COMMUNITY HEALTH NURSING II- MODULE 1
Part 1
Health- a state of complete physical, mental, and
social well being and not merely the absence of
disease or infirmity (WHO,1994).
Community
Requisites for health (OTTAWA 1986):
● Peace
● Shelter
● Education
● Food
● Income
● Stable ecosystem
● Sustainable resources
● Social justice
● Equity
Healthy Community
- continually creates and improves the
environment and expands resources such that
the prerequisites for health are provided and all
citizens move toward the broad definition of
health.
Public health practice:
- “What we, as a society, do collectively to assure
the conditions in which people can be healthy (IM,
1988).
- “An organized activity of society to promote,
protect, improve, and when necessary restore
health (Scutchfield & Keck, 2009).
Era’s:
1st Epidemiologic Era- infectious disease
2nd Epidemiologic Era- cellular aberrations
3rd Epidemiologic Era- mental, physical,
emotional alterations
Branches of Public Health:
Nursing
Medicine
Engineering
Public health-Nursing:
Community-oriented nursing
- A philosophy of nursing service delivery
that involves the generalist or specialist
public health and community health nurse.
- The nurse provides health care through
community diagnosis and investigation of
major health and environmental problems,
health surveillance, and monitoring and
evaluation of community and population
health status for the purpose of disease
and disability and promoting, protecting,
and maintaining health to create
conditions in which people can be healthy.
Community-based nursing
- Setting specific practice whereby care is
provided for clients and families where
they live, work, and attend school.
- The emphasis of community-based
nursing practice is acute and chronic care
and the provision of comprehensive,
coordinated, and continuous practice.
- Nurses who deliver community-based
care are generalists or specialists in
maternal/infant, pediatric, adult, or
psychiatric/mental health nursing.
Public Health Foundation Pillars:
● Assessment
● Policy Development
● Assurance
Service Delivery Concentration:
● Health promotion
● Health protection
● Disease prevention
Public Health Intervention Wheel:
● Advocacy
● Social Marketing
● Policy Development
● Surveillance
● Etc. (+11 interventions)
Community-Oriented Nursing Practice Model
(Stanhope & Lancaster, 2012)
Assumptions:
● The model shown is a flying balloon,
representing community-oriented nursing
and is filled with knowledge, skills, and
abilities needed in this practice to carry
the world.
● The public health foundation pillars of
assurance, assessment and policy
development hold up to the world of
communities, where people love, work,
play, go to school, and worship.
● The ribbons flying from the balloon
indicate the interventions used by nurses.
This serves to provide lift and direction,
tying the services together for the clients
that are served.
“Fulfilling society‟s interest in assuring conditions
in which people can be healthy (IM, 1988).”
Public Health foundation Pillars:
- The public health foundation pillars of
assurance, assessment, and policy
development hold up the world of
communities, where people love, work,
play, go to school, and worship.
FIRST PILLAR: Assessment
 Regularly and systematically collect,
assemble, analyze, and make available
information on the health of the
community. It includes statistics on health
status, community health needs, and
epidemiologic and other studies of the
population (Scutchfield & Keck, 2009).
 Refers to systematically collecting data on
the population, monitoring the population‟s
health status, and making information
available about the health status of the
community (Stanhope & Lancaster,
20120).
Assessment
First: Understand the Systems within the
Community
>Place
Measures: geopolitical boundaries, local or folk
name of area, size (in acre, sq. miles, blocks),
transport avenues (such as rivers, highways,
railroads, and sidewalks), history, physical
environment (such as land use patterns, housing
conditions).
> People and Person
Measures: population (no. and density),
demographic structure of population (age, race,
socioeconomic status, racial distribution, rural and
urban character).
Informal groups: block clubs, service
clubs, friendship networks
Formal groups: schools, churches,
businesses, industries, gov‟t bodies,
unions, health & welfare agencies.
> Function
Measures: production, distribution and
consumption of goods and services.
- Socialization of new members,
maintenance of social control, adapting to
ongoing and expected change.
Examples of data sources:
Maps
Local News Paper
City gov‟t
Library Archives
Census data
Local Housing
Offices
Examples of data sources:
Census data
Tourist Bureau
Churches
Tel. Directory
Senior Center
State Officials
Civic groups
State Departments
Examples of data sources:
State Dept.
Police Station
Business & Labor
Welfare Agencies
Local Library
Churches
Social and Local
Res. Reports
Second: Understand the Dimensions
within the Community
> Status
Three areas of concern:
a. Biological part- focuses on health
indicators (Mortality & Morbidity rates, life
expectancy rates, case fatality
ratio/rate,etc).
b. Emotional part- measured through
satisfaction rates and mental health
indices.
c. Social part- measured through the social
functional level of the members of society
(e.g crime rates, worker absentism).
>Structure
Measures:
Health facilities such as: hospitals, nsg. homes,
industrial and school health services, health
departments, voluntary health associations.
Health manpower such as: physicians, dentists,
nurses, environmental sanitarians, social workers.
Health resources use pattern such as:
Bed occupancy days, client/provider visits.
>Process
Measures: commitment to community health,
awareness of self and others and clarity of
situational definitions, effective communication,
conflict containment, management of
relationships with society.
Examples of data sources:
Health Dept.
NGO‟s
Support Groups
Census Date
Examples of data sources:
> Structure
Measures of community health services and
resources:
a. Service use patterns
b. Provider-to-client ratio (data will provide
number of available hospital beds or the
number of necessary facilities within a
care facility).
Local News Paper
Health Insurance
Databases
Local Gov‟t.
Professional
Licensing boards
Hospital Reports
> Process
- Community health when viewed in terms
of process deals with the process of
effective community functioning or
problem solving. In its sense, it will direct
the study of community health for
community action.
>Status
Measures: vital statistics (live births, neonatal
deaths, infants deaths, maternal deaths),
incidence and prevalence of leading causes of
mortality and morbidity, health risk profiles of
selected aggregates, functional ability levels.
Examples of data sources:
State Dep‟t.
Community Meeting
notices
Local History
Windshield survey:
Observation of
interactions
Neighborhood Help
Org.
Third: Understand the Community
Behavioral Health Needs
-
-
We need to understand the theory in the
community because theories comprise
principles devised to explain a group of
facts or phenomenon.
Thus, health behavior theories are meant
to provide broader understanding of that
behavior and its links to the general
human condition. As these are vital and
influential to the social determinants of
health in the community.
Common Theories:
● Communication
● Economics
● Psychology
● Philosophy (broad)
Common Theories utilized in Practice:
● Communication Theories:
(Prochaska & DiClemente, 1998)
 Communication Persuasion Model
(1989)
 Transtheoretical Approach
● Behavioral Change Theories
- Provide strategies for tailoring
interventions to individual
participants.
- Behavioral Analysis Theory
(Skinner, 1953; Holland & Skinner,
1961; Baer et.al.,1968;
Miller,1980)
- Social Learning Cognitive Theory
Things to Note when Facilitating Assessment
as a Pillar:
-
Understanding of the community and
practice and population and the indices
that influence and work within =
ASSESSMENT
The practitioner will be able to:
1. Facilitate collation and analysis of data
2. Identification, clustering, and prioritization
of problems/needs
3. Planning of health programs and
intervention
4. Implementation of plans/ programs
5. Monitoring and evaluation
COMMUNITY NURSING PROCESS (ADPIE)


ONPRIME MODEL
ONPRIME integrates many of the public
health core competencies within a single
phase, recursive model.
ONPRIME components will contribute
toward the development skills in:
 Leadership and systems thinking
(comm. organizing)
 Analysis and assessment (esp. needs
assessment and evaluation)
 Policy dev‟t and program planning
(priority setting)
 Community dimensions of practice
(needs and resource assessment)
 Communication (interventions)
 Management (monitoring and eval)
 and Cultural competency as well as
 Public Health
Organization
- refers to whether the program entails working
within existing organizations, working through
various community gatekeepers, program
planners, grassroot workers to develop a
sponsoring structure where no apparent
candidate exists.
- Therefore, establishing organizations
within the community provides links and
relationships to facilitate entry,
assessment and delivery of programs.
Needs & resource assessment
- this phase may include key informant reviews,
archival research, surveys, examinations of
existing health and related env‟t needs, economic
and social problems. The program planner may
also be directed through activities that have been
conducted in the past and how community
resources have been, or could be used to
address the problem.
-
Therefore, a successful health program
looks at the community as one that has
many strengths, abilities, and potential
resources that can be employed to
address a problem.
Priority setting
- occurs after data are collected by health
officials, community advisory boards,
representative individuals within the community.
Health data and information is examined to help
establish health-and-disease-related priorities.
- Therefore, communities that have been
successful in selecting their own
interventions or targeted health priorities
will likely embrace a program over a
longer period of time.
Research
- in this process, research does not focus on
epidemiology (as a separate context for research
in public health) or survey research to identify
health problems. Instead, focus on the formative
and other qualitative/ quantitative research
needed to develop health behavior change.
- Therefore, qualitative and quantitative
research is conducted specifically to
develop new techniques or refine old
ones.
Intervention Activities
- done after the aforementioned (ONPR) phases
have been completed. The program planner/
manager develops a set of intervention activities
through the most techniques available.
Techniques:
 Individual level behavioral change
 Communication activities
 Changes in physical and environment
 Skills building
 Policy change
Monitoring
- comprises both the monitoring of the
implementation process
(e.g “were televisions shows aired on their
supposed time slot?”) as well as responses to
interventions (e.g “after a grocery store promotion
was undertaken, what sales changes occured?”)
Evaluation
- determine whether a program was effective or
which of its elements were most effective.
- Therefore, evaluation information may be
used to determine whether to extend a
program and promote its generalization to
other communities, or conversely, whether
to terminate or revise the effort.
ASSESSMENT AS CORE FUNCTION
(Activities and Sub-Activities)
1. Monitor health status to identify
community health problems
 Participate in community assessmentproofing, comm. Survey, etc.
 Identify subpopulation at risk for
disease or disability- high risk infants
under the age of 1 year, unmarried
pregnant adolescents.
 Collect information on interventions to
the special population.
 Define and evaluate effective
strategies and programs- by
evaluation, assessment of strategies
and programs will help determine the
baseline efficacy of such to the
population.
 Identify potential environmental
hazards.
2. Diagnose and investigate health
problems and hazards in the
community
 Understand and identify determinants
(personal and social) of health and
diseasePersonal: health seeking behavior,
practices;
Social: health systems, environment,
socially learned behaviors, etc.
 Apply knowledge about environmental
influences of health.
 Recognize multiple causes or factors
of health and illness.
 Participate in case identification and
treatment with persons with
communicable diseases.
SECOND PILLAR: Policy Development
 Serve the public interest in the
development of comprehensive public
health policies by promoting use of
scientific knowledge (Scutchfield & Keck,
2009).
 Refers to the need to provide leadership in
developing policies that support the health
of the population, including the use of
scientific knowledge-based in making
decisions about policy (Stanhope &
Lancaster, 20120).
Public Policy
- Is described as all gov‟t activities, direct or
indirect, that influences the lives of all
citizens.
Policy
- Is a settled course of action to be followed
by a specified gov‟t or institution to obtain
a desired end = SPECIFIC.
Policy Development
- The law affects public health by setting
boundaries of authority among decision
makers and to the extent possible,
ensuring transparency and accountability
in the process.
- Public health law may be defined as that
branch of jurisprudence which treats the
relation and application of the common
statutory law to the principles, and
procedures of hygiene, sanitary science,
and public health administration (Tobey,
1947 in Bhattacharya, 2013).
- Public health law is the study of legal
powers and duties of the state, in
collaboration with its partners (e.g health
care, business, the community, the
emedia, and the academe), to ensure the
conditions for the people to be healthy,
and of the limitations on the power of the
state to constrain for the common good
the autonomy, privacy, liberty, propriety,
and other legally protected interests of
individuals (Gostin, 2008 in Bhattacharya,
2013).
1. State and National Legislation
 Statutes- the state and national
legislation create the law through the
enactment of statutes that are often
broadly worded yet provide a
framework and objectives as guidance
for addressing a specific issue.
 Regulations- agencies are often
delegated the task of implementing a
particular statute by issuing
regulations that may entail defining
core terms, adopting standard for the
industry, interpreting ambiguous or
broadly worded phrases of terms, and
outlining attendant costs and benefits.
Policy Development (The Process)
- Process of turning health problems into
workable action solutions.
 Cost- how will this impact the economy
of the country, state, and
organization?
 Access- with the bill, will there be
access and would the targeted
population benefit?
 Quality- how is quality assured in
terms of law enforcement, outcomes
delivery and the processes involved?
Policy Development (Key Elements)
 A- statement of health care problem
 D- Statement of policy options to
address the health problem
 P- adoption of a particular policy
option
 I- implementation of the policy product
 E- evaluation of the policy‟s intended
and unintended consequences in
solving the original health problem
- Thus, the policy process is very similar to
the nursing process, but the focus is on
the level of the larger society and the
adoption strategies require political (the
art of influencing others to accept a
specific course of action) action.
Policy Development (Evaluation Process)
 Engage Stakeholders- this includes
those who are involved in planning,
funding, and implementing the program,
those who are affected by the policy, and
the intended users of its services.

Describe the Program- the program
description should address the need for
the program and should include the
mission and goals. This set the standard
for the judging results of the evaluation.

Focus the Evaluation Design- describe
the purpose for the evaluation, the users
who will receive the report, how it will be
used, the questions and methods to be
used, and any necessary agreement.
o Gather Credible Evidencespecify the indicators that will be
used, source of data, quality of
data, quantity of information to be
gathered, and the logistics of the
data gathering phase. Data
gathered should provide credible
evidence and should convey a
well-rounded view of the program.
○
Justify Conclusions- the
conclusions of the evaluation
should be validated by linking them
to the evidence gathered and then
appraising them against the values
or standard set by the
stakeholders. Approaches for
analyzing, synthesizing, and
interpreting the evidence should be
agreed on before data collection
begins to ensure that all needed
information will be available.
○
Ensure Use and Share of
Lessons Learned- use and
dissemination of findings require
deliberate effort so that the lessons
learned can be used in making
decisions about the program.
POLICY DEV’T AS CORE FUNCTION
(Activities and Sub-Activities)
3. Inform, educate, and empower people about
health issues
 Develop health and educational plans for
individuals and families in multiple
settings.
 Develop and implement community-based
health education.
 Provide regular reports on health status of
special populations within clinic settings,
community settings, and groups.
 Advocate for and with underserved and
disadvantaged populations.
4. Mobilize community partnership to identify
and solve health problems
 Interact regularly with many providers and
services within each community.
 Convene groups and providers who share
common concerns and interests in special
populations.
 Provide leadership to prioritize community
problems and dev‟t. of interventions.
 Explain the significance of health issues to
the public and participate in developing
plans of action.
5. Develop policies and plans that support
individuals and community health efforts
 Participate in community and family
decision-making processes.
 Provide information and advocacy for
consideration of the interests of special
groups in program dev‟t.
 Develop programs and services to meet
the needs of high-risk populations as well
as broader community members.
 Participate in disaster planning and
mobilization of community resources in
emergencies.
 Advocate for appropriate funding for
services.
THIRD PILLAR: Assurance
- Ensuring that essential communityoriented services are available
- Making sure that a competent public
health and personal health care workforce
is available
- Public health in the assurance should be
involved in developing and monitoring the
quality of services provided (Stanhope &
Lancaster, 20120).
We focus on:
 Healthcare Workforce and Services
 Social Structures and Systems
 Population as Clienteles
 Assuring the constituents that services
necessary to achieve agreed upon goals
are provided, either by encouraging
actions by other entities (public/private
sector), by requiring such acts through
regulation or by providing services directly
(IM, 1988).
Assurance (Role of Devolution in Service
Delivery)
ASSURANCE IN SERVICE DELIVERY
Partnership (Public/Private Partnership):
 Politics
 Advocacy
 Lobbying
Policy and Law Enforcement:
 Health Education
 Social Marketing
 Community Organizing Activities
Assurance (Law Enforcement)
> Executive Branch- suggests, administers, and
regulates policies.
 President
 Vice- President
 Cabinet
> Legislative Branch- identifies problems and to
propose, debate, pass, and modify laws to
address problems.
 Congress
 Senate
 House of Representatives
>Judicial Branch- interprets laws and their
meaning, as in its ongoing interpretation of rights
to define access of health services to the state.
 Supreme Court
 Other courts
Key Areas:
1. Healthcare Workforce and Services
2. Social Structure and Systems
3. Population as Clienteles
Healthcare Workforce and Services
● Entry Level Competence
- Bachelor‟s Degree Holder in Nursing
- An Active Philippine Nursing License
●
Advanced Practice, Supervisory Roles
(Health Program Manager, Nurse
Supervisor), Specialty Practice (Nurse
Epidemiologist, Researcher, Nurse
Genetic Counselor)
1. Professional experience in Public
Health
2. Program Trainings
3. Post Graduate Education
Masters:
- Master in Public Health
- Master in Science in Nursing major in
Community or Public Health
Doctorate:
- Doctor in Public Health
- Doctor in Philosophy, Nursing, Nursing
Science
- Doctor in Nursing Science
4. Certified in Public Health License
(optional)
Ethics in Public Health
- “A branch of philosophy that includes both
a body of knowledge about the moral life
and a process of reflection of determining
what persons ought to do or be, regarding
life”
Bioethics
- “A branch of Ethics that applies the
knowledge and process of ethics to the
examination of ethical problems in health
care”
Ethical Theories
- Consequentialism
- Deontology
- Utilitarianism
GUIDING THEORIES OF ETHICS
- GOAL: “To choose that action or state of
affairs that is good or right in the
circumstance”
Consequentialism
- “Holds that the consequences of one‟s
conduct are the ultimate bias for any
judgment about rightness or wrongness of
that conduct”
Putting Into Perspective
1. The Nurse may diagnose a situation on
the basis of the best available information
then choose the course of action that
seems to provide the best ethical
resolution to the issue.
2. Most of the people agree that lying is
wrong but, if telling a lie would help save a
person‟s life, consequentialism says it‟s
the right thing to do.
Things To Keep In Mind
- Consequentialism is sometimes criticized
because it can be difficult, or even
impossible, to know what the result of an
action will be ahead of time.
- Indeed, no one can know the future with
certainty.
Utilitarianism
HOW TO: Apply the Utilitarianism Ethics
1. Determine the moral rules that are
important to society and that are derived
from the principle of utility.
2. Identify the communities or populations
that are affected or most affected by the
moral rules.
3. Analyze viable alternatives for each
proposed action based on the moral rules.
4. Determine the consequences or outcomes
of each viable alternative on the
communities or populations most affected
by the decision.
5. Select actions on the basis of the rules
that produce the greatest amount of good
or the least amount of harm for the
communities or populations that are
affected by the actions.
Deontology
- “Deontology is an ethical theory that uses
rules to distinguish right and wrong”
- Ex. “Don‟t lie, Don‟t steal, Don‟t cheat, etc)
= Universal Moral Laws
Putting Into Perspective
1. It requires that people follow the rules and
do their duty. This approach fits well
without natural intuition about what is or
what isn‟t ethical.
2. Unlike consequentialism, (which judges
action by their results) deontology doesn‟t
require weighing the costs and benefits.
This avoids subjectivity and uncertainty
because you only have to follow set rules
Things to Keep in Mind
- “People SHOULD follow the rules and DO
their duty”
- For example, suppose you‟re a software
engineer and learn that a nuclear missile
is about to launch that might start a war.
You can hack the network and cancel the
launch but it‟s against your professional
code of ethics to break into any software
system without permission and it‟s form of
lying and cheating.
- Deontology advises not to break or violate
these rules. However, in letting the missile
launch, thousands of people will die.
- So following the rules makes deontology
easy to apply. But it also means
disregarding the possible consequences
of our actions when determining what is
right and wrong.
ETHICS AND THE CORE FUNCTIONS OF
PUBLIC HEALTH
(Population-Centered NUrsing Pactice)
Assessment
- We remember that: “Assessment refers to
the systematic collection of population
data, monitoring the population's health
status and making information available
about the health of the community”
First Ethical Tenet: “Relates to the competency
related to knowledge development, analysis, and
dissemination”
- “Are the persons assigned to develop
community knowledge adequately
prepared to collect data on groups and
population?”
- This question is important because the
research, measurement, analysis
techniques used to gather information
about the population usually differ from
techniques to assess individuals.
- “Wrong research technique can lead to
wrong assessments, which in turn, may
hurt rather that help the intended
population”
Second Ethical Tenet: “Relates to virtue ethics or
one‟s moral character”
- “Is the person selected to develop,
assess, and disseminate community
knowledge process integrity?”
- The importance of this virtue is self
evident: without integrity, the core function
of assessment is endangered. Persons
with compromise integrity are easy prey
for scientific misconduct.
- “An example: Nurses would be bias in
collecting or reporting based on racism or
homophobic grounds.”
Third Ethical Tenet: “Relates to do no harm”
- “Is disseminating appropriate information
about groups and populations morally
necessary and sufficient?”
- The answer to “morally necessary” is yes,
but to “morally sufficient”, it‟s no.
-
“The fallacy with dissemination is that
there is no built-in accountability that what
is disseminated will be read or
understood, harm could come to groups
and populations regarding their health
status.
Policy Development
- We remember that: “Refers to the need in
developing policies that support the health
of the population, including the use of
scientific knowledge base in making
decisions about policy.”
First Ethical Tenet: “An important goal of both
policy and ethics is to achieve the public good
(Silva, 2002)”
- “The concept of the „public good‟ is rooted
in citizenship (Denhardt & Dendhart, 2000;
Rogers, 2006; Ruger, 2008)
- “Democratic Citizenship”, as a stance in
which citizens play a more substantial role
in policy development. For this to occur,
citizens must be willing NOT ONLY to be
informed about policy, but also to DO what
is in the interest of the community.
Second Ethical Tenet: “Service to others over self
is a necessary condition of what is “good” or
“right” policy”
- Perspective of the 2nd Tenet accdg. to
Denhardt & Denhardt (2000):
1. “Serve rather than steer, is to help citizens
accumulate and meet their shared interest
rather than to attempt to control or steer
society in a new direction”
- “Attuning oneself with the felt needs of the
community to develop their potential
(Gaviola, 2019)”
2. “Serve citizens not customer, thus public
servants do not merely respond to the
demands of customers but focus on
building relationship of trust and
collaboration with and among the citizens”
3. “Value citizenship and public service
above entrepreneurship, where there
should be commitment to making
meaningful contributions to society rather
than acting as if public money is solely
owned.
Third Ethical Tenet: “States that what is ethical is
also good policy”
- “What is ethical should be singular
foundational pillar upon which nursing is
based”
Assurance
- We remember that: “Refers to the role of
public health in ensuring that essential
community services are available, which
may include providing personal health
service.”
- “Assurance also refers to making sure
that competent public health and personal
healthcare workforce is available”
First Ethical Tenet: “All persons should receive
essential personal health services or, put in terms
of justice, “to each person a fair share”, or
reworded, “to all groups and populations fair
share.”
- This perspective does not mean that all
persons in society should share all of
society‟s benefits equally, but that they
should share at least those benefits that
are essential”
Second Ethical Tenet: “Providers of public health
service are competent and available.”
- This doesn‟t speak directly to workforce
availability but, it does speak directly to
ensuring professional competence of
public health employees.
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ETHICS IN THE PRACTICE PUBLIC HEALTH
(Population-Centered Nursing Practice)
● Public health should address principally
the fundamental causes of disease and
requirements for health, aiming to prevent
adverse health outcomes
● Public health should achieve community
health in a way that respects the rights of
individuals in the community.
● Public health policies, programs, and
priorities should be developed and
evaluated through processes that ensure
an opportunity for input from community
members.
● Public health should advocate and work
for the empowerment of disenfranchised
community members, aiming to ensure
that the basic resources and conditions
necessary for health are accessible to all.
Public health should seek the information
needed to implement effective policies
and programs that protect and promote
health.
Public health institutions should provide
communities with the information they
have that is needed for decisions on
policies or programs and should obtain the
community‟s consent for their
implementation.
Public health institutions should act in a
timely manner on the information they
have, within the resources and the
mandate given to them by the public.
Public health programs and policies
should incorporate a variety of
approaches that anticipate and respect
diverse values, beliefs, and cultures in the
community.
Public health programs and policies
should be implemented in a manner that
most enhances the physical and social
environment.
Public health institutions should protect
the confidentiality of information that can
bring harm to an individual or community if
made public. Exceptions must be justified
on the basis of high likelihood of
significant harm to the individuals or
others.
Public health institutions should ensure
the professional competencies of their
employees.
Public health institutions and their
employees should engage in
collaborations and affiliations in ways that
build the public‟s trust and the institution‟s
effectiveness.
ASSURANCE IN THE PUBLIC HEALTH
1. The Healthcare Workforce and Services
●
-
-
Professional Development and
Competence
Entry Level Competence (Bachelor's
Degree in Nursing and Active Professional
Board Licenses)
Advanced Practice (Post Graduate
Education, e.g Masters/Doctorate, Post
Graduate Certifications/Licenses
●
●
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Theories of Ethics
Utilitarianism
Deontolgy
Consequentialism
Ethics in Public Health
12 Ethical principles in Public Health
Practice
2.
3.
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Social Structure and Systems
Population as Clienteles
[Applicable for 2&3]
Culture
Culture Development
The Philippine Public Health Culture of
Care
Culture Competence and Development
-
Culture
- “A set of beliefs, values, adn assumptions
about life that is widely held among a
group of people and that are transmitted
intergenerationally”
ASSUMPTIONS:
- It takes time for culture to develop and is
resistant to change
- In response to the need of its members
and the environment, culture provides
tested solutions to life‟s problems and as a
result, guides our thinking, discussion and
actions.
- Individuals learn about their culture during
the process of learning language and
becoming socialized, usually as a child.
- Each culture has an organizational
structure that distinguishes it from other.
You May Come To Ask?
- How does this influence one‟s care?
- Who are we as Filipinos and how should
we approach caring for the Filipino
population?
Let‟s Take into Account…
Assumption 1: It takes time for culture to develop
and is resistant to change
- Question1: Why is it necessary to
examine the evolution of the Philippine
Culture?
Collective Unconscious
- “Refers to structures of the unconscious
mind which are shared among beings of
the same species
Culture Modification
- Data Banking capability of the collective
unconscious to modify culture. (Gaviola,
2019)
Assumption 3: Individuals learn about their culture
during the process of learning language and
becoming socialized, usually as a child.
Assumption 4: Each culture has an organizational
structure that distinguishes it from others.
DISCUSSION OF THE THEORETICAL MODEL
Archetype
Archetypal constructs are abstract images that is
collectively shared (Jung, 1980)
THE ARCHETYPAL THEORY OF PHILIPPINE
PUBLIC HEALTH CARE
1. The collective unconscious is assumed as
affecting universally, shared by all,
through the constant collection of social
experiences.
2. The openness of the diagram collects the
unconscious databanking capacity and the
ability to cultural modification.
3. The residue of pre-colonial and colonial
era of which are integrated and
continuously influence society at present.
4. This then provides a collectively
understood unconscious that;
a. From pre-colonial era, the
flourishing of culture of the
Philippines and its health practices
have been grounded in faith
healing, belief of the unknown,
herbal medicine and tabooed
practices.
b. During the colonial era, Spanish
culture was forcedly introjected for
three hundred years that entailed
oppression, caste segregation,
civilization, normative formation
and religion establishment to the
native Filipinos which conversely
influenced today‟s segregation of
social conception and practices
especially in the area of public
healthcare.
Propositions:
1. Culture birth begins with a blank state or a
state of “Tabula Rasa” which continuously
nourishes itself from historical and present
events
2. The collective unconscious functions to
society through its data banking capability
that molds culture.
3. The mind‟s evolutional residue, ticks for
recognition on the present time from
formed social archetypes.
4. Caring in Philippine public health is
influenced by the pre-colonial and colonial
identity.
Assumptions
1. Social archetypes from ancestral history
develops through time and by a series of
social events, phenomenon, and
occurrences.
2. Social archetypes of culture determines
the definition of care for each culture and
lastly,
3. Caring is influenced by culture. Which, at
its diversity, differs based on caringculture history and formed archetypes.
Question 2: How does culture affect the quality of
care we render to the population?
Question 3: How are our clients based on this
cultural representation?
DEVELOPING CULTURAL COMPETENCE
So how do we develop cultural competence?
Cultural Competence
- Combination of culturally congruent
behaviors, practice attitudes, and policies
that allow nurses to use interpersonal
communication, relationship skills, and
behavioral flexibility to work effectively in
cross-cultural situations.
- Nurses who strive to become culturally
competent respect individuals from
different cultures and value diversity
- Culture competence reflects a higher level
of knowledge than cultural sensitivity.
1. Cultural Awareness
- Refers to the self-examination and indepth exploration of one‟s own beliefs and
values as they influence behavior
- Culturally aware nurses are conscious of
culture as an influencing factor on
differences between themselves and
others; and are receptive to learning about
the cultural dimensions of the client.
- EXAMPLE: At a community outreach
program, a nurse was teaching a racially
mixed group, the screening protocol for
breast and cervical cancer detection. An
African-American woman in the group
refused to give the return demonstration
for BSE. When encouraged, she said “My
breasts are much larger than those on the
model. Besides, the models are not like
me. They are all white.”
4 Principles in Culture Competent Practice
1. Care is designed for the specific client.
2. Care is based on the uniqueness of the
client‟s culture and includes cultural norms
and values.
3. Care includes self-empowerment
strategies to facilitate client decision
making in health behavior.
4. Care is provided with sensitivity and is
based on the cultural uniqueness of the
client.
Key Elements in Developing Cultural
Competence
1. Experiences with clients from other
cultures
2. An awareness of these experiences
3. Promotion of mutual respect for
differences
Culturally
Competen
t
Culturally
Sensitive
Culturally
Competent
Cognitive
Dimension
Oblivious
Aware
Knowledgeable
Affective
Dimension
Apathetic
Sympathetic
Committed to
change
Psychomotor
Dimension
Unskilled
Lacking
some skill
Highly Skilled
Overall Effect
Destructive
Neutral
Constructive
Adapted: The Cultural Competence Framework;
Stages of Competence Development, (Orlandi,
1992)
2. Cultural Knowledge
- Process of searching for and obtaining a
sound educational understanding about
culturally diverse groups
- Emphasis is on learning about the client‟s
world view from an emic (native)
perspective
- EXAMPLE: Middle Eastern women might
not attend prenatal classes without
encouragement and support from nurses.
The nurse understands at middle eastern
culture, the mother‟s focus is at the
present and what is happening on an
immediate environment. The nurse may
interject by forming strategies that would
facilitate understanding that prenatal
sessions are beneficial for the baby‟s
future.
3. Cultural Skill
- Ability of the nurse to effectively integrate
cultural awareness and cultural knowledge
when conducting cultural assessment and
to use the findings to meet needs of
culturally diverse clients.
- Culturally skillful nurse elicit from clients
their perception of the health problems,
discuss treatment protocols, negotiate
acceptable options, select interventions
that incorporate alternative treatment
plans, and collaborate with all stakeholder.
-
EXAMPLE: Culturally competent nurses
use appropriate touch during conversation
and modify the physical distance between
and others while meeting mutually agreedupon goals.
4. Cultural Encounter
- Refers to the process that permits nurses
to seek opportunities to engage in crosscultural interaction
- 2 types of Cultural Encounter: Direct
(Face-to-Face) and Indirect
- EXAMPLE 1 Direct Encounter: A direct
cultural encounter occurs when nurses
learn directly from their Puerto Rican client
about spicy foods that she will avoid
during periods of breastfeeding.
- EXAMPLE 2 Indirect Encounter: An
indirect cultural encounter occurs when
nurses share these assessment findings
with other nurses to help them develop
their knowledge to effectively care for
other Puerto Rican clients who are
breastfeeding.
5. Cultural Desire
- Refers to the nurses‟ intrinsic motivation to
want to engage in the previous four
constructs necessary to provide culturally
competent care.
- Nurses who have desire to become
culturally competent do so because they
want to, rather than because they are
directed to do so.
- They demonstrate a sense of energy and
enthusiasm about the possibility of
providing culturally competent nursing
interventions.
- Unlike other constructs, cultural desire
cannot be directly taught in the classroom
or in other educational or work settings.
- Nurses should be aware that having
cultural competence is not the same as
being an expert on the culture of a groups
that is different from their own.
Indicators of Successful Encounter
1. The nurse feels successful about the
relationship with the client.
2. The client feel that interactions are warm,
cordial respectful, and cooperative
3. Tasks are done effectively
4. Nurse and client experience little or no
stress
PUBLIC HEALTH CONCENTRATIONS
1. Health Promotion
- Health promotion enables people to
increase control over their own health. It
covers a wide range of social and
environmental interventions that are
designed to benefit and protect individual
people‟s health and quality of life by
addressing and preventing the root
causes of ill health, not just focusing on
treatment and cure.
2. Health Protection
- Health protection offers equality of
opportunity for people to enjoy the highest
attainable level of health, and is achieved
through the development and
implementation of legislation, policies and
programmes in the areas of environmental
health protection and community care
facilities. Health protection in the modern
public health age focuses mainly on:
- 1. Preventing and controlling of infectious
disease
- 2. Protecting against radiation, chemical
and environmental hazards.
3. Disease Prevention
- Prevention in health calls for action in
advance, based on knowledge of natural
history, in order to make it improbable that
the disease will progress subsequently.
Preventive actions are defined ass
interventions directed to averting the
emergence of specific diseases and
reducing their incidence and prevalence in
populations.
THE PUBLIC HEALTH INTERVENTION WHEEL
RESEARCH IN PUBLIC HEALTH
● Logico Positivist Paradigm (Quantitative
Research)
● Naturalist Paradigm
(Qualitative Research)
EPIDEMIOLOGY
- Epidemiology is the basic science of
disease prevention and plays major roles
in developing and evaluating public
policies relating to health and to social
legal issues.
Component 1:
- The Model is Population Based
Competent 2:
- The Model encompasses Three Levels of
Practice
1. Community level practice = increase the
knowledge and attitude
2. Systems Level Practice = change the
laws, policies
3. Individual/Family Level Practice = change
the laws, policies
Competent 3:
- The Model identifies and Defines 17
Public Health Interventions
1. Epidemiologic Approach to Disease and
Intervention
2. Epidemiology to Identify the Causes of
Disease
3. Epidemiology Application in Evaluation
and Policy
Epidemiology and Its Objectives
1. Identify the etiology or cause of a disease
and the relevant risk factors.
2. Determine the extent of disease found in
the community
3. Study the natural history and prognosis of
disease
4. Evaluate both existing and newly
developed preventive and therapeutic
measures and modes of healthcare
delivery
5. Provide the information for developing
public policy relating to environmental
problems, genetic issues, and other
considerations regarding disease
prevention and health promotion
NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
1ST EPIDEMIOLOGIC SHIFT
AGE OF PESTILENCE AND FAMINE
(Infectious)
THE EPIDEMIOLOGIC SHIFTS
Epidemiology - came from the latin word “epi” which means upon and “demos” which
means population and logos which means study.
Pestilence - by the term itself pestilence or from pests
Epidemiology - is a study about what befalls or what happens/ what comes upon a
population.
Back in history, if you could recall stories in the bible and actual famine stories brought
about by several diseases or droughts, severe climate changes -these actually
contributed to a high mortality rate.
- it is also known as a study of dynamics between disease and the population.
Back in 1971, there was a person called Mr. Abdel Omran
He coined the term epidemiological transition or epidemiological shift
To denote the change in disease patterns and the cause of death within a
population.
This could be due to various demographic economic industrial and sociological factors
March 2019, it was the start of the “novel coronavirus pandemic”
Many of those affected with or who contracted the virus have been affected negatively,
most severely those who died with the pandemic. These changes in the population like
for example in the coronavirus pandemic these changes in the population with the
death of those who were affected contributes to the increasing mortality rates.
Mortality is central to the epidemiological shifts.
The 3 Main Epidemiologic Shifts
1st Epidemiologic Shift
AGE OF PESTILENCE AND FAMINE
2nd Epidemiologic Shift
AGE OF RECEDING PANDEMICS
3rd Epidemiologic Shift
AGE OF DEGENERATIVE AND MAN-MADE DISEASE
Main concept that you should remember in the first epidemiologic shift is that
“It is marked by a high mortality rate and a high occurrence of infectious
diseases.”
★
Back then, people were not really aware about these diseases and the treatment for
them was very limited. The scientists still studied about all those diseases so the
treatment was not readily available.They did not have the advanced technology and the
equipment to make these certain cures for the diseases.
The average life expectancy at birth is low and its variable ranges from 20 to 40 years
from the time a person is born.
One example was the “Black Plague”
This was an infection from rats.
Most violent form of epidemic that belongs to stage once in the age of
pestilence and famine
2ND EPIDEMIOLOGIC SHIFT
AGE OF RECEDING PANDEMICS
(Non-communicable)
-
term itself receding pandemics, it's not as vicious as it is
marked by a decline in the mortality theory
Population growth is sustained because there are also women giving birth so it’s trying
to balance out those who have died.
There is a shift of disease here in this stage from infectious to non-communicable
diseases. People were trying or slowly discovering these vaccines to treat disease
among these infectious diseases.
Non-communicable diseases started to become popular
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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Examples:
Lifestyle diseases
Common examples are Diabetes, Hypertension, Cancer.
Average life expectancy at this stage increased slightly higher from 30 to 50 years.
There are still problems occurring because of the term itself receding pandemic. There
are still these infectious diseases that are present but mostly in industrial cities where
people crowd together.
3RD EPIDEMIOLOGIC SHIFT
AGE OF DEGENERATIVE AND MAN-MADE DISEASE
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NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
Income and social status
- Higher income is linked to better health because you can pay or have all the
money to be treated overseas, internationally, and the best doctors in the world.
- Social status is between the rich and the poor. If there is a really big gap between
the rich and the poor it means there is a greater difference in health. More
detrimental effects if there is a bigger gap in the social standing of people.
Education
Stable low and decline in mortality rates and a shift in the primary cause of
death which is from non-communicable diseases
More like cardiovascular and degenerative diseases like cancer and diabetes still considered as non-communicable diseases but primarily myocardial
cardiac diseases.
- Low education levels are linked to poor health. If a person isn’t educated and
doesn't know is very ignorant about such things.
- Low education also more stress because you will be looking for jobs
The average life expectancy at birth rises gradually by more than 50 years. It has the
highest life expectancy.
- Safe water is the most basic one of the most basic necessities that people need
to be healthy
- Clean air
- Healthy workplace
- Safe houses
- Communities and roads
-
The last report or last study of the average life expectancy of a person is 77 year old.
*(77.1 or 0.2 background of 77 years old)
Major health issues with this shift or the third shift are mostly heart attacks and cancer
as I have stressed out cardiac diseases. There is also a decline in infectious diseases
here because of the discovery of vaccines and the roll out of these vaccines to the
majority of the people.
Physical Environment
Now the physics that contributes to physical environment so if one of those are very
problematic
Now we need all those to have good health with the physical environment.
10 DETERMINANTS OF HEALTH AND DISEASE
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Income and social status
Education
Physical Environment
Employment and working conditions
Social Support Networks
Culture
Genetics
Personal Behavior and Coping Skills
Health Services
Gender
Employment and Working Conditions
- Employed people are healthier, especially those with control over their working
conditions.
Social Support Networks
- These could be families, our friends, communities.
If we have these networks of people that support us, now it also links to better health
because we are not an island so we need other people to help us deal with stress,
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
problems which contribute to better health and a happier life. Social support is very
important so we try to ward off those negative people in our lives.
FOCUS ON PUBLIC HEALTH IN RELATION TO THE FILIPINO POPULATION
GROUP
Culture
- Culture also affects health. The customs, traditions, and beliefs.
For example, in a place in the Philippines, very rural areas. They have a tradition there
of treating cough with leaves.
1.
2.
3.
4.
Preventing Disease
Prolonging Life
Promoting Health and Efficiency
Health Protection
1.
Preventing Disease
Genetics
-
Inheritance plays a role in determining the lifespan, longevity, healthiness
Genetics plays a role in developing the likelihood of us developing certain
illnesses which affects health.
Personal Behavior and Coping Skills
- Public health or community health really focuses on preventing disease,
promoting “health promotion disease prevention”.
2.
- We modify the different lifestyles such as the diet, the activities, the
exposure to these pollutants.
- These are very individual factors
Changes that you do to your life or lifestyle such as having a balanced diet, being more
active, engaging in sports, quitting smoking, quitting drinking. Whatever practices or
strategies that you have to deal with stress and positively impact our health.
Health Services
-
-
Access to health services is a very important priority talking about public
health because we are looking out for the best of the majority of the residents
in a certain community
The access to health services is really very central
Gender
-
Prolonging Life
3.
Promoting Health and Efficiency
- By campaigning like the DOH in strengthening the public to get their
booster doses.
4.
Health Protection
- Like a cluster of all these three with preventing disease with prolonging life
and promoting health and efficiency. We are protecting the health of the
population.
CORE PUBLIC HEALTH FUNCTIONS
There is a difference between men and women
There are diseases that men suffer more compared to women and there are
diseases also women suffer slightly more compared to men
Assessments
Policy Development
Assurance
(Acronym: APA)
Different types of diseases across different ages:
●
●
Men are more prone based on statistics to car developing cardiac diseases
Women also have higher rates of developing breast cancer
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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Assessments
-
Assessments involve the regular collection analysis and information sharing
about health conditions.
To address these, we try to measure the risks and the resources that are
available in the community
NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
HEALTH PROMOTION AND LEVELS OF PREVENTION
Primary
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Policy Development
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-
Policy development in public health -it’s the use of information that we have
gathered during the assessment. In order to develop these local and national
policies,
we could suggest that to local boards or city counselors. If the problems are
very common that really involves or really risks the health of a population and
to direct the resources for those policies because let’s say once policies are
there are being laid out or rolled out. There needs to be a resource so where
will the budget come from then
The budget is the supporting actor.
These local and national policies there need to be a backup where you will get
the resources. Who will be the people involved in doing these? So those are
parts of the policy development
Assurance
-
It focuses on the availability of necessary health services. There needs to be
an assurance that health services are readily available in the community.
Activities aimed to prevent problems before they occur.
The main concept of primary is that before diseases occur or before a person
gets sick we try to alter their susceptibility to these certain diseases or reduce
their exposure to these pathogens and all especially to those susceptible
individuals.
● GENERAL HEALTH PROMOTION
○ Try to target the well population or those who aren’t sick but are healthy. We
try to enhance their resiliency with different aspects in their life including
lifestyle, healthy diet, the right exercise, keeping away from vices and all.
* Adequate shelter, providing a safe and secure shelter -one that's durable for families
is really a basic need.
● SPECIFIC PROTECTION
○ This means we try to reduce or eliminate the risk factors of our clients. For
example, immunization because we try to protect the kids now with these
immunity against different illnesses. We also have water purification by
purification, distillation, filtration or the use of chemical agents to purify waters
so that the public won’t catch any illness from waterborne diseases
Secondary
-
ESSENTIAL PUBLIC HEALTH FUNCTIONS
-
Health Situation Monitoring and Analysis
Epidemiological Surveillance/Disease Prevention and Control
Development of Policies and Planning in Public Health
Strategic Management of Health Systems and Services
Regulation and Enforcement
Human Resources and Development in Public Health
Health Promotion, Social Participation and Empowerment
Ensuring Quality of Health Services
Research, Development and Implementation of Innovative Public Health
Solutions
Early detection and prompt interventions during the period of early disease
pathogenesis.
This could be implemented before the actual signs and symptoms appear
The target population are those with high risk factors
rson needs to get a check
Tertiary
-
Populations with disease or injury, focuses on limiting disability and
rehabilitation.
We target clients that already have an existing disease or injury focusing on
limiting their disability and then rehabilitation as well.
Our aim for this is to reduce the effects of the disease and to restore the
client’s optimum level of functioning.
Example:
A client just had a stroke. He is being enrolled in rehabilitation therapies every Saturday.
That’s already included as a tertiary level of prevention so as to improve the client’s
level of functioning, every day and every session.
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
Another example is a diabetic client taking insulin so we try to teach the client how to
self-administer insulin at home. That’s also tertiary part of the rehabilitative process
since the client is for discharge already so as part of the tertiary level prevention we try
to teach the client.
* Health teaching is very central to these levels of prevention so that we can prevent
grave consequences or more serious consequences if the illness is not managed.
- Primary are for those well clients.
- Secondary are for those who will undergo screening such as laboratory diagnostics
before the appearance of signs and symptoms or trying to prevent a more serious
complication.
- Tertiary are those with already existing illnesses, Those were discharged and the
clients for rehabilitation
Family
-
Those married couples without children are considered a family. Those who
have children such as nuclear families, extended families, cohabiting
Group or Aggregate
Example: Self-help groups, breastfeeding moms, a community of parents with
children with autism, alcoholics anonymous
Community and Population
-
We’re talking about location, a locality of vicinity where people live in is
considered a social system
Our clientele in the biggest scope in public and community health nursing
It also connects with the levels of prevention according to clientele.
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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For example:
1. Mothers Breastfeeding class - Group or Aggregate and Level of Prevention is
Primary
2. HIV Screening Programs for Communities - Community and Population Level
of Prevention is Secondary
3. Screening for Cervical Cancer - Individual and Level of Prevention is
Secondary
4. Exercise Therapy - Individual and Level of Prevention is Tertiary
5. Skincare for incontinent (bed ridden) clients - Family and Level of Prevention
is Tertiary
NCM113 (THEORY) | 2M : SOCIO-CULTURAL DETERMINANTS OF HEALTH
Notes by BSN 3B Batch RHO Third Generation Class of 2024
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EPIDEMIOLOGY
Vital statistics