Community Health Nursing: Theories, Principles and

Applications

Difference between community health nursing and public health nursing

- There is a big difference between the two fields, the COMMUNITY HEALTH is concerned with the health of the local
communities (preventive, medical and clinical care) while the PUBLIC HEALTH is concerned with the health of the
communities as a whole, especially the preventive ones.
- Public health nurses provide healthcare to people and communities who are unable to seek assistance. Community
health nursing involves advocacy and policy development to eliminate healthcare disparities.
- Public health focuses on the scientific process of preventing infectious diseases, while community health focuses
more on the overall contributors to a population's physical and mental health.

FHSIS – Field health service information system

- The primary information banking system

Active case finding – involves recording cases as they access your health facility. This is where you go out of your facility and
start looking for cases. Includes house to house case finding.

- Happens during epidemics (ex. Contact tracing)

Passive case finding – Passive case-finding requires that affected individuals are aware of their symptoms, have access to
health facilities, and are evaluated by health workers or volunteers who recognize the symptoms of TB and who have access
to a reliable laboratory.

Community Based nursing-

Community health nurse- clinical based

 Ex. School nurses, community-based nursing, home care nurses, public health nurses

Public health nurse- subset in CHN. Element in community health practice

Fundamental Concepts of Community Health Nursing

- Community / public health nursing is the synthesis of nursing practice and public health practice.
 Major goal of CHN is: to preserve the health of the community and surrounding population by
focusing on health promotion and health maintenance of individual, family and group within the
community.
- Thus, CHN / PHN is associated with health and identification of population at risks rather than
with an episodic response to patient demand.
  Mission of Public Health: is social justice that entitles all people to basic necessities, such as
adequate income and health protection, and accepts collective burdens to make possible.

Definition of Health according to:

a. WHO – a state of complete physical mental and social well-being and not merely the absence of
disease or infirmity.
 Medical Model
 Health Illness Continuum
 High level wellness Model
 Role performance Model
 Eudaemostic Model
 Agent-Host environment Model
b. Murray – a state of well-being in which the person is able to use - purposeful, adaptive, responses and
processes physically, mentally, emotionally, spiritually, and socially.
c. Pender – actualization of inherent and acquired human potential through goal directed - behavior,
competent self-care, and satisfying relationship with others.
d. Orem – a state of person that is characterized by soundness or wholeness or developed human
structures and of bodily and mental functioning.

 Social – of or relating to living together inorganized groups or similar close aggregates.

 Social health – connotes community vitality and is a result of positive interaction among groups within
the community with an emphasis on health promotion and illness prevention.
 Community – is seen as a group or collection of locality-based individuals, interacting in social units
and sharing common interests, characteristics, values, and/or goals.

Community Health Nursing as a Specialty

- Community health nurses are in a position to assist in the transition of the Philippine health Care
System from a disease-oriented system to a health-oriented system.
o The budgetary allocation for healthcare is relatively small.
- Community health activities focusing on health promotion and disease prevention are therefore the
essence.
- Nurses constitute a large group of health care workers; therefore, they are in a position to create a
health care delivery system that will meet the health-oriented needs of the people.

The Mission
- Public health with its egalitarian tradition and vision conflicts with the predominant model of market
justice that only entitles people to what they have gained through individual efforts.
- C/PHN must align themselves with public health programs that promotes and preserve the health of
populations by influencing sociocultural issues such as human rights, homelessness, violence and
stigma of illness.
 o This allows nurses to be positioned to promote the health, welfare and safety of all
individuals.

Determinants of Health
OLOF - OLOF (Optimum Level of Functioning)
1. Income and social status - higher income and social status are linked to better health.
- The greater the gap between the richest and poor health, the
greater differences in health.

2. Education – low education levels are linked with poor health, more stress and lower self-
confidence.

3. Physical Environment – safe water and clean air, healthy workplaces, safe houses communities
and roads all contribute to good health.

4. Employment and working conditions – people in employment are healthier, particularly those
who have control over their working conditions.

5. Social support networks – greater support from families, friends and communities is linked to
better health.

6. Culture – customs and traditions, and beliefs of the family and community affect health.

7. Genetics – inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing illnesses.

8. Personal behavior and coping skills – balanced eating, keeping active, smoking, drinking and
how we deal with life’s stresses and challenges all affect health.

9. Health services – access and use of services that prevent and treat disease influences health.

10. Gender – men and women suffer from different types of diseases at different ages.
Indicators of Health and Illness
- National Epidemiology Center of DOH, PSA and local health centers/offices/departments – provide
morbidity, mortality and other health status related data.
- Local health centers/offices/departments – are responsible for collecting morbidity and mortality
data and forwarding the information to the higher level of health, such as Provincial Health office.

o Nurses should participate in investigative efforts to determine what is precipitating the

increased disease rate and work to remedy the identified threats or risks.

Definitions and Focus of Public Health and Community Health

- C.E. Winslow defines public health as “The science and art of preventing diseases, prolonging life and
promoting health and efficiency through organized community effort for:

1. Sanitation of the environment

2. Control of communicable infection
3. Health education in personal hygiene
4. Organization of medical and nursing services for early detection and preventive treatment of
diseases.

Key Functions of the Nurse in Public Health

1. Assessment – regular collection, analysis and information sharing about health conditions, risks and
resources in a community.
2. Policy Development – use of information gathered during assessment to develop local and state
health policies and to direct resources towards policies.
3. Assurance – focuses on the availability of the necessary health services throughout the community. It
includes maintaining the ability of both public health agencies and private providers to manage day to
day operations and having the capacity to respond to the critical situations and emergencies.

Public health efforts focus on preventive and promotion of population health at the national and local levels.
These efforts at the national level concentrate on providing support and advisory services to public health
structures at the local level.
The local level structures provide direct services to communicate through;
1. Environmental health services which protect the public from hazards such as polluted water, air and
tainted food.
2. Personal health care services such as immunization, and family panning services, well infant and maternal
care and treatment prevalent health conditions, both communicable and non-communicable.
The terns Community Health extends the realm of public health to include organized health efforts at the
community level through both government and private efforts.
Essential Public Health Functions:
1. Health situation monitoring and analysis
2. Epidemiological surveillance / disease prevention and control
3. Development of policies and planning in public health
4. Strategic management of health systems and services for populations health gain
5. Regulation and enforcement to protect public health
6. Human resource development planning in public health
7. Health promotion, social participation and empowerment
8. Ensuring the quality of personal and population-based services
9. Research, development and implementation of innovative public health solutions

Health Prevention and Levels of Preventions

 Medical Care focuses on disease management and cure. Public health efforts
are mainly focused on health promotion and disease prevention.
 Health promotion resources directed at improving well-being
 Disease Prevention protect people from disease and effects disease.

Levels of Prevention;
1. Primary Level – relates to activities directed at preventing a problem before it occurs by
altering susceptibility or reducing exposure for susceptible individuals.
Elements:
- General health promotion
- Specific protection (ex.: Immunization, taking regular exercises, birth control,
using of condoms, regular dental care, hand-washing)

2. Secondary Level – refers to early detection and prompt intervention or early treatment, during
the early period of disease pathogenesis. (ex.: STI’s)
 Breast self-examination; help you to be familiar with how your breasts look and
feel so you can alert your healthcare professional if there are any changes.
 MRI; can help you – and your GP – determine any health risks you may face if
it's outside of the healthy range.
 HVI testing; detect the presence of the HIV virus, HIV antigens, and/or HIV
antibodies.

3. Tertiary Level – targets population that has experienced diseases or injury and focuses on
limitation of disability and rehabilitation. (ex.: teaching insulin administration at home;
screening of patients with diabetes for diabetic retinopathy to prevent progression to
blindness through prompt treatment; prevention of opportunistic infections in HIV infection;
provision of prostheses and medical devices to enable persons to take part in social life)
Definition and Focuses of Community Health Nursing, Public Health Nursing and Community
based Nursing
Community Health Nursing

- A SPECIAL FIELD OF NURSING PRACTICE

- AN ENCOMPASSING TERM.
- The American Nurses Association (ANA) - defines CHN as a synthesis of nursing practice and public
health practice applied to promoting and preserving the health of the population.
- It is considered to be a broader and more general specialty area that encompasses sub-specialties that
include;
1. Public Health Nursing
2. School Nursing
3. Home Health Nursing
4. Hospice Care
5. Independent Nursing Practice

Community Based Nursing

- Refers to application of the nursing process in caring for individuals, families and groups where they
live, work or go to school as they move through the health care system.
It’s setting specific and emphasis is on acute and chronic care. (ex.: Outpatient nursing)
- CHN practice is Population Focused.
It concentrates on specific group of people and focuses in health promotion and disease prevention.

Characteristics of Population Focused

 Focuses on entire population

 Based on assessment of the population health status
 Considers broad determinant of health
 Emphasizes on local level prevention
 Intervenes with the communities, systems, individuals and families.

Types of Information useful for Population Focus

 Demographic data
 Groups at high risk
 Services/providers available

Levels of Clientele in Community Health Nursing

1. Individual
2. Family
3. Groups/Aggregate
 4. Community

Public Health Interventions

1. Surveillance – Describes and monitors events through assessment, analysis, and interpretation of
health data for planning, implementing and evaluating public health interventions.
- part of case finding. Sometime done to look for cases.

2. Disease and other Health Event Investigation – Systematically gathers and analyzes data regarding
threats to health of populations, ascertains the source of the threat, identifies cases and others at risk
and determines control measures.
- analysis part for surveillance. Investigate and analyze.

3. Outreach – Locates population of interest and provides information, what can be done and how
services are obtained.
- reaching out to the population.

4. Screening – Identifies individuals with unrecognized health risk factors or asymptomatic.

5. Case finding – locates individuals and families with identified risk factors and connects them with
resources.
o
6. Referral and follow up – Assists individuals, families, groups, organizations and community to identify
and access necessary resources to resolve problems.

7. Case management – Optimizes self-care capabilities of individuals and families and the capacity of
systems and communities to coordinate and provide service.

8. Delegate functions – tasks that a registered nurse does under the authority of another health care
professional as allowed by law.

9. Health teaching – Communicates facts, ideas and skills.

10. Counseling – Establishes interpersonal relationships with a community, a system and a family or
individual with the intention of enhancing their capacity for self-care and coping.

11. Consultation – Seeks information and generates optional solutions to perceived problems or issues
through interactive problem solving.
- form of problem solving. Brainstorming with the doctor, nurse, and the client to perceive the
problem or issue.

12. Collaboration – Commits two or more persons or an organization to achieve a common goal through
enhancing the capacity of one or more members.
 13. Coalition building – Promotes and develops alliances among organizations or constituents for a
common purpose.

14. Community organizing – Helps community groups identify common problem goals, mobilize
resources, develop, and implement strategies for realizing they have collectively set.

15. Advocacy – Acting on someone’s behalf.

“The processes by which the actions of individuals or groups attempt to bring about social
and/or organization change on behalf of a particular health goal, program, interest, or
population.”

16. Social Marketing – utilizes marketing principles and technology for programs designed to influence
the knowledge attitudes, values and beliefs.
- strategy to influence the client to access the service by changing their attitudes, values, and
beliefs.

17. Policy development and enforcement – Places issues on decision makers. Compels others to comply
the law, rules, regulation, ordinances and policies.

Competency Standards in Community Health Nursing

1. Safe and quality nursing care
2. Managing or resources and environment
3. Health education
- to empower clients.
4. Legal responsibility
5. Ethico-moral responsibility
6. Personal and professional development
7. Quality improvement
8. Research
9. Records management
10. Communication
11. Collaboration and teamwork

EMERGING FIELDS OF CHN IN THE PHILIPPINES

 HOME HEALTH CARE – this practice involves providing nursing care to individuals and families in
their own places of residence mainly to minimize the effects of illness and disability.
 HOSPICE HOME CARE – homecare rendered to the terminally ill. Palliative care is particularly
important.

HISTORY OF PUBLIC HEALTH AND PUBLIC HEALTH NURSING IN THE PHILIPPINES

1577 - Franciscan FriarJuan Clemente opened medical dispensary in Intramuros for the indigent
1690 – Dominican Father Juan de Pergero worked toward installing a water system in San Juan del Monte and
Manila
1805 – smallpox vaccination was introduced by Franciwsco de Balmis , the personal physician of King Charles IV of
Spain
1876 – first medicos titulares were appointed by the Spanish government
1888 - 2-year courses consisting of fundamental medical and dental subjects was first offered in the University of
Santo Tomas. Graduated were known as “cirujanosministrantes” and serve as male nurses and sanitation
inspectors
1901 – United States Philippines Commission, through Act 157, created the Board of Health of the Philippine
Islands with a Commissioner of the Public Health, as its chief executive officer (now the Department of Health)
Fajardo Act of 1912 – created sanitary divisions made up of one to four municipalities. Each sanitary division had
a president who had to be a physician
1915 - the Philippine General hospital began to extend public health nursing services in the homes of patients by
organizing a unit called Social and Home Care services
Asociacion Feminista Filipina (1905) – La gota de Leche was the first center dedicated to the service of the
mothers and babies
1947 – the Department of Health was reorganized into bureaus: quarantine, hospitals that took charge of the
municipal and charity clinics and health with the sanitary divisions under it.
1954 – Congress passed RA 1082 or the Rural Health Act that provided the creation of RHU in every municipality
RA 1891 – enacted in 1957 amend certain provisions in the Rural Health Act - Created 8 categories of rural health
units corresponding to the population size of the municipalities
RA 7160 (Local Government Code) – enacted in 1991, amended that devolution of basic health services including
health services, to local government units and the establishment of a local health board in every province and city
of municipality.

Theoretical foundations of community health nursing practice

 HISTORICAL PERSPECTIVE ON NURSING THEORY

Florence Nightingale was the first nurse to formulate a conceptual foundation for nursing practice.
 She believed that clean water, clean linen, access to adequate sanitation and a quiet
environment would improve health outcomes.
Other early nursing theories were extremely narrow and depicted health care situations that
involved only one nurse and one patient. Noticeably, the family and other health care
professionals were absent from the context of the theories.
 From 1980 onwards, several nursing theorists including, Dorothy Johnson, Sister Callista Roy,
Imogene King, Betty Neuman and Jean Watson have included community perspectives in their
definition of health.

 HOW THEORY PROIVIDES DIRECTION TO NURSING

The goal of theory is to improve nursing practice by acting as a guide.

o General Systems Theory

 This theory is the basis, in part, of several nursing theories.
 It is applicable to the different levels of the community health nurse’s clientele:
individuals, families, groups or aggregates and communities.
 The client is considered as a set of interacting elements that exchange energy,
matter or information with the external environment to exist (Katz and Kahn,
1966, von Bertalanffy, 1968)

o This theory is useful when analyzing interrelationships of the elements within the client and
the environment.
For example: the family has the basic structures that all open systems have.
 It has boundaries that separate it from the environment.
 Culture and the Family Code dictate the boundaries of the Filipino Family.
 The family environment constitutes everything outside its boundaries that may affect it;
the family home and the community and its institutions make up the immediate
environment and should be considered in the assessment of family health status.
 The family gets inputs of matter (food, water, energy, and information) from the
government.
 Outputs are material products, energy and information that result from the family’s
processing of inputs.
o Examples are; health practices and the health status of the family
members.
 Feedback is the information from the environment directed back to the system, it
allows the system to make the necessary adjustments for better functioning.
 Subsystems (a self-contained system within a larger system) are the components of a
system that interact to accomplish their own purpose. (Family members)
 Suprasystems (a highly complex system, such as a nation or society) are a bigger system
composed of families who interrelate with and affect one another. (Families)

o Social Learning Theory

 It is based on the belief that learning takes place in social context; people learn
from one another and learning is promoted by modeling or observing other
people.
 It assumes that all personas are thinking beings that are capable of making
decisions and acting according to expected consequences of their behavior.
 The environment affects learning but learning outcomes depend on the
learner’s individual characteristics.
 Application of the theory can be done by;
 Catching the person’s attention with different strategies
 Promoting retention of learning
 Providing opportunities for reproduction or imitation of the procedures
 Motivating the person by explaining the benefits possible by practicing the behavior

o The Health Belief Model

 Initially proposed in 1958, the model provides the basis for much of the practice
of health education and promotion today.
 This model found that information alone is rarely enough to motivate people to
act for their health.
 Individuals must know what to do and how to do it before they can take
action.

Concept definition:
Perceived susceptibility – one’s belief regarding the chance of getting a given condition.
Perceived severity – one’s belief in 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 an action – strategies or conditions in one’s ability to take action to reduce
health risks.

The model’s concepts all relate to the client’s perceptions

for example: The cue to action in the prevention of dengue fever may be provided through
an information campaign. This makes the people in the barangay aware of the disease and
that everyone is susceptible to the possibly fatal disease.
- The HBM would be used by the nurse to help clients in making behavior modification to avoid
dengue.

o Milio’s Framework for Prevention

 Nancy Milio (1976) proposed that health deficits often result from an imbalance
between a population’s health needs and its health sustaining resources.
 She stated that diseases associated with excess occurred in affluent societies (obesity)
and diseases that result from inadequacies in food, shelter and water afflict the poor.
Therefore, poor people in affluent societies experience the least desirable combination
of factors.
  Personal and societal resources affect the range of health promoting or health
damaging choices available to individuals. Personal resources include the individual’s
awareness, knowledge and health beliefs. Money and time are also personal resources.
 She proposed that most human beings make the easiest choices available to them most
of the time. Health promoting choices must be more readily available and less costly
than health damaging options for individuals to gain health.
This theory is broader than the HBM, it includes economic, political and environmental
health determinants rather than just the individual’s perceptions.
This theory encourages the nurse to understand the health behaviors in the context of their
societal milieu.

o Pender’s Health Promotion Model

 The model explores many biopsychosocial factors that influence individuals to
pursue health promotion activities.
 The model depicts complex multidimensional factors which people interact
with as they work to achieve optimum health.

o The Transtheoretical Model

 This model combines several theories of intervention.

 It is based on the assumption that behavior change takes place over time, and
progresses through stages.
o Each stage is stable and is open to change; meaning --- one may stop in
one stage, progress to the next stage or return to a previous stage.
- Change is difficult. People may resist change for many reasons.
Change may be unpleasant, require giving up pleasure, be
painful, stressful, etc.

o PRECEDE – PROCEED Model

 It provides a model for community assessment, health education planning, and
evaluation.

PRECEDE; stands for predisposing, reinforcing and enabling constructs in educational diagnosis
and evaluation is used for community diagnosis.

PROCEED; stands for policy, regulatory, and organizational constructs in education and
environmental development, is a model for implementing and evaluating health programs
based on PRECEDE.

 Predisposing factors: Factors or conditions that render an individual vulnerable to a

disease or disorder.
o people’s characteristics that motivate them toward health-related
behavior.
 Enabling factors: refer to individual or structural resources enabling or increasing the
likelihood of service use.
o conditions in people and the environment that facilitate or impede
health related behavior.
 Reinforcing factors: rewards or punishments following or anticipated as a consequence
of a behavior
o feedback given by support persons or groups resulting from the
performance of health-related behavior.