COMMUNITY HEALTH NURSING 2

I. Community Health Nursing:  To this end, the goal of

community health nursing is to
A. According to Clark: “synthesis of help communities and families
nursing knowledge and practice to cope with the discontinuities
and the science and practice of in health and threats.
public health, implemented via a
systematic use of the nursing Objectives:
process and other process to
 To participate in the
promote health and prevent illness
development of an overall
in population group”.
health plan for the community
 Community health nursing is
and its implementation and
one of the two major fields of
evaluation.
nursing in the Philippines.
 To provide quality nursing
 The other is hospital nursing.
services to individuals, families
Those who work in rural
and communities utilizing as
health units (RHUs) or health
basis, the standards set for
centers are community health
community health nursing
nurses and are officially called
practice.
public health nurses (PHNs).
 Occupational nurses  To coordinate nursing services
(company nurses) and School with various members of the
health nurses are classified as health team, community leaders
community health nurses. and significant others GO and
NGOs in achieving the aims of
 According to American Nurses
public health services within
Association:
the community.
 Community health nursing
practice promotes and  To participate in and/or conduct
preserves the health of research relevant to community
populations by integrating the health and community health
skills and knowledge relevant nursing services and
to both nursing and public disseminate their results for
health. improvement of health care.
 The practice is comprehensive  To provide community health
and general and is not limited nursing personnel with
to a particular age or opportunities for continuing
diagnostic group. education and professional
 It is continual, and it is not growth through staff
limited to episodic care. development.
 Community health nursing
practice includes nursing Important Points in Community Health
directed to individuals, Nursing:
families; the dominant  the goal of professional practice is
responsibility is to the the promotion and prevention of
population as a whole. the health of populations;
 the nature of practice is
B. Philosophy and Principles Goal: comprehensive, general, continual
 The ultimate goal of and not episodic;
community health services is to  the knowledge base comes from
raise the level of health of the the nursing and public health;
citizenry.

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 the different levels of clientele-  Settings for community health

individuals, families and groups; nursing can be grouped into six
 the practitioner's recognition of the categories:
primacy of the population as a  Homes
whole  Ambulatory care setting
 Schools
C. Features of Community Health  Occupational health settings
Nursing  residential institutions
 The community at large
Characteristics or Distinguishing  Community health nursing
Attributes of Community Health practice is not limited to a specific
Nursing: area but can be practiced
 greater control for both the nurse anywhere.
and the client in making decisions
related to health care; Clients of the Community Health
 collaboration between nurse and Nurse:
client as equals;  Individual – Sick or well on a
 recognition of the impact of daily basis. These are the people
different factors on health; who consult at the health center
 Nurses greater awareness of their and receive health services such as
client's lives and situations. prenatal supervision, well-child
follow-ups and morbidity services.
The six basic elements of nursing  These also include clients with
practice incorporated in community chronic illnesses such as diabetes
health programs and services are: mellitus and hypertension who
◦ Promotion of healthful living go to the health center for blood
◦ Prevention of health problems sugar and blood pressure
◦ Treatment of disorders monitoring.
 Individuals as clients are also
◦ Rehabilitation
seen during home follow-ups,
◦ Evaluation
school health consultation,
◦ Research workplace visit-conference and
other community-based activities
Major Roles: such as case finding, screening,
 The focus of nursing includes not health education class, nutrition
only the individual, but also the campaign and promotion of
family and the community, healthy lifestyle.
meeting these multiple needs  Family – The family is a very
requires multiple roles such as: important social institution that
performs two major functions:
 Care provider Reproduction and Socialization. It
 Educator is generally considered as the
 Advocate basic unit of care in community
 Manager health nursing.
 Collaborator
 Population Group – or
 Leader
“aggregate” is a group of people
 Researcher
who share common characteristics,
developmental stage or common
Major Settings:
exposure to particular
environmental factors. These

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includes children, men, women,  Origin of the Health Belief

farmers, factory workers, Model
commercial workers, prisoners,  The health belief model was
military men and elderly. created in the 1950s by social
 Community – is a group of scientists who wanted to
people sharing common understand why few people
geographic boundaries and/or responded to a campaign for
common values and interests. tuberculosis (TB) screening.
 The scientists discovered that
Public Health (C.E. Winslow) – is a people were not participating
science and art of preventing disease, because they neither had
prolonging life and promoting health and symptoms nor recognized
efficiency through organized community their risk, or susceptibility, to
effort for TB. The thought of taking
o Sanitation of the time to have a screening test
environment thus felt like a burden: the
o Control of communicable barriers (not having symptoms
infections and the need to take a test)
o Education of the individual outweighed the perceived
in personal hygiene benefits: in this case,
o Organization of medical treatment for TB if needed.
and nursing services for the  The Health Belief Model is a
early diagnosis and theoretical model that can be used
preventive treatment of to guide health promotion and
disease disease prevention programs.
o Development of the social  It is used to explain and
machinery to ensure predict individual
everyone a standard of changes in health
living adequate for the behaviors. It is one of
maintenance of health, so the most widely used
organizing these benefits as models for
to enable every citizen to understanding health
realize his birthright of behaviors.
health and longevity.  Key elements of the Health Belief
Model focus on individual beliefs
Public Health Nursing- a field of about health conditions, which
professional practice in nursing and in predict individual health-related
public health in which technical nursing, behaviors. The model defines the
interpersonal, analytical, and key factors that influence health
organizational skills are applied to behaviors as an individual's
problems of health as they affect the perceived threat to sickness or
community. disease (perceived susceptibility),
o In the Philippines, PHN is seen as a belief of consequence (perceived
subspecialty nursing practice severity), potential positive
generally delivered within “official” benefits of action (perceived
or government agencies. benefits), perceived barriers to
action, exposure to factors that
D. Theoretical Models/ Approaches prompt action (cues to action), and
1. Health Belief Model (HBM) confidence in ability to succeed
(self-efficacy).

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 Health Belief Model as Nursing Health, University of North

Tool Carolina at Chapel Hill. Dr. Milio's
 The health belief model career was given its foundation
asserts that when a person during her high school years in
believes he or she is Denby High School, Detroit,
susceptible to a health Michigan.
problem with severe  She earned her Bachelor of Science
consequences, the person will degree (B.S., Nursing, 1960) and
more likely conclude that the master's degree (M.A., Sociology,
benefits outweigh the barriers 1965) at Wayne State University,
associated with changing Detroit, and her PhD at Yale
one's behavior to prevent the University (dissertation title: The
problem. The health belief Career of an Innovative Project: A
model is a great tool for Study of Inter-organizational
nurses, offering them Strategies and Decision-Making
a theoretical framework for Among Health Organizations).
helping their patients prevent  She is a leader in public health
chronic disease or, if disease policy and education, who
is present, improve quality of originated the notion of healthy
life. public policy which addresses the
 Nurses can use this model to effects of all areas of public policy
clarify patients' perceptions of on health and has been adopted
risk and why they behave in a internationally, including by the
way that is harmful; this World Health Organization.
enables nurses to apply  Milio’s Framework for
strategies that influence Prevention
patients to make healthy  Nancy Milio developed a
lifestyle changes. framework for prevention that
 Patients' perceptions can be includes concepts of community
affected by age, sex, and – oriented, population- focused
personality. Consider your care.
patients who are overweight  Milio stated that behavioural
and diabetic or those who patterns of the populations-and
have high blood pressure and individuals who make up
eat processed convenience populations – are a result of
foods high in sodium. Think habitual selection from limited
about those who never use choices.
sunscreen or have a family  She challenged the common
history of cancer yet refuse notion that a main determinant
screening tests. You can use for unhealthful behavioral choice
the health belief model in all is lack of knowledge.
of these situations.  Milio’s framework described a
sometimes neglected role of
2. Milio’s Framework for community health nursing to
Prevention examine the determinants of a
 Nancy Rosalie Milio, Ph.D., community’s health and attempt
FAPHA, FAAN, is Professor to influence those determinants
Emeritus of Nursing and Professor through public policy.
Emeritus of Health Policy and
Administration, School of Public

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3. Nola Pender’s Health quality of life at all stages of

Promotion development.
 Nola J. Pender is a nursing  The final behavioral demand is
theorist, author, and academic. also influenced by the immediate
She is a professor emerita of competing demand and
nursing at the University of preferences, which can derail
Michigan. She created the intended actions for promoting
Health Promotion Model. She health.
has been designated a Living  The Health Promotion Model
Legend of the American makes four assumptions:
Academy of Nursing. 1. Individuals seek to actively
 The Health Promotion Model regulate their own behavior.
was designed by Nola J. 2. Individuals, in all their
Pender to be a “complementary biopsychosocial complexity,
counterpart to models of health interact with the environment,
protection.” progressively transforming the
 It defines health as a positive environment as well as being
dynamic state rather than simply transformed over time.
the absence of disease. Health 3. Health professionals, such as
promotion is directed at nurses, constitute a part of the
increasing a patient’s level of interpersonal environment,
well-being. The health promotion which exerts influence on people
model describes the through their life span.
multidimensional nature of 4. Self-initiated reconfiguration of
persons as they interact within the person-environment
their environment to pursue interactive patterns is essential to
health. changing behavior.
 Pender’s model focuses on three 4. Lawrence Green’s PRECEDE-
areas: individual characteristics and PROCEED MODEL
experiences, behavior-specific (PRECEDE=Predisposing,
cognitions and affect, and Reinforcing, Enabling Constructs
behavioral outcomes. in Educational Diagnosis and
 The theory notes that each Evaluation)
person has unique personal 5. (PROCEED= Policy,
characteristics and experiences Regulatory and Organizational
that affect subsequent actions. and Environmental
 The set of variables for behavior Development)
specific knowledge and affect  Lawrence W. Green is an American
have important motivational specialist in public health education.
significance. He is best known by health
 The variables can be modified education researchers as the
through nursing actions. originator of the PRECEDE model
 Health promoting behavior is the and co-developer of the PRECEDE-
desired behavioral outcome, PROCEED model, which has been
which makes it the end point in used throughout the world to guide
the Health Promotion Model. health program intervention design,
 These behaviors should result in implementation, and evaluation and
improved health, enhanced has led to more than 1000 published
functional ability and better studies, applications and

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commentaries on the model in the will take an active part in defining

professional and scientific literature. their own problems, establishing
◦ Dr. Green received his B.S. in their goals and developing their
1962 from the University of solutions.
California-Berkeley. He then  In this framework, health behavior
became a Ford Foundation project is regarded as being influenced by
associate and a commissioned both individual and environmental
officer of the US Public Health factors, and hence has two distinct
Service with the University of parts.
California Family Planning ◦ First is an "educational
Research and Development diagnosis" – PRECEDE, an
Project in Dhaka, East Pakistan acronym
(now Bangladesh), serving from for Predisposing, Reinforcing
1963 through 1965. He returned to and Enabling Constructs
Berkeley, where he earned his in Educational Diagnosis
M.P.H. in 1966 and Dr.P.H. in and Evaluation.
1968, both in public health ◦ Second is an "ecological
education. From 1968 to 1970, he diagnosis" – PROCEED,
was lecturer and doctoral program for Policy, Regulatory,
coordinator at Berkeley's School and Organizational Constructs
of Public Health. in Educational
and Environmental Developm
 The PRECEDE–PROCEED ent.
model is a cost–benefit evaluation  The model is multidimensional and
framework proposed in 1974 that is founded in the social/behavioral
can help health program planners, sciences, epidemiology,
policy makers and other evaluators, administration, and education. The
analyze situations and design health systematic use of the framework in
programs efficiently. a series of clinical and field trials
◦ It provides a comprehensive confirmed the utility and predictive
structure for assessing health and validity of the model as a planning
quality of life needs, and for tool.
designing, implementing and
evaluating health promotion and
other public health programs to
meet those needs.
◦ One purpose and guiding principle
of the PRECEDE–PROCEED
model is to direct initial attention
to outcomes, rather than inputs.
◦ It guides planners through a
process that starts with desired
outcomes and then works
backwards in the causal chain to The PRECEDE–PROCEED planning
identify a mix of strategies for model consists of four planning phases,
achieving those objectives. one implementation phase, and 3
◦ A fundamental assumption of the evaluation phases.
model is the active participation of PRECEDE PROCEED
its intended audience — that is, phases phases
that the participants ("consumers")

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Phase 1 – Phase 5 – be able to see the issues just as the

Social Implementatio community sees them.
Diagnosis n
Phase 2 – Epidemiological, Behavioral,
Phase 2 – and Environmental Diagnosis
Epidemiologica Phase 6 – ◦ Epidemiological diagnosis deals
l, Behavioral & Process with determining and focusing on
Environmental Evaluation specific health issue(s) of the
Diagnosis community, and the behavioral and
Phase 3 – environmental factors related to
Phase 7 –
Educational & prioritized health needs of the
Impact
Ecological community. Based on these
Evaluation
Diagnosis priorities, achievable program goals
Phase 4 – and objectives for the program
Phase 8 – being developed are established.
Administrative
Outcome  Epidemiological assessment may
& Policy
Evaluation include secondary data analysis
Diagnosis
or original data collection —
examples of epidemiological
data include vital statistics, state
Phase 1 – Social Diagnosis and national health surveys,
◦ The first stage in the program medical and administrative
planning phase deals with records, etc. Genetic factors,
identifying and evaluating the social although not directly changeable
problems that affect the quality of through a health promotion
life of a population of interest. program, are becoming
◦ Social assessment is the increasingly important in
"application, through broad understanding health problems
participation, of multiple sources of and counselling people with
information, both objective and genetic risks, or may be useful in
subjective, designed to expand the identifying high-risk groups for
mutual understanding of people intervention.
regarding their aspirations for the ◦ Behavioral diagnosis — This is the
common good". analysis of behavioral links to the
◦ During this stage, the program goals or problems that are identified
planners try to gain an in the social or epidemiological
understanding of the social diagnosis.
problems that affect the quality of  The behavioral ascertainment of
life of the community and its a health issue is understood,
members, their strengths, firstly, through those behaviors
weaknesses, and resources; and that exemplify the severity of the
their readiness to change. disease (e.g. tobacco use among
◦ This is done through various teenagers); secondly, through the
activities such as developing a behavior of the individuals who
planning committee, holding directly affect the individual at
community forums, and risk (e.g. parents of teenagers
conducting focus groups, surveys, who keep cigarettes at home);
and/or interviews. These activities and thirdly, through the actions
will engage the beneficiaries in the of the decision-makers that
planning process and planners will affects the environment of the

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individuals at risk (e.g. law include programs, services,

enforcement actions that restrict availability and accessibility of
teens' access to cigarettes). resources, or new skills required
 Once behavioral diagnosis is to enable behavior change.
completed for each health  Reinforcing factors are rewards
problem identified, the planner is or punishments following or
able to develop more specific anticipated as a consequence of a
and effective interventions. behavior. They serve to
◦ Environmental diagnosis — This is strengthen the motivation for a
a parallel analysis of social and behavior. Some of the
physical environmental factors other reinforcing factors include social
than specific actions that could be support, peer support, etc.
linked to behaviors. In this
assessment, environmental factors Phase 4 – Administrative and Policy
beyond the control of the individual Diagnosis
are modified to influence the health ◦ This phase focuses on the
outcome. For example, poor administrative and organizational
nutritional status among children concerns that must be addressed
may be due to the availability of prior to program implementation.
unhealthful foods in school. This ◦ This includes assessment of
may require not only educational resources, development and
interventions, but also additional allocation of budgets, looking at
strategies such as influencing the organizational barriers, and
behaviors of a school's food service coordination of the program with
managers. other departments, including
external organizations and the
Phase 3 – Educational and Ecological community.
Diagnosis ◦ Administrative diagnosis assesses
◦ Once the behavioral and policies, resources, circumstances
environmental factors are identified and prevailing organizational
and interventions selected, planners situations that could hinder or
can start to work on selecting facilitate the development of the
factors that, if modified, will most health program.
likely result in behavior change, as ◦ Policy diagnosis assesses the
well as sustain it. These factors are compatibility of program goals and
classified as 1) predisposing, 2) objectives with those of the
enabling, and 3) reinforcing factors. organization and its administration.
 Predisposing factors are any This evaluates whether program
characteristics of a person or goals fit into the mission statements,
population that motivate rules and regulations that are needed
behavior prior to or during the for the implementation and
occurrence of that behavior. sustainability of the program.
They include an individual's
knowledge, beliefs, values, and Phase 5 – Implementation of the
attitudes. Program
 Enabling factors are those
characteristics of the Phase 6 – Process Evaluation
environment that facilitate action ◦ This phase is used to evaluate the
and any skill or resource required process by which the program is
to attain specific behavior. They being implemented. This phase

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determines whether the program is  tools for measuring and

being implemented according to the analyzing community health
protocol, and determines whether the problems;
objectives of the program are being  Application of principles of
met. It also helps identify management and organization in
modifications that may be needed to the delivery of health services to
improve the program. the community.

Phase 7 – Impact Evaluation 1. School Health Nursing:

◦ This phase measures the effectiveness  School health nursing is primarily
of the program with regards to the determined by the characteristics of
intermediate objectives as well as the their clientele, which is their age,
changes in predisposing, enabling, developmental stage and their
and reinforcing factors. Often this common health problems and
phase is used to evaluate the concerns.
performance of educators.  School health nursing aims at
promoting the health of school
Phase 8 – Outcome Evaluation children and preventing health
◦ This phase measures change in terms problems that would hinder
of overall objectives as well as their learning and performance
changes in health and social benefits of their developmental tasks.
or quality of life. That is, it
determines the effect of the program 2. Occupational health nursing:
in the health and quality of life of the
community.  Occupational health nursing is
nursing in the work place; it is
community health nursing
focused on people in their
places of work.
 Occupational health nursing is
E. Different Fields in Community the specialty practice that
Health Nursing provides for and delivers
health care services to
 Community health nursing is a workers and worker
specialized field of nursing practice. population.
Its basic knowledge and skills are  The practice focuses on
anchored on nursing theories and promotion, protection, and
important concepts from the science restoration of worker's health
of public health such as: within the context of a safe
 emphasis on the importance of and healthy work
the “greatest good for the environment.
greatest number”;  The foundation of
 assessing health needs, planning, occupational health nursing
implementing and evaluating the practice is research-based
impact of health services on with an emphasis on
population groups; optimizing health, preventing
 priority of health-promotive and illness and injury, and
disease-preventive strategies reducing health hazards.
over curative interventions; Occupational health nursing is “aimed at
assisting workers in all occupations to

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cope with actual and potential stresses in informal groups aggregates

relation to their work and work (Shuster and Goeppinger, 2008)
environment. Aggregates are subgroups or
subpopulations that have some common
3. Community Mental Health characteristics or concerns.
Nursing:
 Mental health nursing deals Four defining attributes of a community
with patient with mental (Maurer and Smith)
disorders.  People
II. Concept of the Community  Place
Community  Interaction
 Community is a social unit (a  Common characteristics, interests,
group of living things) with or goals.
commonality such as norms,
religion, values, customs, or Two main types of communities
identity. (Maurer and Smith)
 Communities may share a sense of 1. Geopolitical communities
place situated in a given  the most traditionally recognized or
geographical area (e.g. a country, imagined when considering the
village, town, or neighborhood) or term community
in virtual space through  Are defined or formed by both
communication platforms. natural and man-made boundaries
 It is a group of living things and include barangays,
sharing the same environment. municipalities, cities, provinces,
They usually have shared interests. regions and nations
In human communities, people  Other commonly recognized
have some of the same beliefs and geopolitical communities are
needs, and this affects the identity congressional districts and
of the group and the people in it. neighborhoods.
 Is a collection of people who  Is Also called territorial
interact with one another and communities
whose common interests or 2. Phenomenological communities
characteristics form the basis for a  refer to relational, interactive
sense of unity or belonging. groups, in which the place or
(Allender et al., 2009) setting is more abstract, and people
 A group of people who share share a group perspective or
something in common and interact identify based on culture, values,
with one another, who may exhibit history, interests, and goals.
a commitment with one another  Examples schools, colleges,
and may share a geographic universities, churches, mosques
boundary. (Lundy and Janes, 2009) and various groups or
 A group of people who share organizations
common interests, who interact  Can be described as functional
with each other, and who function communities
collectively within a defined social
structure to address common
concerns (Clark, 2008) Types of Community
 Locality-based entity, composed of Rural Community
systems of formal organizations  Rural area or countryside is a
reflecting society’s institutions, geographic area that is located

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outside towns and cities. Typical for health such as sidewalks and
rural areas have a low population public transit.
density and small settlements.  The built environment also creates
Agricultural areas are commonly challenges to health such as
rural, as are other types of areas sedentary commuting and air
such as forests. quality.
 The areas located outside of cities  Many urban areas and their nearby
and towns are termed “rural”. communities that are socio-
Rural areas have low population economically connected are
density. Rural areas often have a grouped together into metropolitan
lot of undeveloped land, farmland areas.
or forest
 People in rural areas have unique Suburban
differences and challenges when it  A suburb or suburban area is a
comes to economic and community mixed-use or residential area,
development and health. Rural existing either as part of a city or
areas often have fewer service urban area or as a separate
providers and resources for jobs, residential community within
health care and community commuting distance of a city.
services.  Areas are lower density areas that
 Rural communities often have separate residential and
fewer job opportunities and lower commercial areas from one
wages. another.
 Overall, rural residents are at  They are either part of a city or
greater risk for poor health urban area, or exist as a separate
outcomes, with higher rates of residential community within
preventable conditions such as commuting distance of a city. As
obesity, diabetes and injury and cars became the dominant way for
higher rates of unhealthy behaviors people to get to work, suburbs
such as smoking, physical grew.
inactivity and poor nutrition.  Suburban communities tend to be
the most affluent, enjoying the
Urban areas highest socioeconomic status when
 An urban area, or built-up area, is a ranked with rural and urban
human settlement with a high populations.
population density and  Suburban communities often have
infrastructure of built environment. more job opportunities than rural
Urban areas are created through areas though maybe not as many as
urbanization and are categorized by urban areas.
urban morphology as cities, towns,  Overall, suburban residents seem to
conurbations or suburbs. have better health than rural or
 Are locations with high population inner city residents.
density.  People living in suburban
 Urban areas are in cities and towns. communities tend to be more
An urban area is often the main educated. Suburban residents are
area of employment. the most likely to have adequate
 Urban areas have the most human- health insurance and benefit from
built structures. This built longer life expectancy, more access
environment creates opportunities to health care and higher quality of
care.

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 People living in suburban areas

often benefit from access to and
choices for nutritious food, spaces
for physical activity and recreation,
utilities such as water and sewer,
health and dental care,
transportation and even digital
telecommunications.

Determinants of Health and Disease

 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 their
working conditions.
 Social support networks- greater
support from families, friends and
communities is linked to a 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 types of diseases at
different ages.

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Health Statistics and Epidemiology population using data obtained during two
census periods.
A. Tools
1. Demography - Is the science which Absolute increase
deals with the study of the human per year measures the number of people that
population's size, composition, and are added to the population per year. This is
distribution in space. computed using the following data:
a. Sources of Demographic data: Absolute increase per year
 Census = Pt – Po
 Census is defined as an official and
periodic enumeration of population. t
 During the census, demographic, Where:
economic and social data are collected Pt – population size at a later year
from a specified population group. Po – population size at an earlier year
 These data are then collated, t - Number of years between time o and time
synthesized, and are made known to the t
public for purpose of determining and
explaining trends in terms of Relative increase
population changes and planning is the crucial difference between the two
programs and services. censuses counts expressed in recent years
relative to the population size made during an
There are two ways of assigning people earlier year census.
when the census is being taken:
 de jure method – is done when people Relative increase =
are assigned to the place where they Pt - Po
usually live regardless of where they are Po
at the time of the census.
 de facto – is used when the people are Where:
assigned to the place where they are Pt – population size at a later time
physically present at the time of the Po- population size at an earlier time
census regardless of their usual place of
residence.

b. Population size
 Refers to the number of people in a c. Population composition refers to a certain
given place or area at a given time. variable such as sex, age, occupation, and
 Population size allows the nurse to educational level.
make comparisons about population
changes over time.  Sex composition – compares the
 One Method of measuring the number of males to the number of
population size is by determining the females in the population.
increase in the population resulting
from excess of births compared to Sex Ratio = Number of males X 100
deaths. This can be done in two ways: Number of females
The sex ratio represents the number of males
Natural increase for every 100 females in the population.
simply the difference between the number of
births and the number of deaths occurring in a  Age composition:
population in a specified period of time:
1. Median Age – divides the population into
Natural increase = two equal parts. So, if the median age is said to
Number of births – Number of deaths be19 years old, it means half of the population
The second method of measuring population belongs to 19 years and above, while the other
size is to determine the increase in the half belongs to ages below 19 years old.

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2. Dependency Ratio – compares the number

of economically dependent with economically
productive group in the population.
0 – 14 years old and 65 years old and  Maternal Mortality Rate (MMR). This
above are considered economically rate measures the risk of dying from
dependent. causes with childbirth. Maternal death is
15– 64 years old – are considered defined as the death of a mother directly
productive age group due to pregnancy, labor and puerperium
within 90 days of delivery. The MMR is
d. Population Distribution – it can be obtained from the following formula:
described in terms of urban-rural
distribution, population density and
crowding index.
 Urban-Rural Distribution – simply  Crude Birth Rate – The Crude birth rate
illustrates the proportion of people is only a rough measure of fertility in the
living in urban compared to the rural population since it makes use of the mid-
areas. year population (which ignores the number
 Crowding index – describe the ease by of men and women incapable of child
which a communicable disease can be bearing) as its denominator. This rate is
transmitted from one host to another obtained using the following formula:
susceptible host. This is described by
dividing the number of persons in a
household with the number of rooms
used by the family for sleeping.
 Population density – determine how  The SWAROOP’S INDEX is another
congested a place is. It can be proportional mortality indicator. It gives
computed by dividing the number of the percentage of all deaths, which occur
people living in a given land area. in persons 50 years and above as shown in
the following formula:
2. Vital and Health Statistics/Indicators
 General fertility Rate (GFR) – This rate is
a more refined measure than crude birth
rate because the denominator makes use of
the number of women of a child-bearing
age. However, it is still limited in the
sense that not all women of child-bearing
age are expected to give birth for various
reasons. This rate is obtained by the
following formula:

GFR=
Total live births in the calendar year
X 100
Mid-year population of women of Child-
bearing age (15-44 or 48 years) for that year

 Infant Mortality Rate (IMR). This rate is

considered one of the most sensitive
indices of the health conditions obtained in
a population. Infant deaths are associated
with acute communicable diseases and
such factors as poor environmental
sanitation and poor hygiene. This rate is
obtained by the following formula:

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The Swaroop’s index is directly  The leading cause of death in 2017 in the
proportional to the health status of a Philippines was: Although the ischaemic
population. heart diseases were the leading cause of
 For example, a Swaroop’s index of 80% death in 2016, the numerical change is
means that only 20% of the population is statistically significant.
dying before the age of 50 years, which is

LEADING CAUSES OF Le
DEATH TIME SERIES WITH
NUMBER

Cause of Death 2013 2014 2015 2016 2017

Ischaemic heart diseases 65,378 65,551 68,572 74,134 84,120

Neoplasms 53,601 55,588 58,715 60,470 64,125

Cerebrovascular diseases 54,578 52,894 58,310 56,938 59,774

Pneumonia 53,101 53,689 49,595 57,809 57,210

Diabetes Mellitus 27,064 31,539 34,050 33,295 30,932

Hypertensive diseases 29,067 34,902 34,506 33,452 26,471

Chronic lower respiratory

23,867 24,686 23,760 24,365 24,818
infections

Respiratory Tuberculosis 22,013 23,157 24,644 24,462 22,523

Other heart diseases 33,027 34,141 31,729 28,641 22,134

Remainder of the diseases of the

16,785 17,220 18,061 19,759 15,717
genitourinary system
a good indication of the health of a ading Causes of Morbidity
population.
 A low index, on the other hand, implies
the life expectancy is short and people die
more of acute and communicable diseases.

 Morbidity rates - refer to the number of

people within a certain unit of the general
population who have a certain disease or
condition.
 The unit of population is generally
100,000, although this may vary
depending on location and the
condition in question.
 Morbidity rates are used to help
determine the overall prevalence of a
specific illness.
 Morbidity rate = (number of new cases
of a disease during a specific period)/
(number of individuals in the
population)
 LEADING CAUSES OF DEATH, 2017

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MORBIDITY: 10 Leading Causes, Number and Rate Terms used in epidemiology:

 Endemic – the constant
2010* presence of a disease or
Diseases
Number Rate infectious agent within a
given geographic area.
1. Acute Respiratory Infection ** 1,289,168 1371.3  Epidemic – the occurrence in
a community or region of
cases of a disease condition
2. Acute Lower Respiratory Tract clearly in excess of normal
586,186 623.5
Infection and Pneumonia expectancy and derived from
a common or propagated
3. Bronchitis/Bronchiolitis 351,126 373.5 source.
4. Hypertension 345,412 367.4  Pandemic – denoting a
5. Acute Watery Diarrhea 326,551 347.3 disease affecting or attacking
6. Influenza 272,001 289.3 all or a large portion of the
population
7. Urinary Tract Infection** 83,569 88.9  Sporadic – A term describing
8. TB Respiratory 72,516 77.1 the occurrence of a few cases
9. Injuries 51,201 54.5 of a disease every now and
then in a geographic area.
10. Disease of the Heart 37,589 40.0 There are more immunes than
susceptible.
 Infection – the entry and development of
A. Philippine Health Situation an infectious agent in the body of man or
----------------------------- animal.
B. Epidemiology and the Nurse  Infectious agent – an organism, chiefly a
EPIDEMIOLOGY microorganism but including helminths
 Science concerned with the that is capable of producing infection or
circumstances under which diseases infectious disease.
occur, where diseases tend to flourish  Infectious disease – an apparent or
and where they do not. manifest condition of man or animals
 is the field of science, which is resulting from an infection.
concerned with the various factors, and
conditions that determine the  Incubation period – the time interval
occurrence and distribution of health, between exposure to an infectious agent
disease, defects, disability and death and the appearance of the first signs and
among groups of individuals. symptoms
 Is the study of the distribution and  Source of infection – the person, animal,
dynamics of disease occurrence in object or substance from which an
human populations as a basis for infectious agent passes immediately to a
determining preventive and control host.
measures.

Uses of Epidemiology:
 Determine whether
epidemiologic data are
consistent with etiological
hypothesis
 Provide basis for preventive
and public health services.
 Provide knowledge of disease
frequency and distribution
during epidemic and non-
epidemic times

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 Primary case – the first case that occurs  This happens only when the agent comes
to a family or community as a unit.
 Secondary case – a case resulting from a
primary case.
 Reservoir – any human being, animal,
anthropoid, plant, soil, or inanimate object
in which infectious agent normally lives
and multiplies.
 Susceptible- a person or animal
presumably not possessing sufficient
resistance against a particular agent to
prevent contracting a disease if or when
exposed to the agent.
 Carrier – A person (or animal) who
harbors a specific disease-causing agent,
in the absence of clinical manifestations
and who served as a source of infection for
others.
 Contact – A person (or animal) who has
been in association with the infected in contact with a susceptible host and
person or animal or a contaminated under proper environmental conditions.
environment.
 Incidence – frequency or occurrence of 1. Agent Example
new cases of a disease in a population over  Biological - Virus, bacteria, fungus,
a stated period of time expressed as a rate. parasite, protozoa
 Isolation – limitation of movement of a  Chemical - Lead, mercury, insecticide,
person having a communicable disease or gases, dust, vapors, and liquids
of a carrier who harbors an infectious  Physical - Humidity, atmospheric
agent. pressure, radiation, noise
 Quarantine – restriction of movement of  Mechanical - trauma
those who have been in contact with a  Nutritive - Iron or iodine deficiency,
communicable disease for a period during cholesterol
which they may be potentially infectious
to others. 2. Host
 Host – an animal or plant in or upon  Demographic characteristics - age, sex,
which a parasite live. Any organism that ethnic group, etc.
harbors and provides nourishment for  General Health Status - anatomic
another organism. structure, physiological state, nutrition,
 Herd immunity – is the probability of a genetic determinants, reaction to stress.
group or community developing an  Body defenses - skin and mucous
epidemic upon introduction of an membranes, lymphatic system
infectious agent.  State of immunity and immunological
response – natural immunity, artificial
The Epidemiologic Triad immunity (passive, active).
 The interaction of host, agent and the
environment determine the modes of 3. Environment
transmission, natural history, occurrence,  Physical – weather, climate, season,
and control of disease, illness, or other soil, terrain, geology, geography
condition.  Biological – animal reservoirs,
 An agent of a disease is an any, substance, arthropod, vectors, food supply
or force, either animate or inanimate, the  Social – family and community
presence or absence of which may serve as structure, population density and
stimulus to initiate or perpetuate a disease mobility, political and economic
process. realities, occupations, roles and status,

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schools, housing, transportation and

provision of health services.

Phases of epidemiological Approach

1. Descriptive Epidemiology
 concerned with disease distribution
and frequency.

The various aspects involved in descriptive

epidemiology are the following:
 Observation and recording of existing
patterns of occurrence of the health
condition under study.
 Description of the disease/condition
as to person, place, and time
characteristics
 Analysis of the general pattern of
occurrence of the disease or
condition.

2. Analytical Epidemiology
 attempts to analyze the causes or
determinants of disease through
hypothesis testing.
3. Intervention or experimental
epidemiology
 answers questions about the
effectiveness of new methods for
controlling diseases for improving
underlying condition.
4. Evaluation Epidemiology
 attempts to measure the effectiveness
of different health services and
programs.

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COMMUNICABLE DISEASES communicable diseases for a period of

Terminologies time equivalent to the longest incubation
 Infection – implantation and successful period of that disease.
replication of an organism in the tissue of  Reservoir- it is composed of one or
the host resulting to signs and symptoms more species of animals or plant in
as well as immunologic response which an infectious agent lives and
 Carrier – an individual who harbors the multiplies for survival and reproduces
organism and is capable of transmitting it itself in such a manner that it can be
to the susceptible host without showing transmitted to man
manifestations of the disease
 Communicable disease- it is an illness Epidemiologic Triangle: consists of 3
caused by an infectious agent or its toxic components
products that are transmitted directly or  Host- any organism that harbors and
indirectly to a well person through an provides nourishment for another
agency, and a vector or an inanimate organism
object.  Agent- intrinsic property of
 Contact – it is any person or animal who microorganism to survive and multiply
is in close association with an infected in the environment to produce disease
person, animals or freshly soiled  Environment- it is the sum total of all
materials. external condition and influences that
 Contagious disease- it is a term given to affect the development of an organism
a disease that is easily transmitted from which can be biological, social and
one person to another through direct and physical
indirect means.
 Disinfection- it is the destruction of Stages of Infectious Process
pathogenic microorganisms outside the  Incubation Period: extends from the
body by directly applying physical or entry of microorganisms into the body
chemical means to the onset of signs and symptoms.
 Concurrent – it is a method of  Prodromal Period: extends from the
disinfection done immediately after onset of non-specific signs and
the infected individual discharges symptoms to the appearance of specific
infectious material/ secretions. signs and symptoms.
It is a method of infection  Illness Period: specific signs and
when the patient is still the symptoms develop and become evident
source of infection.  Convalescent Period: signs and
 Terminal- it is applied when the symptoms start to abate until the client
patient is no longer the source of returns to normal state of health
infection.
 Habitat- it is a place where an organism CHAIN OF INFECTION
lives or where an organism is usually
found. 1. Causative agent/ etiologic agent/
 Host- it is a person, animal or plant on infectious agent
which a parasite depends for its survival.  Any microorganism capable of
 Infectious disease- it is transmitted not producing a disease
only by ordinary contact but requires  Bacteria, spirochete, virus, rickettsia,
direct inoculation of the organism though Chlamydia, fungi, protozoa, and
a break on the skin or mucous parasites
membrane.  The ability of the infectious agent to
 Isolation- it is the separation from other cause a disease depends on its
persons of an individual suffering from a pathogenicity, virulence, invasiveness
communicable disease. and specificity
 Quarantine- it is the limitation of 2. Reservoir of infection (Source)
freedom of movements of persons or
animals which have been exposed to

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 Refers to the environment and o Examples: food, water, milk,

objects on which an organism blood, eating utensils, pillows,
survives and multiplies mattress
 Human beings, animals, inanimate d. Airborne Transmission- it occurs
objects, plants, general environment when fine particles are suspended in
such as air, water, and soil the air for a long-time or when dust
3. Portal of exit particles contain pathogens.
 It is the path or way in which the o Air current disperses
organism leaves the reservoir microorganisms, which can be
 Common portals of exit inhaled or deposited on the skin of
o Respiratory system- droplet, the susceptible host
sputum e. Vectorborne Transmission- occurs
o GIT- vomitus, feces, saliva, when intermediate carriers, such as
drainage tubes fleas, flies, mosquitoes, rats, snails
o Genito-Urinary Tract- urine, transfer the microbes to another living
urethral catheters organism
o Reproductive tract- semen,
vaginal discharges 5. Portal of Entry
o Skin and mucous membrane  It is the venue where the organism
o Blood- open wound, needle gains entrance into the susceptible
host
puncture site
 The infective microbes use the same
avenues when they exit from the
reservoir
4. Mode of Transmission
6. Susceptible Host
 It is the means by which the infectious
agent passes through from the portal of  When the defenses are good,
exit of the reservoir to the susceptible no infection will take place
host  In weakened host, microbes
 Easiest link to break the chain of will launch an infectious
infection process
a. Contact Transmission
1) Direct contact- involves IMMUNITY
immediate and direct transfer 1. Active Immunization: antibodies are
from person to person (body produced by the body in response to infection
surface to body surface) a) Natural active- antibodies are formed in
2) Indirect contact- occurs when a the presence of active infection in the
susceptible host is exposed to a body. It is lifelong.
contaminated object such as o Recovery from mumps,
dressing, needle, surgical chickenpox
instrument b) Artificial active- antigens (vaccines and
b. Droplet Transmission- it occurs toxoids) are administered to stimulate
when mucous membrane of the nose, antibody production
mouth or conjunctiva are exposed to o Requires booster inoculation after
secretions of an infected person who many years
is coughing, sneezing, laughing or 2. Passive Immunization: antibodies are
talking, usually within a distance of 3 produced by another source, such as animal or
feet. humans
c. Vehicle Transmission- this involves a. Natural Passive- - antibodies are
the transfer of microorganisms by transferred from the mother to her
way of vehicles or contaminated newborn through the placenta or in
items that transmit pathogens. the colostrum.
b. Artificial passive- immune serum
(antibody) from an animal or another

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human is injected to a person. E.g., o A highly infectious disease caused by

Tetanus immunoglobulin human the tubercle bacilli.
Types of Antigen o Common among malnourished
 Inactivated (Killed organism)- individuals living in crowded areas.
 Not long lasting  Infectious Agents
 Multiple doses needed o Mycobacterium
 Booster dose needed o Mycobacterium Africanum
 Attenuated (live organism) (Humans)
 Single dose needed o Mycobacterium bovis (cattle)
 Long lasting immunity  Mode of Transmission
o Airborne droplet method through
ISOLATION coughing, singing or sneezing
 Separation of patients with o Direct invasion through mucus
communicable diseases from others so membranes or breaks in the skin
as to prevent or reduce transmission of may occur but is extremely rare.
infectious agent directly or indirectly o Bovine tuberculosis results from
 Categories Recommended in Isolation exposure to tuberculosis cattle,
a) Strict isolation- prevents highly usually by unpasteurized milk or
contagious or virulent infections dairy products.
b) Contact isolation- prevents the o Extrapulmonary TB other than
spread of infection primarily by
laryngeal, is generally not
close or direct contact
communicable.
c) Respiratory isolation- prevents the
transmission of infectious diseases
 Signs and symptoms
over short distances through the air
o Cough of 2 weeks or more
d) TB isolation- for TB patients with
positive smear or with chest x-ray o Fever
which strongly suggests active o Chest or back pains
tuberculosis o Hemoptysis or recurrent blood-
e) Enteric isolation- for infections with streaked sputum
direct contact with feces o Significant weight loss
f) Drainage/ secretion Precaution- to o Night sweating
prevent infections that are o Fatigue
transmitted by direct or indirect o Body malaise
contact with purulent materials or o Shortness of breath
drainage from an infected body site.  Period of Communicability
 Universal Precaution o As long as viable tubercle bacilli
o Applied when handling blood and are being discharged in the
body fluids sputum.
o This precaution is applied to o Untreated or inadequately treated
patients with HIV patients maybe sputum-positive
o It is intended to prevent parenteral, intermittently for years
mucous membrane, and non-intact o The degree of communicability
skin exposure of health care depends on the number of bacilli
workers to blood borne pathogens discharged, the virulence, and
o This is applied to blood, semen, adequacy of ventilation. Exposure
vaginal secretions and other body to UV light.
fluids o Effective antimicrobial
chemotherapy usually reduces
RESPIRATORY DISEASES communicability to insignificant
Tuberculosis levels within days to a few weeks.
o Is considered as the deadliest disease o Children with primary tuberculosis
and remains as a major public health are generally not infectious.
problem.  Susceptibility and Resistance

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oHighly susceptible: HIV positive, communities by health care

immunosuppressed, underweight, institutions and providers
undernourished, substance abusers, o Strategies
DM 1. Enhance quality TB diagnosis
o The most hazardous period for 2. Ensure TB patients’ treatment
development of clinical disease is compliance
the first 6-12 months after infection. 3. Ensure public and private
o Risk of developing the disease is health care providers’
highest in children under 3 years adherence to the
old. implementation of national
o Reactivation of long latent standards of care for TB
infections account for a large patients.
proportion of cases of clinical 4. Improve access to services
disease in older persons through innovative service
 Methods of Control delivery mechanisms for
Preventive Measures patients living in challenging
 Prompt diagnosis and treatment of areas.
infectious cases. o Objective B: Enhance the health-
 BCG vaccination of newborn, seeking behavior on TB by
infants and grade 1/school entrants communities, especially the TB
 Educate the public in mode of symptomatic
spread and methods of control and o Strategies
the importance of early diagnosis 1. Develop effective, appropriate, and
• Improve social conditions such culturally-responsive IEC/
as overcrowding communication materials
• Make available medical, 2. Organize barangay advocacy groups
laboratory and x-ray facilities o Objective C: Increase and sustain
• Provide public health nursing support and financing for TB control
and outreach services for home activities
supervision o Strategies
 National Tuberculosis Control 1. Facilitate implementation of TB-
Program DOTS Center certification and
o Vision: A country where TB is no accreditation
longer a public health problem 2. Build TB coalitions among different
o Mission: Ensure that TB DOTS sectors
services are available, accessible, 3. Advocate for counterpart input from
and affordable to the communities LGUs
in collaboration with the LGUs 4. Mobilize/ extend other resources to
and other partners address program limitations
o Goal : To reduce prevalence and o Objective D: Strengthen management
mortality from TB by half by the (technical and operational) of TB
year 2015 (Millennium control services at all levels
Development Goal) o Strategies
o Targets 1. Enhance managerial capability of all
1. Cure at least 85% of the NTP program managers at all levels
sputum smear-positive TB 2. Establish an efficient data
patient discovered. management system for both public
2. Detect at least 70% of the and private sectors
estimated new sputum-smear 3. implement a standardized recording
positive TB cases and reporting system
 NTP Objectives and Strategies 4. Conduct regular monitoring and
o Objective A: Improve access to evaluation at all levels.
and quality of services provided to 5. Advocate for political support
TB patients, TB symptomatic, and through effective local governance

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 Key Policies There are 2-,3-, or 4- drug fixed

1. Case finding dose combinations.
 Direct Sputum Smear Microscopy 2. Single drug formulation (SDF)-
(DSSM) shall be the primary diagnostic each drug is prepared individually.
tool in NTP case finding INH, Ethambutol, and
 All TB symptomatic identified shall be pyrazinamide are in one tablet
asked to undergo DSSM for diagnosis form while rifampicin is in
before start of treatment. capsule form.
(Contraindication for sputum collection is  Quality of FDCs must be ensured.
hemoptysis) FDCs must be ordered according to
 Pulmonary TB symptomatics shall be WHO-prescribed strength and
asked to undergo other diagnostic tests standard of quality.
(X-ray and culture)  Treatment shall be based on
 Since DSSM is the primary diagnostic recommended category of treatment
tool, no TB diagnosis shall be made regimen.
based on the results of other exams.
 Only trained medical technologists or  Public Health Nursing
microscopists shall perform DSSM Responsibilities (Adult TB)
2. Treatment o Together with other NTP staff/
 Aside from clinical findings, workers, manage the procedures for
treatment of all TB cases shall be case finding activities
based on a reliable diagnostic o Assign and supervise a treatment
technique (DSSM) partner for patient who will undergo
 Domiciliary treatment shall be the DOTS.
preferred mode of care. o Supervise RHMidwife to ensure
3. Patients with the ff. conditions shall be proper implementation of DOTS
recommended for hospitalization o Maintain and update the TB
 Massive hemoptysis Register
 Pleural effusion obliterating more o Facilitate requisition and
than one-half of a lung field distribution of drugs and other NTP
 Miliary TB supplies
 TB meningitis o Provide continuous health
 TB Pneumonia education to all TB patients placed
 Those requiring surgical intervention under treatment and encourage
or with complications family and community participation
 All patients shall be supervised (No in TB control
patient shall initiate treatment unless the o In coordination with the physician,
patient and DOTS facility staff have
conduct training of health workers
agreed upon a case holding mechanism
o prepare, analyze, and submit the
for treatment compliance
 The national and local government units quarterly reports to the Provincial
shall ensure provision of drugs to all Health Office or City Health Office
smear-positive TB cases.  Treatment modalities
o Short-course chemotherapy: 6
month treatment (izoniazid,
Rifampicin, Pyrazinamide, and
Ethambutol)
 Rifampicin
Empty stomach
 There are 2 formulation of anti-TB Body fluid discoloration (red-
drugs: orange)
1. Fixed-dose combination (FDCs)- Hepatotoxic
two or more first-line anti-TB Nephrotoxic
drugs are combined in one tablet. Permanent discoloration of
contact lenses

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 Isoniazid
Empty stomach
Peripheral neuropathy
Avoid alcohol
Hepatotoxic
Nephrotoxic
Increase intake of Vitamin B6
(pyridoxine)
 Pyrazinamide
Before meals
Monitor signs and symptoms of
liver impairment
Anorexia, fatigue, dark urine,
photosensitivity
Causes hyperuricemia
 Ethambutol
Not affected by food
Report visual disturbances
Hepatotoxic
Not recommended for children,
can cause optic neuritis
 Streptomycin
After meals
Report oliguria
Ototoxic
Neurotoxic

 Nursing management
o Maintain respiratory isolation
o Administer medicines as ordered
o Educate patient about the disease
o Stop smoking
o Cough or sneeze into tissue paper
and dispose secretions properly
o Provide a well-balanced diet (high
calorie)
o Allow rest periods
o Caution the patient who is taking
contraceptive that the contraceptive
may become less effective while
she’s taking rifampicin
 Prevention and control
o Submit all babies for BCG
immunization
o Avoid overcrowding
o Improve nutritional and
health status

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