus

Carriers

*Aedes aegypti

 primary vector; prefers to breed INDOOR in an artificial container

*Aedes albopictus

 most common in rural areas; secondary vector of dengue; prefers to breed OUTSIDE

Mode of Transmission

* Vector (bite of mosquito)

Incubation Period

* 3 – 15 days

Lab / Diagnostics

Rumpel Lead’s Test / Tourniquet Test

 Assess capillary fragility

 Good indication in assessing blood vessels

CRITERIA:

 not in shock
 no abdominal pain
 no signs of bleeding
 6 mos older

Procedures

 Pump up BP cuff on one of the arm to more than venous venous pressure of 70 mmHg
 Keep it for 5 minutes and ease the pressure
 Examine the extremity = (+) if more than 2 spots appear

Complete Blood Count (Platelet)

 counts the cells that make up the blood

 Confirmatory test
Viral Isolate Antigen

 Antigen test that will tell you have a current viral

Health Teachings

Prevention

 Clothing: Reduce the amount of skin exposed

 Use mosquito repellents if not contraindicated.
 Usage of mosquito traps and nets.
 Door and window screens as structural barriers
 Try to avoid being outside at dawn, dusk and early evening
 Checking for and removing

Management

 Drink plenty of fluids and get lots of rest.

 Take antipyretics
 Warn patients to avoid aspirin and other NSAID's medications bc magincrease risk of bleeding
 Monitor patient's hydration status during febrile phase. Educate patients and parents about the
signs of dehydration and have them monitor intake
 Assess hemodynamic status. Closely monitor patients to during defervescence stage. Critical
phase of dengue begins with this and last 24 - 48 hours.

DOH Programs/Activities

Enhanced 4S - Strategy against Dengue, Chikungnya and Zika:

 Search and destroy mosquito breeding sites

 Self-protection
 Seeking carly consultation / immediate treatment
 Support fogging/ spraying only in hotspot areas in anticipation of increased infectious diseases
especially during rainy season

Trainings

 Dengue Clinical Case Management and Program Management

 Nucleic - Acid Amplification Test-Loop Mediated Isothermal Assay (NAAT-LAMP) Training as One
of Dengue Confirmatory Tests of the National Aedes-borne-Prevention and Control Program
(NDPCP)
 National Dengue Death/Mortality Review

Policy Issuances

 Department Order No. 2020- 0536 or known as “Guidelines in the Conduct of a Dengue
Mortality Review
 Administrative Order No. 2021-0009 entitled as "Guidelines for the Establishment of Dengue
Centers of Excellence (COE's) in Tertiary Hospitals”
 Proclamation No. 1204 series 1998 declares month of JUNE as the National Dengue Awareness
Month
LEPROSY
What is Leprosy?

 a chronic disease by a bacteria called Mycobacterium leprae. It primarily affects the nerves of
the extremities, the skin, the lining of the nose, and the upper respiratory tract.

Mycobacterium leprae

 It is the bacteria that causes Leprosy. it is a parasitic bacterium that can only survive inside host
cells. It evades detection by the host's immune system by infecting Schwann cells
 Hansen’s disease
 Schwann cells cannot effectively repair

WHO (2021)

 There were 202,256 new leprosy cases registered globally in 2019 according to the official
figures from 161 countries.
 There are 178,371 cases at the end of 2019, the prevalence corresponds to 22.9 per million
population.

Forms of Leprosy

 Tuberculloid Leprosy
 Lepromatous Leprosy
 Borderline Leprosy

TUBERCULLOID

Immune response is good

 Is a mild, less severe form of leprosy. People with this type have only one or a few patches of
flat, pale colored skin.
 This is less infectious than other forms. This infection heals on its own, or it can persist and
progress to a more severe form.

LEPROMATOUS

Immune response is poor

  A more severe form of the disease. It brings widespread skin bumps and rashes, numbness, and
muscle weakness.
 Affected individuals may also have several lesions including plaques, macules, papules and
nodules. which is often followed by thickening of skin over forehead and earlobes, loss of
eyebrows and eyelashes, misshaping or collapsing of the nose and falling off of the upper incisor
teeth.

BORDERLINE

 People with this type of leprosy have symptoms of both the tuberculoid and lepromatous forms.

Classification of Lesions
  Single lesion Paucibacillary
 Paucibacillary
 Multibacillary

Signs and Symptoms

 Disfiguring skin sores, lumps, or bumps that don't go away after several weeks or months.
 diminished sensation or feeling in the affected areas
 Painless Ulcers
 Eye damage (dryness, reduced blinking)
 atrophy of muscle in the hands or feet
 Muscle Weakness
 Paralysis

Mode of Transmission

Airborne

 Inhalation of droplet spray from coughing and sneezing of untreated leprosy patients.

Reservoir

 Presentations are communication tools that can be used as demonstrations, lectures, speeches,
reports, and more. It is mostly presented before an audience.

Treatment

Dapsone

 Paucibacillary leprosy: You’ll take two antibiotics, such as dapsone each day and rifampicin once
a month.

Rifampin

 A Antibiotic which is accompanied when taking dapsone

Clofazimine

 Multibacillary leprosy: You’ll take a daily dose of the antibiotic clofazimine in addition to the
daily dapsone and monthly rifampicin. You’ll take multidrug therapy for 1-2 years, and then
you'll be cured.

Prednisone

 Anti-inflammatory drugs to control nerve pain and damage related to leprosy

National Leprosy Control Program

 The National Leprosy Control Program (NLCP) is a multi-agency effort to control Leprosy in the
country with private and public partnership in achieving its goals to lessen the burden of the
disease and its mission to have a leprosy-free country.

Policies and laws

 Administrative Order No. 167, s. 1965: Rules and Regulations of Leprosy Control in the
Philippines
 Republic Act No. 4073: An Act further liberalizing the treatment of leprosy by amending and
repealing certain sections of the revised Administrative Code

Program Components

 Early diagnosis and treatment

 Integration of leprosy services
 Referral system
 Case detection and diagnosis
 Advocacy and IEC focusing on stigma discrimination and reduction
 Prevention of Deformity, self-care and rehabilitation
 Recording and reporting
 Monitoring, supervision and evaluation
RABIES
WHAT IS RABIES?

 A zoonotic disease and human infection caused by Lyssavirus, usually occurring after a
transdermal bite or scratch by an infected animal.
 Is estimated to cause 55,000 deaths every year worldwide
o 56% ASIA
o 43.6% AFRICA
 Rabies remains to be a public health problem in the Philippines
 Mode of Transmission
o transmitted among infected animals -> excretion of Ravies virus -> infected saliva -> bite
into broken skin or mucosa of Man

Transdermal bite –scratch, wounds

250 Filipinos every year less than 15 years?? Male; dogs

ABC – Animal Bite Center

The National Rabies Prevention and Control Program (NRPCP)

 a multi-agency effort in controlling and eliminating rabies in the country.

VISION

 Rabies Free Philippines by 2030

GOAL

 To end human deaths from dog-mediated rabies by 2027

Republic Act 9482

 Anti-Rabies Act of 2007

 An Act Providing for the Control and Elimination of Human and Animal Rabies, Prescribing
penalties for Violation Thereof and Appropriating Funds Thereof.

Components of the program as mandated by RA 9482 (Anti-Rabies Act of 2007)

1. Post-Exposure Prophylaxis (PEP)

 Anti-rabies treatment administered after an exposure to potentially rabid animals.

Categories of Exposure

Type of exposure Management

CATEGORY I
 Feeding/touching an animal 1. Wash exposed skin immediately with soap
 Licking of intact skin (with reliable and water.
history and thorough physical 2. No vaccine or RIG needed; Pre-exposure
examination) prophylaxis may be considered for high risk
persons.
  Exposure to patient with signs and
symptoms of rabies by sharing of
eating or drinking utensils
 Casual contact (talking to, visiting and
feeding suspected rabies cases) and
routine delivery of health care to
patient with signs and symptoms of
rabies
CATEGORY II
 Nibbling of uncovered skin with or 1) Wash wound immediately with soap and
without bruising/hematoma water for at least 10 minutes.
 Minor/superficial scratches/abrasions 2) Start vaccine immediately:
without bleeding, including those a. Complete vaccination regimen until
induced to bleed Day 28 if
 All Category II exposures on the head b. May omit Day 28 dose if
and neck area are considered
Category III and shall be managed as
such.
CATEGORY III
 Transdermal bites (puncture wounds, 1) Wash wound immediately with soap and
lacerations, avulsions) or scratches/ water for at least 10 minutes.
abrasions with spontaneous bleeding 2) Start vaccine immediately:
 Licks on broken skin or mucous c. Complete vaccination regimen until
membrane Day 28 if
 Exposure to a rabies patient through d. May omit Day 28 dose if
bites, contamination of mucous
membranes (eyes, oral/nasal
mucosa, genital/anal mucous
membrane) or open skin lesions with
body fluids through splattering and
mouth-to-mouth resuscitation.
 Unprotected handling of infected
carcass
 Ingestion of raw infected meat
 Exposure to bats
 All Category II exposures on head and
neck area

Recommended PEP Regimens for Animal Bites Treatment Centers (ABTCs/ABCs):

INTRADERMAL REGIMEN

 All Animal Bite Treatment Centers (ABTCs) are required to use only the recommended ID
regimen in managing rabies exposures/animal bites.
 ABTCs are also required to administer only vaccines approved by WHO for ID use. Patients with
hematologic conditions where IM injection is contraindicated should receive rabies vaccine by ID
route.
Updated 2-site Intradermal Regimen

Day of Immunization PVRV/PCEC Site of Injection

Day 0 0.1 mL Left and right deltoids or anterolateral thighs in infants
Day 3 0.1 mL Left and right deltoids or anterolateral thighs in infants
Day 7 0.1 mL Left and right deltoids or anterolateral thighs in infants
Day 28 0.1 mL Left and right deltoids or anterolateral thighs in infants

INTRAMASCULAR REGIMEN

 Immunocompromised patients such as those with HIV infection, cancer/etc and patients with
chronic liver disease and those taking chloroquine and systemic steroids should be given
standard IM regimen as the response to ID regimen is not optimum for these conditions.
 Vaccination should not be delayed in these circumstances as it increases the risk of rabies.

Updated 2-site Intramuscular Regimen

Day of Immunization PVRV/PCEC Site of Injection

Day 0 0.5 mL One deltoid or anterolateral thigh in infants
Day 3 0.5mL One deltoid or anterolateral thigh in infants
Day 7 0.5 mL One deltoid or anterolateral thigh in infants
Day 14 0.5 mL One deltoid or anterolateral thigh in infants
Day 28 0.5 mL One deltoid or anterolateral thigh in infants

SUPPORTING MANAGEMENT: ANTI - TETANUS VACCINATION

 All animal bite victims should receive anti-tetanus immunization considering that animal bites
are tetanus- prone wounds.

2. PRE-EXPOSURE PROPHYLAXIS (PrEP)

 Recommended for anyone who is at continual, frequent or increased risk of exposure to the
rabies virus either as a result of their residence or occupation

BENEFITS

 The need for passive immunization (RIG) is eliminated

 PEP requires booster doses only, reducing vaccination from 5 to two doses
 Protection against rabies is possible even if PEP is delayed
 Protection against inadvertent exposure to rabies is possible
 The cost of PEP is reduced

Who should receive PrEP?

 Health care workers directly involved in care of rabies patients

 Individuals directly involved in rabies control
 Personnel in rabies diagnostic laboratories
  Pet owners and household members
 Animal handlers
 Field workers such as dog vaccinators/catchers
 Veterinarians and veterinary students
 Children 5 to 14 years old living in areas where there is high incidence of rabies

3. MASS DOG VACCINATION

 This is the most effective measure to control canine rabies. The Department of Agriculture takes
the lead in mass dog vaccination campaigns and provision of animal rabies vaccine.

Comprehensive approach in mass dog vaccination

 This is done in areas where rabies is endemic, there is high human animal population density
and where LGUs are active in the implementation of the rabies program.

Risk-based Approach to Mass Dog Vaccination

 This strategic approach takes into consideration the existing rabies risk when planning for Mass
Dog Vaccination to prioritize areas where most urgent interventions will be needed to
effectively interrupt rabies virus circulation.

Elimination of rabies can be done through mass dog vaccinations highlighted in the observance of two
important national events namely:

 Celebration/Observance of Rabies Awareness Month – March

 Celebration/Observance of WORLD RABIES DAY – September 28

4. ADVOCACY FOR RESPONSIBLE PET OWNERSHIP

BE A RESPONSIBLE PET OWNER!

 Have your pet dog registered, vaccinated three (3) months old and yearly booster doses while
dog is alive
 Do not allow your pet to roam the streets or any public place without a leash
 Ensure your pets are properly fed and cared for
 As the (pet) owner, you are responsible for your pet’s bite victim’s treatment and management;
including all expenses to be incurred for treatment
 Should your pet bite a victim, it is your responsibility to ensure that your dog is properly
confined during the 14-day observation period.
 It is also your responsibility to inform and consult the Municipal Agricultural Officer/ Municipal
Veterinarian/City Veterinarian if your pet gets sick or died within the 14-day observation period
for proper sample submission to designated laboratories for rabies confirmation.

The behavioral objective of the Strategic Health Promotion and Plan 2020-2025 is by the end of 2025:

 90% or more of pet owners are practicing responsible pet ownership

NATIONAL TUBERCULOSIS PROGRAM
Tuberculosis

 Is a bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an
infected person.
 It mainly affects the lungs (pulmonary), but it can affect any part of the body, including the
abdomen, glands, bones and nervous system (extrapulmonary).
 Causative agent: Mycobacterium tuberculosis.

SIGNS AND SYMPTOMS

 Cough
o Cough for two weeks or more.
 Fever
 Chest or back pain
 Hemoptysis
 Significant Weight Loss
 Other symptoms:
o Fatigue, sweating, body malaise, shortness of breath

National Tuberculosis Program

Vision

 A country where Tb is no longer a problem

Mission

 To reduce TB burden (TB incidence and TB mortality)

 To achieve catastrophic cost of TB-affected households
 To responsively deliver TB service

Objectives:

 Improvement of access to and quality of services

 Enhancement of patients health seeking behavior
 Sustainability of support for TB control activities
 Strengthening management of TB control services at all levels

CASE FINDING

 Is a method of identifying and diagnosing TB cases among individuals suspected with signs and
symptoms of TB.
 Fundamental to case finding is the detection of infectious cases through DSSM.
 Objective: Early identification and diagnosis of TB cases.

Direct Sputum Smear Microscopy

 Is the principal diagnostic method accepted by the NTP.

  It is used to monitor progress of patients with sputum smear positive TB while they are receiving
anti TB treatment and confirm cure at the end of the treatment.

Types of Case Finding

 Active Case Finding

 Passive Case Finding

Policies

 DSSM shall be the primary diagnostic tool in the NTP case finding.
 All TB symptomatics identified shall be asked to under DSSM for diagnosis before start of the
treatment.
 The only contraindication for DSSM is hemoptysis.
 Pulmonary TB symptomatics can only undergo other diagnostic tests (such as chest x-ray and
culture) if necessary only after they have undergone DSSM with 3 sputum specimens.
 No TB diagnosis shall be made based on the results of the chest x-ray examination alone. PPD
result should not also be used as basis for TB diagnosis.

Collection and Transport of Specimen

 Submit three sputum specimen within 2 days. If quality sputum is not collected within 2 days,
the patient is given 1 week to complete the three specimen.
 If the patient fails to complete the three specimen collection within one week, another 3 sets of
specimen should be collected.

A. First spot specimen/on the spot

 It is collected at the time of consultation or as soon as the TB symptomatics is identified.

B. Early morning Specimen

 First sputum produced early in the morning immediately after waking up. It is collected by the
patient according to instructions given by the DOTS facility staff.

C. Third specimen or second spot specimen

 Is collected when the TB symptomatic comes back to the DOTS facility to submit the second
specimen.

Interpretation of Sputum Results/Laboratory Diagnosis

 Smear Positive
o At least 2 positive sputum smear result.
 Doubtful
o Only 1 positive out of 3 sputum specimens.
o Actions to take: Request for another set of 3 sputum specimens.
o Results:
 If at least 1 specimen from the second set of specimens is is positive = diagnosis
is positive
  If all 3 specimens from the second set of specimens are negative = diagnosis is
negative
 Smear Negative
o All three sputum smear results are negative.

CASE HOLDING

 Is the procedure which ensures that patients complete their treatment.

 Treatment compliance is necessary to cure TB and avoid development of drug resistance.
 Objective: Effective and complete treatment of TB cases, especially pulmonary sputum smear
positive cases.

Directly Observed Treatment, Short course (TB-DOTS)

 Is a strategy developed to ensure treatment compliance providing constant and motivational

supervision to TB patients.
 DOT works by having a responsible person referred to as treatment partner that monitors the
TB patient in taking medications every day during the whole course of treatment.

Qualified Treatment Partners

a. DOTS facility staff (midwife/nurse)

b. Trained community member (BHW/Local government official/Former TB patient)
c. Member of the patient's family - must be 18 years old and above

Types of TB Cases

 New
o A patient that is newly diagnosed for TB or who has taken anti-T drugs for less than one
month.
 Relapse
o A patient previously treated for TB, who has been declared cured or treatment
completed, and is diagnosed with bacteriologically positive TB.
 Treatment Failure
o A patient who, while on treatment, is sputum smear positive for five months or later
during the course of treatment.
 Return after Default (RAD)
o A patient who returns to treatment with positive bacteriology, following interruption of
treatment for 2 months or more.
 Transfer in
o Transferred to another facility adopting NTP policies with proper referral to confirm
treatment.

MEDICATIONS

Medications/Dosage Common Side Effects

Isoniazid (H) 300mg Peripheral Neuropathy
Ethambutol (E) 800mg Impairment of Visual Acuity
 Rifampicin (R) 450mg Orange Colored Urine
Streptomycin (S) 1g Hearing Impairment
Pyrazinamide (Z) 1g Hyperurecemia

Category of Tuberculosis Treatment regimen for adults

Category Types of TB patients Treatment regimen

Intensive phase Maintenance phase
I  New smear positive PTB. HRZE (2 months) HR (6 months)
 New smear negative PTB with
extensive parenchymal lesions on
chest x-ray
 Extrapulmonary TB
II  Treatment failure HRZES (2 months) HRE (5 months)
 Relapse + HRZE (1 month)
 Return after default (RAD)
III  New smear - negative PTB with HRZE (2 months) HRE (5 months)
minimal parenchymal lesions on
chest x-ray
IV  Chronic (still smear-positive after Second line generation antibiotics based
supervised retreatment) on results of culture and sensitivity test