Community Health Nursing Concept II - Handouts

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(Maglaya, p. 169)
The Community Health Nursing Process
EDWIN O. BRACAMONTE, RN, MAN 2
(Maglaya, p. 169)
1. health status increased or
decreased morbidity, mortality, fertility,
or reduced capability for wellness
2. health resources lack or absence of
manpower, money, materials, or
institution necessary to solve health
problems
3. health-related existence of social,
economic, environmental, and political
factors that aggravate illness-inducing
situations in the community
(Maglaya, p. 169)
1. heal th status increased or decreased
morbidity, mortality, fertility, or reduced
capability for wellness
2. heal th resources lack or absence of
manpower, money, materials, or institution
necessary to solve health problems
3. heal th acti on potenti al ability of the
state and its people to address the health
needs and problems of the community. It
also mirrors the sensitivity of the
government to the peoples struggle for
better lives. (Maglaya, p. 162)
(Maglaya, p. 158)
A tool in determining the community health status
A systematic approach / study of the health condition
of a community, involving the collection, analysis and
interpretation of data including statistical data
The nurse COLLECTSdata about the community in order
to identify the different factors that may directly or
indirectly influence the health of the population.
Then she proceeds to ANALYZE and seek explanations
for the occurrence of health needs and problems of the
community.
The community health NURSING DIAGNOSES are then
derived and will become the bases for DEVELOPINGand
IMPLEMENTINGcommunity health nursing
i nterventi ons and strategies.
This process is called community diagnosis. Others call it
community assessment or situational analysis.
(Maglaya, p. 158)
The health status of the community is
the product of the various interacting
elements such as
population,
the physical and topographical
characteristics,
socio-economic and cultural factors,
health and basic social services
and power structure within the community.
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(Maglaya, p. 159)
a. Comprehensi ve
Aims to obtain general information about the
community (e.g., assessment of specific
population group in the community)
b. Problem oriented or focused
A type of assessment that responds to a
particular need (e.g., disaster situation or an
outbreak of disease)
(Maglaya, p. 159)
a. Demographic Variables - show size, composition and
geographic distribution of the population
1. Total population and geographical distribution
including urban-rural index and population density
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 projection
It is also important to know whether there are
population groups that need special attention such as
indigenous people, internal refugees, and other socially
dislocated groups as a result of disaster, calamities and
development programs
(Maglaya, p. 159)
b. Socio-Economic and Cultural Variables
1. Social indicators
a.Communication network (formal or informal
channels) necessary for disseminating health
information or facilitating referral of a client to the
health care system
b.Transportation system including road networks
necessary for accessibility of the people to the
health care delivery system
c.Educational level which may be indicative of
poverty and may reflect on health perception and
utilization pattern of the community
d.Housing conditions which may suggest health
hazards (congestion, fire, exposure to elements)
(Maglaya, p. 159)
2. Economic indicators
a.Poverty level income
b.Unemployment and underemployment rates
c.Proportion of salaried and wage earners to
total economically active population
d.Types of industry present in the community
e.Occupation common in the community
(Maglaya, p. 159)
3. Environmental indicators
a.Physical/geographical/topographical
characteristics of the community
land areas that contribute to vector problems
(dengue, malaria etc)
terrain characteristics that contribute to accidents or
pose geohazard zones
land usage in industry
climate/season
b.Water supply
% population with access to safe, adequate water
supply
Source of water supply
(Maglaya, p. 159)
c.Waste disposal
% population served by daily garbage collection
system
% population with safe excreta disposal system
types of waste disposal and garbage disposal system
d.Air, water and land pollution
industries within the community having health
hazards associated with it
air and water pollution index
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(Maglaya, p. 159)
4. Cultural factors
a.Variables that may break up the people into
groups within the community such as:
ethnicity
social class
language
religion
race
political orientation
b.Cultural beliefs and practices that affect
health (beliefs regarding causes of sickness
and health)
c.Concepts about health and illness
(Maglaya, p. 159)
c. Health and Illness Patterns
Can be gathered through primary or reliable
and updated secondary sources
1. Leading causes of Mortality
2. Leading causes of Morbidity
3. Leading causes of Infant Mortality
4. Leading causes of Maternal Mortality
5. Leading causes of Hospital Admission
(Maglaya, p. 159)
d. Heal th Resources
1. Manpower Resources
categories of health manpower available
geographical distribution of health manpower
manpower-population ratio
distribution of health manpower according to
health facilities (hospitals, rural health units, etc)
distribution of health manpower according to type
of organization (government, non-government,
health units, private)
quality of health manpower
Existing manpower development/policies
(Maglaya, p. 159)
2. Material resources
health budget and expenditures
sources of health funding
categories of health institutions available in
the community
hospital bed-population ratio
categories of health services available
(Maglaya, p. 159)
e. Political/Leadershi p Patterns
1. Power structures formal and informal
(community organization, government
structures)
2. Attitudes of people towards the authority
3. Conditions/events/issues that cause social
conflict/upheavals that lead to social
bonding or unification
4. Practices/approaches that are effective in
settling issues and concerns within the
community
(Maglaya, p. 163)
The process of community diagnosis consists of
col l ecti ng,
organi zi ng,
synthesi zi ng,
anal yzi ng
and i nterpreti ng health data.
Before she collects the data, the objectives must
be determined by the nurse as these will dictate
the depth or scope of the community diagnosis.
She needs to resolve whether a comprehensive or
problem-oriented community diagnosis will
accomplish her objectives.
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(Maglaya, p. 163)
1. Determine objectives
2. Define the study population
3. Determine the data to be collected
4. Collect the data
5. Develop the instrument
6. Actual data gathering
7. Data Collation
8. Data Presentation
9. Data Analysis
10. Identifying the Community Health Nursing
Problems
11. Priority-Setting
EDWIN O. BRACAMONTE, RN MAN 19
Decides on the depth and scope of the
data needed to be gathered
Comprehensive or problem-oriented
Identify the population group included in
the study
Identify the specific data to be collected
Decide on the sources of data
Different methods may be utilized to
generate health data
The nurse decides on specific methods
depending on the type of data to be
generated
Primary data Obtained first hand by the
investigator
Secondary data Those which is existing
and obtained by other people
Records review
Surveys and observations (e.g., ocular
surveys)
Interviews (e.g., key informant interview,
individual and group interview)
Participant observation
Explain purpose for collecting the data
Ask appropriate questions
Use words / language on level of
understanding
Clarify technical terms
Establish eye contact
Validate / clarify the information obtained
Be tactful / courteous
Utilize transitional statements
Express appreciation
Document factually
Use proper time management
Use of spot map in planning
Use of campaign / posters
Coordinate with barangay officials
Maximize resources, time, and
manpower
Use markers or stickers in labeling
households
Target number of households/quota in
relation to available time
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Spot map should be oriented to the North.
Geographical boundaries correctly identified.
Households should be numbered according to
the control number in the survey tool for easy
reference, case finding, and contact tracing.
Roads, bridges, arcs (if present) included in
the map.
Significant landmarks and institutional facilities
(health center, brgy hall, church, hospitals,
market, talipapa, recreational facilities, water
district, municipal hall, schools, etc) included in
the map.
Topography (mountains, bodies of water, etc.,
if present) included in the map.
Provide legends for easy reference. Legends
should be simple and easy to recognize.
Important landmarks/facilities should be
labeled with their actual names, not just as
school or street, for example.
Distances among households, facilities, roads,
etc should be realistic and proportioned to
establish areas of congestion or proximity.
Areas that contribute to vector problems and
terrain characteristics that pose hazards
properly identified.
Promptly submits the final version of the spot
map.
Instruments or tools facilitate the nurses
data-gathering activities.
Instruments used
Survey Questionnaire
Interview Guide
Observation Checklist
Meet the people who will be involved in
data collection
The instruments are discussed, analyzed,
and modified or simplified so as not to
overburden the people
Pre-testing of the instrument is highly
recommended
Orientation and training on how to use the
instrument (Role Play)
Checking for completeness, accuracy, and
reliability of information collected.
After data collection, the nurse is now
ready to put together all the information
Types of data
Numerical Data which can be counted
Descriptive Data which can be described
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Mutually exclusive
choices do not
overlap
To cl assi fy sex:
MALE
FEMALE
To cl assi fy monthl y i ncome:
Bel ow P 500
P 501-1000
P 1001-1500
P 1501-2000
Mutual l y exhausti ve
anticipates all
possible answers
Family Planning Methods:
Lactational Amenorrhea Method
Natural
Basal Body Temperature
Cervical Mucus Method
Sympthothermal Method
Standard Days Method
Others (specify):
Artificial
IUDs
Pills
Injectables
Condoms
Others (specify)
Permanent
Tubal Ligation
Vasectomy
Open-ended
questions do not
provide choices
or categories but
the health care
provider can still
facilitate data
collation by
constructing
categories.
Question:
Bakit hindi kayo nagpapasuso ng inyong sanggol?
Response 10: Bawal sa akin, sabi ng doctor.
Response 27: Nagtatrabaho ako.
Response 30: Ayaw ni Mister.
Response 45: Masakit.
Response 59: Masisiraang figure ko.
Response 60: Medical reasons
Response 62: May sakit ako.
Response 67: Modern at convenient ang
formula feeding.
Response 75: Pagod na ako pagkagaling sa
trabaho.
Response 77: Mas gusto ko ang magpasuso sa
bote.
For these responses, possible categories are:
Convenience- Responses 67, 77
Medical reasons- Responses 10, 60, 62
Personal reasons- Responses 30, 45, 59
Economic/work reasons- Responses 27, 75
Manual l y using tally
sheets
Di seases Tal l y Mark Frequency
Parasitism IIIII-IIIII-IIIII-IIIII 20
Diarrhea IIIII-IIIII-IIIII-II 17
Cough IIIII-IIIII-IIIII-IIIII-
IIIII-IIIII-III
33
Usi ng computer using
numbers and codes
Sex Male 4
Female 6
Rel i gi on Catholic 1
INK 2
Methodist 3
Aglipayan 3
Depends on the type of data obtained
1. Descriptive data
Presented in narrative forms (geography,
history, beliefs about illness)
2. Numerical data
Presented into tables and graphs. Provide ease
in comparison including patterns and trends.
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Types of Graphs
Line Graph
Bar Graph/Pictograph
Histogram or frequency polygon
Pie chart or proportional/component bar
graph
Proportionate bar graph
Scattered diagram
Tabular presentation
Type of Graph Data Functi on
Li ne graph shows trend or changes with time or age
Bar graph or
pi ctograph
absolute or relative counts / rates between
categories
represented by bars or rectangles whose
heights or lengths are proportionate to their
values and stand as the basis for
comparison
should have equal width and gaps
maybe drawn horizontally or vertically
Hi stogram or
frequency
pol ygon
shows frequency distribution or
measurement
depicts counts, of each class or grouping
distribution is continuous
no gaps or spaces
Type of Graph Data Functi on
Pi e chart or
proporti onal /com
ponent bar graph
breakdown when number of categories are
too many
show how a whole is divided
portion of the slice is proportionate the
whole pie
Proporti onate bar
graph
bar is divided into smaller rectangles
representing parts
used for comparison between groups that
are compared
Scattered
di agram
shows correlation of variables
Tabul ar
presentati on
easily point out trends, comparison,
interrelationships among variables
Establish trends and patterns in terms of
health needs and problems of the
community
Comparison to standard values
Interrelationship of factors will help the
nurse view the significance of the
problem and implications on the health
status of the community
Water Storage
This refers to containers used by the
families for water storage. The containers
used were observed whether they are
covered or uncovered. Uncovered water
containers could play a significant role in
the occurrence of vector and water borne
diseases
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WATER STORAGE
Definition:
Water storage deals with the manner in which water is
kept. It can either be in a covered or uncovered container.
Significance:
Water-related diseases are the most common cause
of illness and death. Households which utilize proper storage
of water would suffer less morbidity and mortality fromwater-
related diseases. It is significant as it has something to do
with how water is being kept and the occurrence of vector
andwater borne diseases
Methodology:
The method used in collecting data is through
communitysurvey
Tabl e No. 1 Frequency and Percentage Di stri buti on of the Storage
of Dri nki ng Water of the Surveyed Fami l i es i n Barangay FEU,
Mani l a Ci ty as of August 2012
Variables Frequency Percentage
Covered 250 55.56%
Uncovered 200 44.44%
TOTAL 450 100.00%
Fi gure No.1 Percentage Di stri buti on of the Storage of
Dri nki ng Water of the Surveyed Fami l i es i n Barangay
FEU, Mani l a Ci ty as of August 2012
44.44%
55.56%
Covered
Uncovered
Interpretati on:
There were 56% or 250 families that have covered water
containers. On the other hand, 44% or 200 families were found to have
uncovered water containers
Anal ysi s:
This is primarily because of the low educational attainment of
community people that consequently lead to having limited knowledge on
the nature of vector and water borne diseases that was based on the FGD
conducted. Inadequate knowledge about the magnitude of the problem
puts the residents at risk of developing such diseases. (Bonjing and
Manoling 2007)
Heal th Impl i cati on:
Uncovered water containers can lead to different water and vector
borne diseases. Diarrhea, which is one of them, was found to be ranked 3
as the leading causes of morbidity in the community. In the country,
diarrhea is ranked 5 as the leading causes of infant mortality and ranked
10 as the leading causes of adult morbidity (Fundamentals of Nursing,
Kozier, p 171, 2008)
.
1. Health status problems
2. Health resources problems
3. Health-related problems
Use of Problem Trees in explaining and
describing the health problem/s (cause and
effect)
(Maglaya, p. 170)
Prioritizing which problems to address first, considering the
resources available at the moment
Cri teri a for pri ori ty-setting
a. Nature of the problem
The problems are classified as health status, health resources or health-
related
b. Magnitude of the problem
Refers to the severity of the problemwhich can be measured in terms of
proportion of the population affected by the problem
c. Modifiabil it y of the problem
Refers to the probability of reducing, controlling or eradicating the problem
d. Preventive potential
Refers to the probability of controlling or reducing the effects posed by the
problem
e. Social concern
Refers to the perception of the population or the community as they are
affected by the problemand their readiness to act on the problem
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(Maglaya, p. 170)
Criteria Weight
Nature of the problem 1
Health status 3
Health resources 2
Health-related 1
Magnitude of the problem 3
75% - 100% affected 4
50% - 74% affected 3
25% - 49% affected 2
<25% affected 1
Modifiability of the problem 4
High 3
Moderate 2
Low 1
Not modifiable 0
Preventive potential 1
High 3
Moderate 2
Low 1
Social concern 1
Urgent communityconcern; expressed readiness 2
Recognized as a problembut not needing urgent attention 1
Not a communityconcern 0
(Maglaya, p. 171)
Exampl e: Probl em 1
Nature of the problem 3 / 3 x 1 1
Magnitude of the problem 2 / 4 x 3 1.5
Modifiability of the problem 2 / 3 x 4 2.7
Preventive potential 1 / 3 x 1 .3
Social concern 1 / 2 x 1 .5
Total 6.03
Each problem will be scored according to each criterion
and divided by the highest possible score multiplied by
the weight. Then the final score of each criterion will be
added to give the total score of the problem.
Then compare this with other problems from the list.
The problem with the highest total score is given high priority
by the health care provider.
a. Prevalence widely experienced?
b. Severity debilitating, minor
inconveniences, loss of life, quality of
life, etc.
c. Selectivity population affected
d. Amenability willing to cooperate:
responsive to suggestion and likely to
cooperate to intervention
1. Demography
2. Vital and Health Statistics
3. Epidemiology
(Maglaya, p. 171)
a. Definition and Uses of Demography
Helps the health care provider determine the
nature and magnitude of existing potential
community health nursing problems
Helps the health care provider find reasons
or rationale on why or how a particular
population group is influenced by a variety of
factors resulting in vulnerability to diseases
Science which deals with the study of
human population size, composition, and
distribution in space
(Maglaya, p. 171)
Science which deals with the study of:
Popul ati ons si ze
Popul ati on composi ti on
Popul ati on di stri buti on
8/23/2012
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Refers to the number of people in a
given place or area at a given time.
Allows the health care provider to make
comparisons about population changes
over time
Helps in rationalizing the types of health
programs or interventions which are
going to be provided for the community
1. Natural increase (specified year)
2. Rate of natural increase
3. Absol ute Increase per year
4. Relative Increase
Difference between number of births and the
number of deaths occurring in a population in
a specified period of time
Natura| Increaxe =Numher u h|rthx Numher u deathx
(specified year) (specified year) (specified year)
Number of Births =50,850
Number of Deaths =17,459
Natural Increase =33,391
Difference between the crude birth rate and
crude death rate occurring in a population in a
specified period of time
Rate u natura| |ncreaxe =Crude h|rth rate Crude death rate
(specifiedyear) (specified year) (specified year)
Number of people that are added to the
population per year
Ahxu|ute |ncreaxe per year =
P
t
P
u
t

Where:
P
t
=population sizeat a later time
P
u
=population sizeat an earlier time
t =number of years between timeu and time t
Actual difference between two census counts
expressed in percent relative to the population
size made during an earlier census
Re|at|ue |ncreaxe =
P
t
P
u
P
u

Where:
P
t
=population size at a later time
Pu =population sizeat an earlier time
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Commonly described in terms of age
and sex
1. Sex compositi on / Sex ratio
2. Age composition
Median age
Dependency ratio
3. Age and Sex Composition
Compares the number of males to the number
of females in the population
Sex rat|u =
numher u ma|ex
numher u ema|ex
x 1
Male =5553
Females =5393
Interpretati on : Thus, in BarangayMaligaya
in 2011, there were 103 males for every 100
females in the population
Sex rat|u =
numher u ma|ex
numher u ema|ex
x 1
Sex rat|u =
5553
5393
x 1
Sex rat|u =12.98 ur 13
Median age: divides the population into
two equal parts. So, if the median age
is said to be 19 years old, it means that
half of the population belongs to 19
years and above, while the other half
belongs to ages below 19 years old.
Med|an Age =Lch + _
n
2
<c
_|
Where:
Lch =lower boundaryof themedianclass
n =total population
| =classsizeof thefrequencydistribution of ageof themale andfemale
f =frequencyof themedian class
<cf =cumulativefrequencyabovethemedianclass
Age Frequency Cumulative Frequency < L.b - H.b
0-4 382 382 0.5-4.5
5-9 404 796 4.5-9.5
10-14 442 1228 9.5-14.5
15-19 385 1613 14.5-19.5
20-24 429 2042 19.5-24.5
25-29 344 2386 24.5-29.5
30-34 258 2644 29.5-34.5
35-39 240 2884 34.5-39.5
40-44 226 3110 39.5-44.5
45-49 221 3331 44.5-49.5
50-54 175 3506 49.5-54.5
55-59 124 3630 54.5-59.5
60-64 105 3735 59.5-64.5
65-69 57 3792 64.5-69.5
70-74 27 3819 69.5-74.5
75-79 17 3836 74.5-79.5
80-84 10 3846 79.5-84.5
85-89 2 3848 84.5-89.5
90-94 1 3849 89.5-94.5
Med|an Age =Lch + _
n
2
<c
_| MedianAge
MedianAge
=
=
19.5
23.13
+
3849
2
1613
429
5
23 or
8/23/2012
12
Med|an Age =Lch + _
n
2
<c
_|
Med|an Age =19.5 + _
3849
2
113
429
_5

Med|an Age =23.13

=23

Interpretati on:
Half of the population belongs to 23 years old and
above, while the other half belongs to ages below 23
years old.
Dependency rati o: compares the number of
economically dependent with the economically
productive group in the population. The
economically dependent are those who belong to
the 0-14 and 65 and above age groups.
Considered to be economically productive are
those within the 15-64 age group. The
dependency ratio represents the number of
economically dependent for every 100
economically productive.
Dependency Rat|u
=
#u perxunx 14 yrx u|d+#u perxun 5 &ahuue
#u perxunx 15 4 yrx u|d
x 1

DepRatio =#of person 0 - 14 +#of person 65 & abovex 100
#of person 15 64 yrs old
Example:
0-14 =4858
65 above =334
15-64 =5754
Computation: (4858+334) x 100
5754
Dependency Ratio=90.23288 or 90
Interpretation : Thus in Brgy. Balibago, in 2009, every 100
persons in the economically productive age groups had to
support 90 dependents.
EDWINO. BRACAMONTE RN MAN
69
Can be described using a population
pyramid
Population Pyramid
A graphical presentation of the age and sex
composition of the population
1. Compute the percentage of the population
falling in each age-sex group using total
population as denominator
2. A horizontal bar represents each age group.
The first bar representing the youngest age
group is drawn at the base of the pyramid
3. The bars for males are traditionally presented
on the left side of the central vertical axis
while bars females are presented on the right
side
4. The length of each bar corresponds to the
percent of the population falling in the specific
age and sex group being plotted
1. Type 1
Broad base and gently sloping sides
Typical in countries with high rates of birth and death
With low median age and high dependency ratio
2. Type 2
Broader base and its sides bow in much more
sharply as they slant from the 0-4 age group to the
top
Typical of countries that are beginning to grow
rapidly because of marked reduction in infant and
child mortality, but are not reducing their fertility
As a consequence of rapidly increasing population,
the median age is decreasing
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3. Type 3
Old fashioned beehive
Typical for countries with low levels of birth and death
rates found in Western- European countries
Because of low birth rates, the median age is highest and
the dependency ratio is lowest compared with other age-
sex structures. The dependents are mostly elders.
4. Type 4
Bell-shaped
Transitional type
Represents a population which after more than 100 years
of declining birth and fertility rates, has reversed the trend
in fertility while maintaining the death rate at low levels
5. Type 5
Population with marked rapid decline in fertility
Low death rate
EDWIN O. BRACAMONTE, RN MAN 73 EDWIN O. BRACAMONTE, RN, MAN 74
Table 1. Frequency and Percentage Distribution Showing the
Age and Sex Distribution of Individuals Surveyed
in BarangayKunyari,Tutuo,RizalasofJanuary2012
Male Male %% Female Female %% TOTAL TOTAL %%
0 to 4 0 to 4 59 59 5.07% 5.07% 67 67 5.76% 5.76% 126 126 10.83% 10.83%
5 to 9 5 to 9 81 81 6.96% 6.96% 85 85 7.30% 7.30% 166 166 14.26% 14.26%
10 to 14 10 to 14 57 57 4.90% 4.90% 60 60 5.15% 5.15% 117 117 10.05% 10.05%
15 to 19 15 to 19 45 45 3.87% 3.87% 45 45 3.87% 3.87% 90 90 7.73% 7.73%
20 to 24 20 to 24 44 44 3.78% 3.78% 59 59 5.07% 5.07% 103 103 8.85% 8.85%
25 to 29 25 to 29 34 34 2.92% 2.92% 54 54 4.64% 4.64% 88 88 7.56% 7.56%
30 t0 34 30 t0 34 59 59 5.07% 5.07% 49 49 4.21% 4.21% 108 108 9.28% 9.28%
35 to 39 35 to 39 53 53 4.55% 4.55% 43 43 3.69% 3.69% 96 96 8.25% 8.25%
40 to 44 40 to 44 53 53 4.55% 4.55% 46 46 3.95% 3.95% 99 99 8.51% 8.51%
45 to 49 45 to 49 26 26 2.23% 2.23% 25 25 2.15% 2.15% 51 51 4.38% 4.38%
50 to 54 50 to 54 21 21 1.80% 1.80% 19 19 1.63% 1.63% 40 40 3.44% 3.44%
55 to 59 55 to 59 12 12 1.03% 1.03% 16 16 1.37% 1.37% 28 28 2.41% 2.41%
60 to 64 60 to 64 11 11 0.95% 0.95% 99 0.77% 0.77% 20 20 1.72% 1.72%
65 to 69 65 to 69 77 0.60% 0.60% 11 11 0.95% 0.95% 18 18 1.55% 1.55%
70 to 74 70 to 74 11 0.09% 0.09% 22 0.17% 0.17% 33 0.26% 0.26%
75 and above 75 and above 66 0.52% 0.52% 55 0.43% 0.43% 11 11 0.95% 0.95%
TOTAL TOTAL 569 569 48.88% 48.88% 595 595 51.12% 51.12% 1164 1164 100.00% 100.00%
Figure1: POPULATIONPYRAMID
of BarangayKunyari, Tutuo, Rizal asof January2012
Refers to how people are distributed in a
specific geographic location.
Helps the nurse decide on how meager
resources can be justifiably allocated
based on the concentration of
population in a certain place
Urban-rural
di stri buti on
% population in urban
areas: % population in
rural areas
Shows the proportion
of people living in
urban compared to the
rural areas
Crowdi ng i ndex No. of persons in the
household/ no. of rooms
Indicates the ease by
which a communicable
disease can be
transmitted from1 host
to another susceptible
host
Popul ati on densi ty Total population / total
landarea (sq. km)
Determines congestion
of the place;
implication in terms of
adequacy of health
services present in the
community
8/23/2012
14
Population density: Total population
land area (sq. km)
Example:
Total Population 10,596
Total Land Area 40,000 sq. km
Computation: 10,596
40
=264.9 or 265
Interpretation : In Brgy. Balibago, in 2012, there are
about 265 persons in every sq km of the land area
EDWINO. BRACAMONTE RN MAN
79
(Maglaya, p. 172)
Census
Sample surveys
Registration system
Census is defined as an official and periodic
enumeration of population
Demographic, economic and social data are
collected from a specified population group
Data are later collated, synthesized and made
known to the public for the purpose of
determining and explaining trends in terms of
population changes and planning programs
and services
Is usually very expensive undertaking
It will require money to pool together people
and resources to complete the census in a
limited period of time
(Maglaya, p. 172)
1. De jure
People are assigned to the place where they
usually live regardless of where they are at
the time of census.
2. De facto
People are assigned to the place where they
are physically present at the time of census,
regardless, of their usual place of residence.
Instead of a census, demographic
information can still be collected from a
sample of a given population, this is
called a sample survey
Even if the obtained data come from a
small number of people proportionate to
the total population, the results will
always be generalized for the whole
population
RA 3753 (Civil Registry Law)
Registration system such that collected by
the civil registrars office deal with
recording of vital events in the community
Vital events refer to births, marriages,
divorces and the like
Other registration systems can also be
used to describe specific characteristics of
the population
(RA 3753: Civil Registry of Births within 30
days)
8/23/2012
15
(Maglaya, p. 175)
The application of statistical measures to
vital events (births, deaths and common
illnesses) that is utilized to gauge the levels
of health, illness and health services of a
community
Rati o is single number that represents the
relative size of two numbers.
Proporti on is a special type of ratio in which
the numerator is part of the denominator.
Rate refers to the frequency of occurrence of
an event over a given interval of time.
1. Fertility Rates
Crude Bi rth Rate
General Ferti l i ty Rate
2. Mortality Rates
Crude Death Rate
Speci fi c Mortal i ty Rate
Infant Mortal i ty Rate
Neonatal Mortal i ty Rate
Post-neonatal Mortal i ty Rate
Maternal Mortal i ty Rate
Proporti onate Mortal i ty Rate
Swaroops Index
Case Fatal i ty Rate
3. Morbidity Rates
Inci dence Rate
Preval ence Rate
Fertility Rates
Crude Birth Rate Measures howfast people are added to the population
throughbirths. It is affected by fertility/marriage
patterns and practices, sex and age composition, birth
registrationpractice.
General Fertilit y Rate Or the true fertility rate is a more specific rate than
crude birthrate as it is related to the segment of the
populationcapable of giving birth.
Crude btrth rate =
number uI ltve btrths
mtdyear pupulattun
x 1
Ceneral Ierttltty rate =
mtdyear pupulattun uI wumen, 15 44 yrs uld
x 1
Mortality Rates
Crude Death Rate The rate with which mortality occurs ina given
populationover a particular time period. It is affected
by age and sexcompositionof the population, adverse
environmental and occupational conditions, and peace
and order situationof a place.
Specific Mortality
Rate
Showthe rates of dying inspecific populationgroups. It
canbe made specific to age, sex, occupation, exposure
to risk factors, or combinationof these.
Crude death rate =
number uI deaths
mtdyear pupulattun
x 1
SpetIt murtaltty rate =
number uI deaths tn a spetIted gruup
mtdyear pupulattun uI the same spetIted gruup
x 1
Mortality Rates
Infant Mortality Rate Is a sensitive health index reflecting the number of
deaths of infants under 1 year of age inevery 1000 live
births inthe same period. It is indicative of the level of
maternal and child health care, nutrition, environmental
sanitationand health service delivery. It canbe
subdivided into: neonatal mortality rate and post-
neonatal mortality rate. Insome instances, it may be
presented together withfetal mortality rate.
Neonatal Mortality
Rate
InIant murtaltty rate =
deaths under 1 year uI age
x 1
Neunatal murtaltty rate =
deaths 28 days
x 1
Mortality Rates
Post-neonatal
Mortality Rate
Maternal Mortality
Rate
Pust neunatal murtaltty rate =
deaths 28 days tu 1 year
x 1
Maternal murtaltty rate =
deaths due tu pregnany,deltvery & puerper|um
x 1
8/23/2012
16
Mortality Rates
Proporti onate
Mortal i ty Rate
Is the percentage of deaths occurring in a
particular age group or due to a particular cause.
Be cautious in comparing PMR of diseases.
Swaroops Index Is a sensitive health indicator also known as the
proportionate mortality indicator.
Prupurttunate murtaltty rate =
deaths Irum a parttular ause
tutal deaths
x 1
Swaruup
s tndex =
number uI deaths amung thuse 5 years & uuer
tutal deaths
x 1
Mortality Rates
Case Fatality Rate Measures howmuch of those afflicted withthe disease
die fromit. This depends onthe nature of the disease,
diagnostic ascertainment, and the level of reporting of
the population. CFR of diseases inthe hospital will be
higher than inthe community.
Case Iataltty rate =
number uI deaths Irum a spetIted ause
number uI ases Irum the same dtsease
x 1
Morbi di ty Rates
Inci dence Rate Measures the proportion of existing cases of a
disease in the population at a particular point
(point prevalence) in time or interval of time
(period prevalence)
Preval ence Rate Measures the development of a disease in a
group exposed to the risk of the disease in a
period of time.
Intdene rate =
number uI new ases uI dtsease Irum a pertud uI ttme
pupulattun at rtsh uI develuptng the dtsease
x F
Prevalene rate =
number uI uld and new ases uI a dtsease
pupulattun examtned
x F
(Maglaya, p. 178)
Defi ni ti on and Uses of Epi demi ol ogy
Study of the occurrence and distribution of
health conditions such as disease, death,
deformities, or disabilities of human populations
Nurse measures frequency and distribution of
health conditions using vital statistical indices
Used to analyze different factors that contribute
to disease development
Study of occurrences and distribution of
diseases as well as the distribution of
determinants of health states or events in
specified population, and the application of this
study to the control of health problems.
(Cuevas, p. 62)
(Maglaya, p. 178)
Screening presumptive identification of
unrecognized diseases through application of
diagnostic/ laboratory tests and clinical assessment
Case finding done to look for previously
unidentified cases of diseases
Sensitivity proportion of persons with a disease
who tested positive on a screening test; measures
the probability of the test correctly identifying a
positive case of a disease.
Specificity proportion of persons without a
disease who have negative results on a screening
test; measures the probability of correctly identifying
non-cases.
(Maglaya, p. 178)
Attack rate used to calculate an
identifiable population exposed to an
infectious agent; (no. of incidence / no.
of exposed) X 100
Herd immuni ty represents the
immunity and susceptibility levels of
individuals comprising the population
Sporadic occurrence intermittent
occurrence of a few isolated and
unrelated cases in a given locality; few
and scattered; on and off (EX: rabies)
8/23/2012
17
(Maglaya, p. 178)
Endemi c continuous occurrence
throughout a period of time, of the usual
number of cases in a given locality; always
occurring (EX: Malaria in Palawan)
Epi demi c unusually large number of
cases in a relatively short period of time;
the more acute is the disproportion, the
more urgent and serious is the problem
(EX: the emergence of H1N1 influenza A
virus in a town in Mexico)
Pandemi c simultaneous occurrence of
epidemic of the same disease in several
countries (EX: AIDS)
Mul ti pl e Causati on Theory or Ecol ogi c
Concept of Di sease
Disease development does not rest on a single
cause
Health conditions result from a multitude of
factors
There are 3 model s to expl ai n the
theory:
1. The Wheel
2. The Web
3. The Ecol ogi c Tri ad
(most hel pful to the nurse)
1. Agent Any element, substance or force, animate or
inanimate, presence or absence of which may serve as
stimulus to initiate/ perpetuate a disease process.
2. Host any organism that harbors and nourishes another
organism characteristics of host will affect its
susceptibility or resistance
3. Environment sum total of all external conditions and
influences that affect the life and development of an
organism. Affects both the agent and the host: Physical,
Biological, Socio-economic
The three elements of the triad interact with one another
in an attempt to maintain equilibrium.
Any major change in any one of the factors may bring
about a disturbance in the equilibrium provoking the
appearance of a health problem.
The Natural History of Any disease of Man
Interrelations of Agent, Host &
Environment Factors
Production of stimulus
Reaction of the HOST to the STIMULUS
Early Pathogenesis Discernible early
Lesions Advanced disease
Convalescence
Prepathogenesis Period Period of Pathogenesis
(Maglaya, p. 179)
Promoting health and preventing health
problems make up most of the nurses
activity in the community. Prevention
refers to identification of potential
problems and further eradication or
minimization of disability in a population-
at-risk to a negative exposure factor.
Directed to the healthy population
Focusing on prevention of emergence of risk factors
(primordial prevention) and removal of the risk factors or
reduction of their levels (specific protection)
Interventions before agent enters host and cause
pathological changes
Aims to strengthen host resistance, inactivate the agent or
interrupt the chain of infection through environmental
manipulation/modification and prevention of spread to
human reservoir and other susceptible human hosts
Health promotion activities: provision of proper nutrition,
safe water supply and waste disposal system, vector
control, healthy lifestyle and good personal habits
Specific measures include provision of immunization and
prophylaxis to vulnerable or at-risk groups (e.g.
chemoprophylaxis for travelers to malaria endemic areas)
8/23/2012
18
Aims to identify and treat existing health problems at
the earliest possible time
Interventions at this stage can still lead to the control
or eradication of the health problem
Interventions: screening, case-finding, disease
surveillance, prompt and appropriate treatment
In communicable disease control health education
on signs and symptoms will enable the client to
identify illness and seek early care or treatment
Knowledge of health risk behaviors that contribute to
the spread of the disease may influence patients and
their families to modify this behavior and thus assist
in the prevention of disease
Limits disability progression
Nurse attempts to reduce magnitude or
severity of the residual effects of both
infectious diseases and non-
communicable ones
Day care centers and sheltered
workshops are examples of
opportunities to achieve the objective of
tertiary prevention in mental illness and
drug abuse
(Maglaya, p. 184)
After establishing the disease frequency
and distribution in a population and
defining the characteristics of the disease
or condition in relation to time, place and
person, the nurse proceeds to correlate the
data and attempts to formulate a causal
association between the disease under
study and the probable factors surrounding
it.
This stage is called hypothesis testing.
The exposure factors and the disease will
be tested or proven in the next phase of
the epidemiological process.
(Maglaya, p. 181)
1. Descriptive Epidemiology study of disease
distribution and frequency
2. Analytical Epidemiology attempts to analyze the
causes or determinants of disease through hypothesis
testing
3. Experimental Epidemiology answers questions
about the effectiveness of new methods for controlling
diseases or for improving underlying conditions
4. Evaluation Epidemiology attempts to measure the
effectiveness of different health services and programs
For the purpose of explaining the interrelationship of
factors that bring about community health problems, we
will just focus on DESCRIPTIVE EPIDEMIOLOGY
Various aspects involved in descriptive
epidemiology include:
1. Observation and recording of existing
patterns of occurrence of health conditions
under study
2. Description of the disease/condition as to
person, place and time characteristics
3. Analysis of the general pattern of
occurrence of disease or condition
(Maglaya, p. 187)
The Community Health Nursing Process
8/23/2012
19
Includes statement of objectives or desired
outcomes and specific nursing interventions.
Formulation of steps to be undertaken in the
future in order to achieve a desired end and to
efficiently allocate available resources.
The planner assesses the nature and extent of
the problems for which the programs is being
planned for as well as the constraints and
limitations that may affect planning decisions
Is done in our desire to improve the present
state of affairs
Futuristic
Change oriented
Continuous and dynamic process
Flexible
Systematic process assessing health
problems and need, setting goals,
intervention
(Maglaya, p. 169)
1. health status increased or
decreased morbidity, mortality, fertility,
or reduced capability for wellness
2. health resources lack or absence of
manpower, money, materials, or
institution necessary to solve health
problems
3. health-related existence of social,
economic, environmental, and political
factors that aggravate illness-inducing
situations in the community
(Maglaya, p. 169)
1. heal th status increased or decreased
morbidity, mortality, fertility, or reduced
capability for wellness
2. heal th resources lack or absence of
manpower, money, materials, or institution
necessary to solve health problems
3. heal th acti on potenti al ability of the
state and its people to address the health
needs and problems of the community. It
also mirrors the sensitivity of the
government to the peoples struggle for
better lives. (Maglaya, p. 162)
(Maglaya, p. 188)
As the community health nurse plans to
meet the health problems and needs of
the population, four basic questions are
asked:
1. Where are we now?
2. Where do we want to go?
3. How do we get there?
4. How do we know we are there?
(Maglaya, p. 188)
Situational Analysis
Gather health data
Tabulate, analyze, &interpret data
Identify health problems
Setpriority
Goal and Objective
Setting
Define programgoals &objectives
Assignpriorities among objectives
Strategy / Activity Setting
DesignCHN programs
Ascertainresources
Analyze constraints &limitations
Evaluation
Determine outcomes
Specifycriteria &standards
8/23/2012
20
1. Situational Analysis Where are
we now? (Maglaya, p. 188)
Get comprehensive picture of the health
problems in the community
Guide in choice of health interventions
a. Gather data
b. Identify and explain problem
c. Projects need for change
Identify target group
Identify contributing factors
1. Identifying Health Problems and
Prioritizing the health problems
Magnitude of the problem must be clearly
specified
Details about the population experiencing the
problem
Criteria for Priority-Setting
a. Nature of the problem
b. Magnitude of the problem
c. Modifiability of the problem
d. Preventive potential
e. Social concern
2. Analysis of the health problems
Provides additional data about the factors
that are contributing to the health problem
Wherein, contributing risk factors may
become the focus of subsequent
interventions
Sort factors into logical order that will help
tease out the causal pathways leading to
the problem
a. Identify the risk factors
b. Identify contributing risk factors
c. Sort the contributing risk factors into:
Predisposing
Enabling
Reinforcing
Predisposing are factors that exert their
effects prior to a behavior occurring, by
increasing or decreasing a person or
population's motivation to undertake that
particular behaviour.
Awareness and knowledge
Beliefs and Fear
Values
Attitudes
Self-efficacy perception of the person on how he
can effectively perform a particular health behavior
Behavioral intention
Existing Skills
Non-modifiable factors such as age, sex, genetics,
socio-demographics
Enabling factors which make possible a
certain behavior or action possible.
Accessibility, affordability, availability of
resources
Health care resources health manpower,
hospitals, public health clinics, health programs
and services
Community and other Environmental conditions
if community conditions are supportive to
change, then it can enable a change in behavior
Tax for tobacco
Presence of parks and recreation facilities for
weight management
8/23/2012
21
Reinforcing factors which may
reward or punish the carrying out of
behavior or the maintenance of the
situation.
Influences coming from parents, health
care providers, teachers and media
1. Individual attitudes, knowledge, beliefs, self-esteem,
health locus of control, literacy
2. Social role models, social support, social desirability,
cultural norms
3. Environmental physical environment, population,
housing, transport values, routes, water supply
4. Health Service availability, accessibility, acceptability to
target groups
5. Financial cost of services for preventive care; financial
incentives for prevention
6. Political political self-efficacy; opportunities for
participation in decision- making; policies on health and
equity
7. Legislature safety regulations; environmental
protection, laws regarding exposure to hazardous
materials; school immunization
Health
Problem
Risk Factors
Predisposing Enabling Reinforcing
Goals
Objectives
Sub-
Objectives
Contributing Factors
High incidence and prevalence of
intestinal parasitism among
children
poor personal
habits
lowlevel of
education
poverty
unsanitary
waste disposal
system
lackof basic
health facilities
government
neglect
health is least priorityin
terms of budget
poor child care
preoccupation
with earning a
living
poor utilization
of health
negative
attitude of
health
providers
job
dissatisfaction
(Maglaya, p. 189)
2. Goal and Obj ecti ve Setti ng Where do
we want to go? (Maglaya, p. 190)
Goal
Change in the health problem or condition
Leads desired end, towards solving health
status problems
Broad and not constrained by time or resources
It targets the Health Problem
For Goal, you must state magnitude of the
reduction, the target population and the target
number of years you want to achieve the goal.
Example: To reduce the incidence and prevalence of
hypertension in BrgyMaligaya by 85% in 2 years
time
Obj ecti ves
More precise, specific, measurable terms
Changes for the target group in terms of their
behavior
It targets the Risk Factors
Sub-obj ecti ve
Change in a factor which is a prerequisite in
the change of behavior.
It targets the Contributing Risk Factors
8/23/2012
22
HealthProblem High incidence and prevalence of intestinal
parasitismamong children
Goal To reduce the incidence and prevalence of
intestinal parasitismamong children of Sitio
Camachile
Objectives 75% of children below 6 years old will test
negativefor parasites after one year
80% of households will have access to safe
wastedisposal systemwithinsix months
80% of households will have access to safe
andadequate water supply withinsix months
75% of children under 6 years old will have
regular clinic visits
3. Strategy / Activity Setting How do we get
there? (Maglaya, p. 191)
Strategies and activities to achieve goal and
objectives
Identification of resources
Involves designing health programs, budgeting,
making time plan or schedule
Program Plan
Series of activities to correct health problem
Organized set of activities, projects, processes
or services
Broader scope
Can be services or developmental (training)
Objective Activity Targetdate,
timeand
venue
Target
group/
number
People
responsible
Resources Evaluation
Activities Time
Objectives Project Strategy
Objectives
Strategy
Activities
Target
date, time
andvenue
Target
group/
number
People
responsible
Resources Evaluation
(Output,
Effect,
Impact)
4. Evaluati on How do we know we are
there?
To find out if the programs and services
achieved the purpose for which they are
formulated
Determine if program is relevant, effective,
efficient and adequate
Determine input, process and output /
outcome
Phi l i ppi ne Heal th Care Del i very System
(Maglaya, p. 24)
The health care delivery system is the totality of
all the policies, infrastructures, facilities,
equipment, products, human resources, and
services that address the health needs,
problems and concerns of all people.
Both public and private sectors maintain their
own health facilities (such as hospitals, clinics,
and diagnostic centers).
Preventive health care is a major concern of the
government-owned health centers while curative
care is provided by hospitals, both government
and private.
(Maglaya, p. 24)
With the exception of a few government
agencies operating their own health facilities,
the Department of Health remains to be the
governments biggest health care provider.
It is used to have control and supervision over
all barangay health stations, rural health units,
and hundreds of hospitals throughout the
country (special and specialty hospitals,
medical centers, and regional, provincial,
district and municipal hospitals).
Today, only the regional hospitals, medical
centers, special and specialty hospitals are
directly under the DOH.
8/23/2012
23
(Maglaya, p. 25)
One of the most significant laws that have radically
changed the landscape of health care delivery in the
country is RA 7160 or more commonly known as the
Local Government Code.
The Code aims to: transform local government units
into self-reliant communities and active partners in
the attainment of national goals through a more
responsive and accountable local government
structure instituted through a system of
decentralization.
In 1993, health services were devolved or
transferred from the DOH to the local government
units all provincial, district and municipal hospitals
to the provincial governments and the rural health
units (RHUs) and barangay health stations (BHSs) to
the municipal government
(Cuevas, p. 32)
1. Primary Level of Care
2. Secondary Level of Care
3. Tertiary Level of Care
devolved to the cities and municipalities
health care provided by health center
physicians, PHN, RHM, BHW, traditional
healers and others at the barangay
health stations and RHU
is usually the first contact between the
community members and the other
levels of health facility
given by physicians with basic health
trainings
given in health facilities privately owned
or government operated such as
infirmaries, municipal and district
hospitals, and OPD of provincial
hospitals
this serves as a referral center for the
primary health facilities
capable of performing minor surgeries
and simple laboratory exams
rendered by specialists in health
facilities including medical centers as
well as regional and provincial hospitals,
and specialized hospitals
serves as a referral center for the
secondary care facilities
complicated cases and intensive care
requires tertiary care
(Cuevas, p. 34)
Tertiary
Secondary
Primary
National
Health Services
Medical Centers
Teaching &
Training Hospitals
Regional Health Services
Regional Medical Centers
And Training Hospitals
Provincial / City Health Services
Provincial / City Hospitals
Emergency / District Hospitals
Rural Health Unit
Community Hospital and Health Centers
Private Practitioners / Puericulture Center
BarangayHealth Stations
8/23/2012
24
The Millenni um Development Goals
(www.undp.org.ph)
The Millennium Development Goals (MDGs)
are a set of eight time-bound, concrete and
specific targets aimed at significantly
reducing, if not decisively eradicating
poverty, by the year 2015:
(Cuevas, p. 3)
1. Eradicating extreme poverty and
hunger
2. Achieving universal primary education
3. Promoting gender equality and
empowering women
4. Reducing child mortality
5. Improving maternal health
6. Combating HIV /AIDS, malaria and
other diseases
7. Ensuring environmental sustainability
8. Developing global partnerships for
development
(Cuevas, p. 26)
What i s FOURmul a ONE for Heal th?
Defining the Road Map for Reforms FOURmula
ONE for Health is the implementation framework
for health sector reforms in the Philippines for
the medium term covering 2005-2010. It is
designed to implement critical health
interventions as a single package, backed by
effective management infrastructure and
financing arrangements.
Goal s of FOURmul a ONE for Heal th
1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing
1. Health Financing the goal of this health
is to foster greater better and sustained
investments in health.
2. Health Regulation the goal is to ensure
quality and affordability of health goods
and Services
3. Health Service Delivery the goal is to
improve and ensure the accessibility and
availability of basic and essential health
care in both public and private facilities
4. Good Governance the goal is to
enhance health system performance at
the national and local levels
General Obj ective:
FOURmulaONE for Health is aimed at achieving critical
reforms with speed, precision and effective coordination
directed at improving the quality, efficiency, effectiveness
and equity of the Philippine health system in a manner
that is felt and appreciated by Filipinos, especially the
poor.
Specific Obj ectives:
FourmulaOne for Health will strive, within the medium
term, to:
1. Secure more, better and sustained financing for health;
2. Assure the quality and affordability of health goods and
services;
3. Ensure access to and availability of essential and basic
health packages; and
4. Improve performance of the health system
(Cuevas, p. 30)
An essential health care made universally accessible
to individuals and families in the community by
means acceptable to them through their full
participation and at a cost that the community and
country can afford at every stage of development
Declared during the 1
st
International Conference on
Primary Health Care held in Alma Ata, USSR on
Sept. 6-12, 1978 by WHO
Goal: Health for all by the year 2000
Adopted in the Philippines through Letter of
Instruction 949 signed by Pres. Marcos on Oct. 19,
1979
Theme: Health in the Hands of the People by 2020
8/23/2012
25
(Cuevas, p. 31)
1. Environmental Sanitation (adequate supply of
safe water and good waste disposal)
2. Control of Communicable Diseases
3. Immunization
4. Health Education
5. Maternal and Child Health and Family
Planning
6. Adequate Food and Proper Nutrition
7. Provision of Medical Care and Emergency
Treatment
8. Treatment of Locally Endemic Diseases
9. Provision of Essential Drugs
EDWIN O. BRACAMONTE, RN, MAN 145 EDWIN O. BRACAMONTE, RN, MAN 146

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