NURSING PRACTICE IN
THE COMMU !N ITY
Fifth Edition
ARACELIS. MAGLAYA
Editor
Philippine Cop y rig h t© 2 009, 2004, 2 003, 2002, 2000, .1 997
by
ARGONAUTA CORPORATION
Marikir1a City
and
ARACELIS . MAGLAYA
ROSALINDA G . CRUZ-EARNSHAW
MA. BRIDGETTE T. LAO-NARIO
MA. CORAZON S. MAGLAYA
LUZ BARBARA L. PAMBID-DONES
LUCILA B. RABUCO
WINIFREDA 0. UBAS- DE LEON
ALL RIGHTS RESERVED
A written permissio n of the editol" an d publish er must be sec u r ed if a ny part of th.is
book is reproduced by any means and in any Cro m whatsoever.
Every auU1eatic copy of this book bears a serial n umber a nd the signature of the
editor or any one o f th e contrib utors.
ISBN 978-9 71• 91924 - 4 -2
673 3
Published and exclu sive ly
d istribute d by:
Argon au t a Corp o r ation
No. 1 Maki li ng Street
M a r ikina Village. N angka
Mariki n a Cjty
Tel. No. 9 4 1- 6 1- 60
CONTRIBUTORS
Araceli S. Maglaya, RN, PhD
Professor
Centeaniill Pmressorial Chair
Colle.ge of N ursing
lfoivc1-sity of the P hilippines M,mila
Rosalinda G . Cruz-Earnshaw,
RN, MN, MPA
Ma . Bridgette T. Lao-Nario,
RN, MA
N urse Ed11cator
EcurnenicaJ Christian College
T nrlm: City
Former Facul ty
College of Nu rsing
University of th e Phi lippines
Maniln
Former Consul t,m t
P h iJippineJ)epartment of
llcalth- Local Government
Assistance an<l Monitoring
Service and Essentia l Natio nal
Hea ith Resectrch
Fac11lly
Azusa Pacific School of N ursing
Secon d Caceers in Nursing
PrO?,l'WTI
Azusa, California, USA
Telemetry Nurse
Definitive Observation Un it
Whittier 1-lospita l Medico]
Center
Azusa, California, USA
Luz Barbara L. Pambid- Dones,
RN, MPH
Winifreda 0. Ubas-de Leon,
Associate Professo r
College of Nursing
Professor (Retired)
Depa r tm ent of Porasitology
College of Public Health
University of the Ph ilippines,
Manila
Unive rsity of the Philippines
M an ila
Ma. Corazon S. Maglaya, MD
Medical Co ns ulta nt
Smjth Bell Group of Companies
Resource Person
" Doctors-On-Line" Program,
DZAS
BSMT, MPH
Lucila B. Rabuco, MSc Public
Hea lth (Nutrition), PHO
Professor
Centenn inl Professorilll Chair
Department of N11trition
College of Pu blic Health
University of the Philippines
Manjla
-
PREFACE
The fifth edition of lhe book Nursing Practice in Lhe Commun ity focuses
on theory-based practice methodologies us ing th e competenc.-y-based framework.
Theories which describe, explain and predict behavior of clients (particu](lrly families ,
groups and the community) pro~ide background frameworks to guide readers on
the bases for th e selection of cont ent and c r itical thinking directions by phase of the
nursing process. Within these purposes and background of th e book, the cdito1· and
contributing authors hope to enhance the teaching-learning empowering compele ncics
of practitioners, teachers and students based on the uniqueness o f every client and th e
hea lth-healing situation in every nurse-clien t relat ionship. Precision aDd cohel'cnce
in concept elaboration and illustration hopefuJly achieve clarity iu b ,-eaking <lown
complex processes to describe the application of the 11u1·sing process by type of dieat.
Particularly fo.r clinical instructors and students challenged enoug h to pursue the
breadth and depth of community health nun;:e practice, the Lheory-based melhodologies
presented in this book provide teaching-learning altern atives to prevent the likelihood
of using ''ready-made·~ nursing care plans and client r ecor ds to comply with course
requirements.
The book begins with a presentation of com mun ity health nursi ng (CI-fN) as contel\.i:
and practice using a four-client perspective: the individuaJ, family, population grou p
and community. \'Vithin the backdrop of social, political, cuJtural and economic
determi nanL-; of health and il1ness, the chapter discusses the h ealth care delivery system,
the nalional health situation and the co mponen ts, prncesses and e thicolegal aspects
of community he alth nursing practice. As a CHN praclice option in ma.ny countries,
community-based case management is discussed towards the end of the chapter.
Chapter 2 presents theory-based methods and tools on assessment in family health
nursing practice. The ,!\ssessment D ata Base and The T ypology of N u rsing Problems
in Family Nursing Practice are updated using precise concepts related with major
family theories: The Systems Model, Interactional and Development Models and The
Structural Functional Framework. Genograms, ecomap and family-life chronology
are discussed as additional assessment tools with speci,f ic guides on construction and
interpretation contained in Appendices B1 to 83.
Chapter 3 focuses on concepts, steps and intervention options in developing t he family
nursing care plan. A sample evaluation plan ill ustrates bow to specify evaJuation
criteria/indicators, standards and types of method s and tools.
Chapter 4 covers concepts, methods a nd tools related with the implementation and
evaluation phases in family nursing practice. Two types of evaluation a1·e discussed:
formative and surnmative evaluation. Each type is present ed to address s pecific
components of fami ly h.e altb nursing care b a sed on evaluation criteria/indicators and
standards. Challenges and directions include supervision of a case load of priority
families by geographical assignment or catchment area and t11e case management
approach in worki ng with priority fam ilies.
Chapter 5 focuses on the nursing perspective of the partnersh.ip approach a nd the
participatory action methodology explicitly illustrating the "Look-Think-Act" cyclical
process using empirical data on the emp owering experiences of fam.i lies in a village
in Abra Province. Tnterdisciplinazy teamwork and interagency collaboration are
enhanced t hrough competencies on partnership with diverse groups form ing cross
functional teams.
Chapter 6 presents the concepts a nd meth ods of the work b'TOupapproach in d eveloping
community com petence.
Chapter 7 describes the processes, meth ods and tools for assessing co mmunity health
needs by type of community diagnos is. Application o f demography, vital statistics and
epidemiology as public health tools are illustrated by major concept o r tool.
Ch apter 8 discusses the ,ipproaches and s teps im·olved in pla n ning commu nity health
nursi ng programs a nd services. Comm unity competence and com m unity stre ngtb or
empowerme nt as change outco mes are iltustr::ited as ex,1mples of evaluation m eas un::s
to p ursue us ing tl1e pa rticipatory- approach.
Chapter 9 p resents the nu.rsi.ng interventions for comm unity heallh at1d development.
Within the perspectives of primary health care, henlfh promolio11 and comm unity
com petence. co mmuni ty h ealth developme nt ;;trntegies include communi ty organizi ng
t owards commtlllity participation in hi:;:ilLh. cafrncity -building t hrough competencybased trnining, partn ership ant.! collab1n,1Lion, a<lvocacy and supervision. Caseload
management is described as a process and ;m appro ach to systematiCTtlly address th e
heal th needs and p roblems of a number of dients under specific health prngra ms or
services.
Chapter IO prese nts assessment and management protocols for safe moth e rhood and
well- baby care.
Chapter n d escribes nu rse-managed maternal ca re in the community. Based on
s tandards of prenatal care, h ome delivery and postpartum care, application o( the
nursing process in a nurse-managed care is present ed.
Chapter 12 describes indepe ndent nu.r sing prnctice us ing specific strategies, examples
and experiences s uch as conducting d evelop men tal screerung for preschoolers and
maintaining a health p romotion clinic to iiddress client concerns like nutrition,
comfort, m obility and sleep pattern. The com ponents of nursing con sultation togeth er
wi.th otl1er topics such as charging nursing pro fession al fee, marketin g services of the
n urs ing clinic and est ablishing linkages and a referral system are discussed.
Ch apter 13 focuses on enhancing competencies on nut rition for wellness, presenting the
fu nctions and foo<l sources of macrnnutrients (carbohydrates, proteins and fats) and
m it:ronutrients (vitaminsaud mi.ne rals). Methods and t ools to assess nutritional status
.(e.g. d ietary a nd a nthropo metric method s, biophysical tests and clinical examination)
are a lso described in the chapter. Competencies on nutrition and wellness enhance the
nurse's confidence to assume an independent role or wnrk in co11nbor-ation ,,ith t he
health team in addressing malnutrition as a health problem and risk factor oflifestyle
diseases in many communities in t he Philippines and in m any parts of the world.
Ch apter 14 focuses on concepts, strategies and intervention s to address malnutrition in
early cbildhood based on common causes of undernutrition among Filipino children.
Chapter 15 describ es th e life cycle and measures for prevention and control of parasites
as causative agents of selected communicable diseases such as malaria, filariasis,
schistosomiasis and intestinal parasitism.
C hapter 16 describes assessment and management protocols to ad dress selected
common lifeslyle-i:elated health concerns a nd ptoblems of adult clients.
Ch apter
presents th e c~mce pls a nd _princ:i!,les of nu rsing mau agernen t .
17 th system. Et h1colcgal cons1deral1ons a r e discussed.
public heal
m the lo cal
Finallv chapter 18 discusses commu nity-based pa r ticipatory re
co11in;L:11itY hea lth nursing prac tice. The n ature, process and oseta,r c h to enJ, auce
•
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t d
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u conies
of ~
3
em powerm ent are 1 11stn• e
usmg e mp1rica
at a b ased •
•. · .-amilv
1 • t10 u rty-mont
mu ltidisciplirwry r esearch
nnd control iin
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.don t maflaria·u prevention
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famili es as comtnullll)' re~• e n ·s o a VI age o Daoglas ]VJ u.n ic ipality
x~-n ine
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' Ab I·..a P •rovince.
The fifth ed ition is a pro duct of fivi: years o f explorin g o p t i o n s based
ti
practi tioners, clinical instru ctor:,;, s enior fo cuJty and s tude nts O 1on ecclback from
and faci.lit ,1te
critical. thinking.d and
in Jcommuriity
healntl1 ,ow_
o 0ne ncouroge
l
tl analysis
·1
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.
nu.1st_
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.
Theoret1ca p«:rspech~·es prOVl . e le 1ases , or t 1e applicatio n o f the 11 1..
, rnct1ce.
by tn>c of
cl,cot
usin g pract1cc-h nsed m e th odolog i.es. Each c l ·
smg process
.
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.
l" · I ·
rnpt e 1 p ro 1·d
opportuni ty ,or pnict1oone rs. c 1111ca 111st1·uctors a nd students l
• th " cs an
practice perspective from the vu ntage point of partic ipaton
s ee
c n u rsing
e nJ11mcing client's empower ing potent ial.
_r app roac h towa rds
~
°
The b ook is d e dicated to all families and n urses who are s ources· of h o
.
strength to enhance healing a nd ;1tta in wellness.
pe, v.-,sdom a nd
Araceli S. Maglaya
.Tagaytay Cil)'
.July J6, 2009
1
TABLE O F CONTENTS
CHAPTER 1
Community He alth Nursing: Conte xt and Practice
Rosalinda G. Cruz-Earnshaw
19
Community Health Nursing 16
Framework for Community Healt h Nursing 11
Clients of Community Health Nurses 17
•
Individual 17
•
Family 18
•
Popu lation group 18
•
Community 18
Health 1 9
•
Factors affecting health J9
Health Care Delivery System 22
•
Public health 22
• The Philippines health care d elivery system 23
• Department of Health 23
• MIiien nium Developmen t Goals (MDGs) 24
• Medium-Term Philippine Development Plan (MTPDP) 24
• Health Sector Reform Agenda (HSRA) 24
• FOURmula ONE for Health (Fl) 24
• National Objectives for Heal th (NOH) 25
•
Devolution of health services 25
The National Health Situation 26
•
Demographic profile 26
•
Health profile .27
Primary Hea lth Care and Health Promotion 30
•
Pr imary health care so
•
Healt h p romotion 32
Nursing Practice in t he Community 33
•
Critical thinking in community health nursing 34
•
Nursing process 34
!'
Program planni ng, implementation and evaluation 38
•
Health education 38
•
Management and supervision 38
•
Research and evidence-based nursing practice 38
Community Hea lt h Nursing i n the Ph ilip pines 39
•
Public healt h nursing 40
•
Occupational health nursing 42
•
School nursing 42
Community- Based Case Management 43
Ethlcolegal Aspect s of Community Health N ursing u
_ _______,,,,,,,,,,,,,,-,
CHAPTER 2
50
Assessment in Family Health N ursing Practice
A mceli S. Maglaya
Fami ly Perspective In Community Health Nursing Practice 50
Family Nursing Practice: Theoretical Perspectives 51
NursinB Assessrne~t: Operational Framework 511
Steps in Family Nursing Assessment ss
Data Collection SJ
•
Types of Data in Family Nursing As.sessment S7
•
Data-gathering Methods and Tools 57
Data Analysis 62
Nur sing Diagnoses: Family Nursing Problems 63
Th e Typol ogy of Nursing Problems in Fami ly Health Care 64
Conclusion 72
CHAPTER 3
76
Developing the Family Nursing Care Plan
Araceli S . Maglaya
The Family Nursing Care Plan 76
•
Steps in Developing a Fami ly Nurst n g Care Pl an 76
•
Prioritizing Hea lth Conditions and Prob le m s 77
•
Factors Affecting Priority-Se tting 79
•
Scoring 81
•
Formulation of Goal s and Obj ectives o f Care a1
Developing t he Intervention Pl;:1n 83
•
Analyze Realities and Possibilities b ased on Fami l y's Lived Experience of
Meaning and Concerns 8 4
•
Focus on Interventions to Help the Family Perfor m t h e Heal t h Tasks as
•
Cata lyze Behavior Change Through Motivation and Support 90
•
Criteria for Selecting t he Type of Nurse-Famil y Conta ct 9l
Developing the Evaluation Plan 92
Documentation 92
CHAPTER4
Implementation and Evaluation in Family Nursing Practice
Araceli S. Maglaya
Expert CarinB: Methods and Possibilities 97
Competency-Based Teaching 98
•
Learning is an Intellectual and Emotional Process 99
•
Learning is facllltated when experi ences h ave me aning to the learner
•
Learning is an Individual Matter: Ensure Mastery of Competenci es fo r
Sustained Actions 102
Maximizing Caring Possibilities l.03
Expertise through Reflective Practice 105
The Evaluation Phase 1D7
Challenges and Directions 101
97
101
d
CHAPTERS
The Partnership Approac h and the Participatory Action Methodo logy: Th e Nursing
Perspective
110
A 1·aceli S. M ag laya
Human Care and Nursing Practice 1 .1 0
Opti o ns ror Change 111
Partici pa tor y Ac tion and Empowering Exp eriences of Fam ilies i n Dan glas, Abra 114
En hancing Interdisciplinary and ln teragency Co ll aboratio n
Ll 5
The Essential Ingre dients o f Pa r t nershi p !lG
•
Belief In Ega litarian Rel ;:i tio nship 116
•
Open -mi nded n ess U G
•
Respec t .;111d Tru sl 117
•
Commit m ent to Enh ance e<1ch oth er's Ca pab ilities for Par t n ership !H
Capabili ties Necessary for Pa rtner ship
us
•
Ski lls Nece ssar y to Function as a n In tegra ted Un it l J 8
Summary 1 211
CHAPTER 6
1 30
o eveloplng Community Competen ce t hro u gh t he Work Group Approach
Araceli S. Maglaya
Introduction 130
Community Compete nce 1 31
The Work Gro up Model as Stra tegic Approach to Community Co m pete nce
The Staee s of Group Deve lopm ent 132
•
The Stage of Orientation 132
•
The St age of Conf'lict 133
•
The St age of Cohesiveness 134
•
The Work Grou p Stage 134
•
The Term ination Stage 135
•
The Various Stages at Wo rk 135
Interventi o ns to Faci lit.:ite Group Growth
135
•
Provide the Necessary Orienta ti on, Structure and Directi on
1 31
136
•
•
Process, Negotiate and Resolve Con flict s to Member 's Satis fac tion 138
Be Awar,e of the Effects of Own Beh avior on th e Group: Use th e Self for Gro u p
Growth J4 5
•
Act as t he Group's Co m pleter / Re~ource Perso n 14 7
•
Derive O p por tuniti es to Apply Lea rn ing on Another Situation 1.47
Wor k Group: Hu b o f Communit y Organizati o n, Co mpetence an d Empower ment 1,11
CHAPTER 7
Assessing Community Health Needs
Luz Barba1'a P. Dones
Introduction 1so
The Community Diagnosis 150
•
Ecologic Approach to Commu n i t y Diagnosis 151
•
Types o f Community Diagnosi s is 2
•
Compre hensiv e Communi t y Diagnosis 152
•
Probl em -Oriented Community Diagnos is '15S
Communi ty Diagnosis: The Process 155
150
tins com m unity Diagnosis iss
Steps i n con d uc
,
•
Determining the Objectives 15 7
•
Defining 1he Study Population 157
•
Determining th e Data to be Collected
158
•
•
•
•
•
•
•
Collecting the Data 158
Developing t he Instrument 161
Actuill Data Gat hering 16B
Data collation 169
Data Presentation 171
Data Analysi s 17 4
Identifying lhe Community Health !Nu rsing Problems
Priority-setti ng 17 s
f Public Health Tools in Commun i ty Health Nursing
App II canon o
Demography 179
•
So urces of oemograph·l c Data 179
•
Pop ulation Size 1so
•
Population Composition 181
•
Population Dis t ribution 183
•
•
Vital Statistics 1s 4
Epidemiology 186
•
The Multiple Causation Theory 186
•
Natural History of Disease 188
•
Levels of Prevention of Health Prob lems 188
•
Concept of Causalit y and Association
191
•
The Epidemiological Approach 192
•
Descriptive Epidemio logy 192
•
Analytical Epidemiology 197
•
lnterventional or Experimental Epidemiology
•
Evalua tio n Epidemiology 19s
Conclusion 199
174
179
198
CHAPTER 8
Plannin g for Community Healt h Nurs ing Progra m s a nd Services
202
Luz. iklrbara P. Dones
Introduction 202
What Is Planning? 202
Approaches to Planni ng Health Programs 203
•
Participatory Planning for Community Heal t h
•
Planning for Heal th Promotion 204
The Planning Cyc le 206
•
Situational Analysis 206
•
Goal and Objective Setting 212
•
Strategy and Activity-Setting 213
•
Oeveloplng an Evaluation Plan 214
Conclusion 220
203
JI
CHAPTER 9
Nursing Interventions for Community Health and Development
L11z /Jorhnra P. Do nes
223
Introdu ction 223
Community Competence as Outcome or Community Hea lth Nursing Interventions 223
Co m munity Health Develo p ment Strat egies 225
Health Promotion 226
Community Or,iani2ing t owards Community P.>rtic lpotion in Heal th 229
Capacity-Building through Competency-based Training 23 3
Partner sh ip and Co llabo ra tion 236
Advocacy 237
Sup ervis ion 238
•
Making a Supervisory Pl ,m 239
•
M et hods and Too ls for Supervi sion 240
•
Conduc ti ng a Supervisory Visit 2•0
•
Case Study Illu strating th e A pp l lea tion o f the Steps in Supervisory Pl anni ng 241
C;,se load Managem e nt 241
Conclu sion 243
CHAPTER 10
Logic Trees for Safe Motherhood and Well-Baby Care
Ma . Corazon S . .Maglaya and Araceli ,Vfagla11a
247
Introduction 247
The Us e of Logic Trees 247
Assessment Protocol for l nltlal Pre- natal Check- up 24 8
Logic Tree Flow char t No. 28 :iso
M anagement Protocol for Initial Pre-natal Check-up 251
Assessment Protocol for Follow-up Pre-nata l Check- up 255
Logic Tree Flowc hart No. 29 257
M anagement Protocol for Follow -up Pre-natal Check-up 258
Assessment Protocol for Home Delivery 260
Logic Tree Flowchart No. 30 261
Management Protocol for Home Delivery 262
Assessm ent Protocol fo r Care of the Newborn Immediately after Birth 267
Logic Tree Flowchart No. 31 269
Management Protocol for Care of t he Newborn Immediate ly after Birth 270
Assessment Protocol fo r Postpar t um Check-u p 273
Logic Tr ee Flowchart No. 32 274
Mana ge m ent Protocol for Postp artum Check-up . 275
Assessment Prot ocol for W ell Ba by Ch eck-u p 280
Logic Tree Flo w char t No. 33-A 2a1
Management Protocol for Well Baby Check-up 282
Assessment Protocol for Well Baby Check-up, Patient is more than one month old 284
Logic Tre e Flowchart No. 33 -B 285
Management Protocol for Well Baby Check-up, Patient is m o re t h an one month old 286
1
CHAPTER 11
N urse-Managed M at erna l Care in the Community
i'1aria Brigelle T. La.o-Nctrio
In troduction 288
Role of Maternal Care 289
Standards of Pre natal Care 290
Components of Pre gn ancy C.ire 291
• A ntenatal Reg i·s tration 293
• Teta nus Toxoid Immunization
293
• Macronutrient and M icronutrient Supplemen t ation
294
• Micronu t rient Su ppl ementation: Iron Supplem e ntation
294
• Vitam i n A Suppl ementation 295
• Treatment of Diseases a nd Other Conditions 296
• Earl y Detection and Management of Complications of Pre g n ancy
• Family Pl an ning Counselin g 2!l7
• STD/HIV/AIDS Preven tion and Man agement 297
Standards in Home Delivery 297
Standards in Postpartu m V isit
300
T he Nursin g Process in a Nurse-Managed Ca r e 302
Nursing Assessme nt and Diagnoses 3 0.2
D etermining Outcomes of Care 3 03
Choosing Nursi ng Inter ventions 30.a
Home Visit as an Interve ntion 304
CHAPTERlZ
2 96
3W
De m_onstrating Independent Nursing Practice
ll-1a. Brigei-te T. Lao-Na1·io
Expe riences in Setting up Independent Nursing Practice 311
Me tro M anila Developm e ntal Screeni ng for Presch oo lers 311
Providing Consul ting Services 3!3
The Health Pr omotion N u rsing CJin ic 3 1 6
Commo n ly Used N ursing Di ag noses 318
Establ ishi ng t he Outcomes of Care 320
The N ursi ng Consultation and its Components 320
Chargi ng Clients a Nursing Professiona l Fee 322
Marke ti ng the Services of the Nursing Clin ic 323
Establishing Linkages and a Referra l System 323
CHAPTER 13
Enhancing Competencies on Nutrition for Wellness
Lucila 13. Rabuco
Introduction 326
Nutrition 326
Food 327
N utrients 327
•
Macronut rients 327
•
M fc ronutrients 32()
Assessmen t of Nulritional St atus
•
Indire ct methods 334
288
·
333
•
Direct met hod s
337
Common Nutritional Prob lem s of Public HC!illt h Importance!
•
Protei n -Energy Ma lnutri tion (P.E.M .) 340
•
Iro n Deficiency Ane m ,a 34 1
•
Vit;im ,n A 0eflclency Di sorders 3a2
•
Iodine Deficiency Disorders 34 3
•
Overweight anrt o besity 344
Summary 344
340
CHAPTER 14
Appropriate Technology for the Prevention and Cont rol of Malnu trition in
Early Childhood
346
Arac;e/i S . M t1g laya
Nutritional Sta tus o f Filipino Chi ldren: Con~eq uen ces and lrnpl icalions 346
Causes or M alnuLrition Rela Led to Feeding Pr;:ic ticcs 3 4 7
• Non -breast-feeding or Early W ea ning 3 47
• Absence or or Inadequate Com p lement ary Feedinr, d u ring Exten ded Per iods of
Breastfeedi ng or Dependence on Artificial Feeding 348
• Lac k of or Inadequate Skill in Man aging Dl3 rrh ea at Home 348
Interventi ons Using Appropria te Technology 34 8
• Family Com p ete ncy -Buildlne on Nutritio nal Sta t us o f Childre n and Options to
Enhance Proper Nu trition 348
• Regular Complementary Feedi ng Using Protein Powders 349
• Increase Knowledge o n the Daily Recom m ended Energ y an d Nutrient Intakes (RENI)
for Infants and Toddlers 351
• Appropriate Home Managemen t of Dinr rhea 3 52
Summary 35 4
CHAPTER 15
Parasitology in Nursing Practice
Wi11{freda 0. Ubas-de L eon
Introduction 356
Tne Paras ites 356
Dir ectly-Trans m i tted Parasite 357
•
Enterobius (Oxyuris) ver m icula rls 357
Soll -Transmitted Par asit es 358
•
Ascaris lumbricoides 3S8
•
Trichurls trich lu ra 362
•
Hoo kworms 362
Foo d Transmitted Parasites 369
•
Taenia solium and Taenia sagin ata 369
•
Par agonimus westerm ani 370
•
Capill ar ia i:;hllippinensis 37 1
•
Hete ro phyi d Flukes 37]
Water-borne Protozo a 372
•
Entamoeba hi st o lytica 372
•
Giard la lambli a 373
•
Oyptosporidi um ho minis 37"'
•
Cyclospora tayiltensis 377
356
•
Blastocysts hominis 377
Veclor-Borne Parasites 378
•
Plasmodia 378
•
Babesia spp 37'9
• Wuchereria bancrofti an d Brugia malayi
• Schistosoma japonicum
384
Conclusio n 385
380
CHAPTER 16
388
Logic Tree fo r Co mmo n Adult Health Problems
Ma, Corazon S. Maglaya and Araceli Maglaya
Introduction 38"8
The Logic Trees 388
Assessment Protocol for Problem on Cough, Colds or Di fficulty of Breathing not
Associated w ith Fever 389
Logic Tree Flowchar t No. 7 391
Management Protoco l for Problem on Cough, Col ds o r Difficulty of Breathin g not
Associated with Fever ·3 92
Assessment Protocol for Problem on Skin Lesions 394
Logic Tree Flowchart No. 9 395
Management Protocol for Problem o n Skin Lesions 396
Assessment Protoco l for Problem on Body Weakness 399
Logic Tree Flowchart No. 10 aoo
Management Protocol for for Pr oblem on Body Weakness
401
Assessment Protornl for Problem on Abdomina l Pain, Epigastrlc
403
Logic Tree Flowchart No. 11
404
Management Protoco l for for Problem on Abdominal Pain, Epigastric
405
Assessment Protocol for Problem on Insomnia
407
Logic Tree Flowchart No. 16
408
d09
Management Protocol for Prob lem Insomnia
Assessment Protocol for Probl em on Dizziness
412
Logic Tree Flowchart No. 24
413
414
Management Protocol for Problem Dizziness
CHAPTER 17
Nurs·
•ng M anagement in the Loca l Public Health System
.Rosalinda G. Cruz-Earnshaw
Introduction 419
Management Functions 419
Management i n Public Health 421
• The Loe.a l Public Health Organization . 4 2 1
Th • Context of t he Local Public Health Or ganii:ation
e PHN as a Manager and Supervisor 421
•
Planning 421
• Organizing 423.
• Staffing 425
•• Leading (directing) 425
Et))·
Controlling 426
'COlegal Considerations d2.9
· 421
419
CHAPTER 18
Enhancing Practice through Community-Based Participatory Research
Araceli S . Mag laya
Int roduction " 3 2
Communi ty-Based Pa r ticipatory Resea rch 432
Enh ancing Empowering Potential: The Hum an Response Perspective 4 33
Faci litating Behavior Chans e t hru Motivation-Support Interventions 435
Emp owerment: Nature, Process an d Outcomes 436
Heal th in t he Ha11ds of t he People 438
Behavio r Ch ange Over Tim e 4 38
Com m u ni ty Lea ders Update the Resear cher at t he U niv er sity 43'.I
Co mmu nity- Based Re search: Insights for Enh ancing N u rsi ng Practice 439
APPENDICES
Al
A2
A.3
Com munity Healt h Nursing Pr actice Mode l 445
Law s t hat Im pact o n Peopl e's Heal t h and CHN 446
Hea lth Program s of t he DOH 448
B
Family Assessment Tools aqg
Bl Construc ti ng an d Int erpreti ng a Genogram a q9
B2 Con stru cti ng t he Fam i ly Eco ma p 45S
B3 Constructing the Fam ily-Life Chro no logy 456
Cl
C2
C3
Charting Nursing Care, Pro gre ss Notes and Client Responses/Outcom es
Family Service Progress Reco rd 45 8
Instructio ns on the Use of t he Family Ser v i ce an d Progress Record 461
D
Selecting a Fruit Exercise
E
Empowerm ent fo r Heal th Promotion/ Lif estyle Ch ange
F
Recommend ed Energy and Nutrie nt Intakes Per Day For Se lected Population
Groups 473
G
Trends in Cdmmunity Health and Commu nity Health Nursl ng Practice
4 S7
467
472
474
432
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Chapter 1
COMMUNITY H EA LTH
NURSING:
CONTEXT A N D PRACT ICE
Ros alinda G. Cruz-Earnshaw
Commuuil')' healtl1 1mrsing (CHN) is one of tl1e two majo1· fields o f n ursing in tl1e
Phili ppines; Lbe other is h ospital 1rnrsing. Some people u se t he terms commun ity
h caltli nursi ng a ml public health nu rsing interchan geab ly. H owever. th e former is
b roadi::r th:m Lhe lat ter ; it inc:ludes p u blic hea]th nu rsing, occupatio nal h ealth nu rsing
and sd1uul uursing.
COMMUNITY HEALTH NURSING
Clark defines com m u nity health nursing tis a "synth esis of nurs ing k n owledge and
p ractice and the science and practic.:e of pub lic health, imple m en ted v ia a systemalic
use of the nurs ing process am) o l.hm· p1·ocess,es lo promo te health a ml preve n t illness in
popula tinn grou ps~ (;mo8:5). The o ther processes isiduui.: m a nagem ent, superv ision ,
rescan:h. advocacy and polilic.11 action. Annex Al. pn?se nts a m o del of community
beal lh nu rs ing practice \>vhich ill us t rates t h e relationsh ip betv.reeo nursi n g l)ractice
as sc.i c.ncc a nd art, core com m uni ty J1 ealtb fm,ctions an d essenti al communily hea.1tl1
services.
The follm\in g st,itements cha racter ize CHN: (1) Promotion of health and prevention of
dise;.1sc are th e goals of p ro fessional praclice: (2) Co m mun ity h ealth nursing p ractice
is co mpre he ns ive, ge neral. continual anti no t episodic;; (3) There are differe n t levels of
clie nlcle-- individ1wls . fa milies and p opufati o n g r ou p s a nd the practitioner 1·eco~nb:es
Lhc prima cy o f t he p o pula ti o n as a whole; ( 4) The n urse and t h e client have gre.ite r
cont rol in mak ing dccis io11s relate d to h ealth ca re and they collaborate as equals;
(5) The nurse recognizes t h e impact of d i fferen t factors on h ea lth and h a s a gn:a te r
awaren.e..<;s of bis/h er clients' lives a n d s ituat io ns (Clark. 2008: 10- 13).
CHN is t·h e tot11lity nf its philosophy and b e liefs, p rin ciples, processes and s t a nda rds.
As o ne of th e subsystem s, it influe nces and is in fluenced by the health care. delivery
sys te m. C H N is practiced with in a s pecific econornk, political, socio-cultural a nd
e rwironmcn tal conlext. T h e rol es a nd functio ns of C H Ns directly contribute to the
health o f their clie nts.
·n1e essence of nurs ing is t he same even if practiced in differ e nt settin gs. Nursing is
defined as the scie nce a nd 11rt of caring. N11rsi n g as an art is r efl ected in the nurses'
interactions a nd com m 11nica \ion \-.; t h clients that nre geare d Inwards tl1e i mprovement
not j11st of th eir health h ut ;1lso th ei r ab ility l<> dea l with t h e dete rminants and
consequences o{ th eir healt h problems.
Accord ing to Parse, the responsibility o f nurs ing t o society is to guide ind ividaals and
16
families "in choosing possibil ities in ch anging tl1c health process w hi ch is accomplis h ed
by inte rs ubjective participation "'ith people" (George, 2002:439 ) . T he art of n ursing
is d emons trated by nlll'ses w ho c,m main tain th e delicate balance between c.lo i.ng
thi ngs fo r their clie nts an d doing th ings wi th th em, th us co-cre;i ting a bet ter or more
m e.111ingful reali ty. The p rnctice of co m m un ity he al t h nursing, therefore, e ntai ls
active in teraclion a nd pa r tnersh ip between the n urse .ind the clie nt. Sud, pa r lne,-:.hi p
recognizes t he autonom y of b oth parties an d the po te ntial of e;ich one in unrid1ing
thei r relationsh ip.
N u rsi ng is also a scie11ce, which m ea ns th at co m m unity hea lth nu rses should use
p racti ce-based and evi dence-b ased m e thods a nd tools . 'I11ey :.ilso need to e ngage in
gen e rating e vidence to s upp ort thei r practice t h rouRh resea rch. Qua nti lative research
is needed lo descrihe or q ua n ti fy vari<1blcs o f inter·es t lo comm un i Ly health nurses o r to
eval 11 at e Ih e cffeel iveness of e:dsting; pr-icli.ces, proccd u res or intc rveu Lions. Qua Iitut ive
research can be do ne to un derstan d specific hum a n respo nse phe nome n a such as
client-p a rtners' livetl experiences o n poverty ,1 nd ad apta tio n .
T he roles of CHNs are grouped b y Cla rk (:2008; 14-22) into clie11t-0 1·ie11ted roles
(caregive r, ed uca tor, coun selor, refern1l i·esource, role mod el a nd case m anager) ;
deliverv-m·ien led M ies (coordi natm·, colla borator and li,\ison); a nd, pvp11/a1ionoriented roles (case finder, leader, chan ge agent, comm un ity mobilizer. coc1li t ion
builde r , policy advocate, social m a rkete r and researche r ).l n rcccnl years, lhe case
manage r ro le in tbc com m unity settin g is ga ini ng importance as a n innovative s trategy
to p rovide h ig h quality care in a· financially rest ricted environment. As lhe case
m anagemen t concepts of clie nt independe n ce. con t rol, ad vocacy a nd coo rd inatio n ctre
already reflected in cu rrent nursing m odels and philosophies, nurses are considered
t h e m ost appropriate professionals to fill th e ro le of cnsc m a nagers(KnoUm ueller,
198 9 ; Bergen, 1992). As a CHN practice o p tiott in many countries, community-based
case management is discussed at le ngth tow ards the end o f this chapter.
FRAMEWORK FOR COMMUNITY HEALTH NURSING
The p ractice of nursing, particularly in CI-IN differs from one geographic a rea (co untry
o r region) to a nother. It is in fluen ced by a n um be r of factors primarily th e scope of
practice as "defined by the nu rsing Jaw, policies and standards of th e Department of
Hea lth a nd o rgan izations where CHNs WO("k and the h ealth needs and proble m s of the
people.
The m acro framework for CH N practice has four components: (1 ) th e h eal th care
delive ry system, w ith its CHN s ubsys te m ; ( 2 ) the cl ients (individua l, family, popuJ ation
g roup and comJnuuity); (3) health which is the goal of the h ealth care deliveiy system
(HCDS); and, (4) the economic, sociocultural, political and envi ronmenta l facto rs that
affect th e 1-JCDS, tl1e practice of com m unity healtl, nursing and the people's health.
These constitu te th e conte.xt of com m u.njty health nu rsing practice in tbe Phili ppines
This chapte r elabo rates on th e different co mponen ts o f the fram ework.
CLIENTS OF COMMUNITY HEALTH NURSES
There a.re d ifferent levels of clie ntele in co mmunity h ealth n ursing-the in divid u al,
family, population group and community, w ith the la tter os t h e prim ary client.
Individual
The C HN deals with individ u nls- s ick or well-- o n a dai ly ba.sis . S ince th e h e a lth
problems o f indh;du als are intertwined wi th th ose of t h e o l11 c r m e m ber s o f t h e fam ily
and coma11m ity, Lh ey are a lso considered as an "en t ry p o int'' in working \•v ith lhe.se
clien ts.
Family
Fro m a syste m s perspective. n fami ly is d e tin ed a s a collection o f p eople who are
i nte!!,nilcd, i11 t1•r:wt i11g and intt.!n lepe nd en t (T h m t, 1997:126). ,Ju s t like other system s ,
th e parts (family mcm h er.s) inte ract with e.1ch o t he r a n d th e action o f one affects tJ1c
other members . The family has a bo un dar y wh ich.mea ns thatotherpe opl e con recognize
it s mP. mbers a nd those who arc not. In fact a person may be iden tified prima rily ns a
member of a particular family.
There have heen man y cl1 a11ges in the soc ial coote11.1: o f t h e FiJip ino fa m ily a nd these
m ay have mod ified ho w it performs its healt b tasks and its ca pacity to re1nain as t h e
p rim,u-y so urce of su ppo rt to its member s.
Population g ro up
A population sroup is a grou p of people who shar e common cha r acteristics ,
developmental s tage or comm.on e.:-::posure to particular environ m.en ta l factors, ru1d
co nseq ucnlly co mmon hea lth p1·oblems, issues a n d con cerns. Allender a n d Spr a dley
(200 1) identifietl population "ag,;re~ates" withdeuelopmentalneeds (su ch us: maternal,
prenatal arnJ newborn populations; infant, todd ler and preschool populations ; schoolaged and adolescen ts: adulls and working populations; and, o lder adult popu lations)
and tJ1ose th at are t•u/nerable (ru r aJ clients, the poo r , m igrant workers, m in o ri ty
pop uJotio ns experiencing health tl.ispa ri lies, Lhose w'it l1 mental health issu es, t hose
living with a.d dict ion. tho!>e in correctiona l facilities a n d th ose i n long-term care
setti ngs). Population groups a.re lbe usual targets o r benefi ciar ies of social ser vices a n d
benllh progrnms.
Community
A community is a group of p eople s h aring com m on geogr aph ic b oundaries a n d /o r
commo n values and interests " ; thin a spe-cificsocial system . This social systCJTI inclu des
heaJtJ1 syst em , family system, economic syste m , educa t ional system, r e lig io u s sys tem,
welfare l>")'Stem, political system, recrea l ional system, legal system a n d commu nka tio n
syste m (Allender an d SpradJey. p. 3 6 0 ), Beh r inger and R ichards describ e a community
as "" ·el.>s of people s haped by relationships, interdep end e n ce, m u t u a l interests and
patterns of in teract ion (Leonard , 2000:93) .
Alt hough a ll co mmunities :ire the sam e (acco rd ing to the general system s t heory), each
one is un ique beca use it functions \,itbin a specifi c sociocuJ t uraJ, political, economic
and e n \'i ro nmental conle.'<l. They also va ry i n terms of commu ni ty dynrunics--cilizeu
participation. power a nd decision malting s t ructures anc.l community collaboration
e ffons (Allender and S pradley, 362-~164).
A comm unity is regarded as an organisnl \\i lh its o,vn s tages o f develop m ent and i t
m atu res through rime. Development Lo; facilj ta ted by some catalysts from with in and
outsidr the com m unity.
Anderson and McFarlane (Anderson , 2000 : 157) d eveloped t he community-as- client
18
-
model which later: on was rcnamccl w cornmunity-ns-partner model. The two elements
of th e model urc: foc:11s on 11lc comrnuni1y ns partner anti the,: use of the nursing
process. At th e coreofthc asscssmcncwhccl ;ire lhcpcoplcof1hecomm11nity-their
d emographics, valu es, llclids und history. The: people ;tr'(;affcctcd hy, and also influence
eight subsy:;tcm:;; ur the cn1111111111ily- physkal environment. cducntinn, snfcty and
trnns po,·tntinn, politics and government, health and social services, commu nication,
economics and recreatio n.
HEALTH
Heallh is a hnsi1: l111m,1n right. On the 6' 1' Globa l Conference rm I lealth Promotion in
200.5 the Uni lcll Nations a ffirm ed its r ecognition tluit the e njoyment of the highest
s t:mdard ()f hcu 1th is <lnC of the fundamental rights of every h mnan being (The 13angkok
Charter for Health Promotion, 2005).
Health which is viewed as a continuum, is considered as the goal o f public health in
gcnernl, ,rnd com muni ty health nursing, in pa rticular. It is an im portant pre requisite
{u11d conseq1.1enr1!) of development. By promotin-g health a n d preventing d isease,
CBNs, therefore, co ntrib11te to the country's economic and socia l development.
There a.re a number of deli nitions hjghlightiap; the different dimensions of health and
basicnlly focusing o n the individual. These should guide nurses in identifying areas for
assessmenl and interventions. The most frequently cited is that of the WHO: "Healtl1
is a state of com pletepl1ysic:al, menta l and social well-be ing and not merely the absence
of disease or infirmity" (vVH O, 199.5).
Dubn (1959, in Pender, 1987:21), Oil th e other band, emphasized high-level welJJless
which be defined as: "an integrated metl1od of functio ni.ng which is oriented toward
ma'Cimizing the potential which the indivi dual is capable. It requiresthat the individual
maintain a co11tin uum of balance and purposeful direction w itl1in the environment
where he is fu ncti onu1g'".
Rene Dubas in his book JVlan Adapting (1965) defined health as "a quality of life,
involving social, emotional, mental, spiritual and biological fitness o n Lhe part of the
irtdividunl, which results from adaptations to the 1mvi ro.nment (Butler, 2001: 2).
Florence N ightingale looked into health and illness in relation to the environmentventilaLion, noise, ligbt, cleanliness, diet and restful bed. She prescribed ways to improve
hen 1th by manipulati ng the environment. Doro thea Orem, on Lhe other hand, defi ned
heaJth as a "state charncterized by soundness and wholeness of h uman structures and
bodily and mental fonctions~(1985 in Pe nder, 23).
Factors affecting health
There is a strong link between a society's health and its economk development, which
i.n turn is determined by its social and political structu·res and processes. The link
between inequalities in income and wealth and inequali ties in health is"vell-established
(Wilkinson, 1996 in Naidoo and WiUs, 2000:12). Culture and environ m ent which
impact on people's heal th are also affect ed by the country's politics and econo my.
The different' intern ational conference.s on health pr()motion identified thedeterminan ts
of, or prerequisites for health such as peace, food and shelter, clea n wate r, education,
adequate economic resources, a stable ecosystem, sustiunable resources, social justice
and equity a nd access to basic httman rights. In her keynote address d uring the 5 <b
19
inte rnati o nal Conference on H ealth Promotion i n 2000, t·h e UN Secretary Ge n eral
pointed out th at "many o.f th e maj or dete nninnnt·s of h e tte r hea lt h lie ot1 ts ide Lhe
health s ·stem. K.nowledp,c m ade available· to people. Clr~a n e nvin) nmcnts. Acce ss
to bas k ser·vices. Fair societies. Fulllllcd ·1,um;in r igh ts . Gond gove rnm e nt. £ nnb ling
p eop le to make d ecisions relevnn t to thci1· lives, a nd t<> net o n I he m " (Pro.ceed ings o f
the 5 th Jnterm.tlio nal Con feren ce on Health Promotion, 2000) .
I n 2005, the Hangknk Char ter fo r Hea lth J>rnm otio n identified "critical factors"
that now influence he nl th 11 11d these ::ire: inc reasi ng ineqtLalilies within ,rnd between
cou n tries, new pntterns of cons umption a n d communication, comme rcialization,
global e n vironm e ntal t hnnge nnd urbanization. T he o th er faclors lhat influen ce health
idenlifh,,<l bv the C harter a rc rnpid nnd often,,tlverse social, econon1ic ,111d d e m ographic
changes lh~t affect t]J e worldng conclitiou s. learning envirnnmenls, fami ly patterns,
and the ct1ltur e a nd sociHl fal;ric o f communities. ·
Poverty and h ealth
Povertv is an inclic:1tion of the co nti nuing sodal injustice and foilw·e o f a country's
develop,;;ent efforts . It is a multidimensional 1.:011stnicl Llmt goes beyond inco m e
m easureme nts. The United Nnti ons(UN) Human Developm ent Index (HDI) su mmarizes
a composite index of life e.-..--pectaacy, .,cl ull lilerac~, rat e , com b ined primary, seeon<lm,>
a.nd tertiary gross e nroll men t .rnt.io and gross domes tic product (GDP), among olh ers
(MTPDP 2004 - 201 0 ). The Philippines is t h e 90'" among the 177 cou ntries ranked by
the United ~ations Development Progrnm i n term s of ht1m an developruenl (Phi lippine
Star, 2/28/08).
The po\'crl.y incidence in the country was esti m ated at 3 4 96 in 20 0 0, up from 33% in
1997 (MTPDP 2004-2010). Mo re than half of the total i11come flows to the richest 20 %
of the population (MTPDP 1993-1998). Accordi11g to the Social W eather Statio n (SWS),
almost 16 of every 100 survey respondents claim ed to have experienced involu ntary
hunger because they bad noth ing to eat in early 2008 (Mangahas, 2 008).
The pour have poor health hecause t hey do not have th e rcsou1·ccs to afford the bnsic
requisites of health; they are not covered by h ealth insurance; and they do not h ave the
capacity to effectively tra nsnct or nego tiate ,vit11 the healt h cam system wh ic h seems to
be mo1·e res1)ortsive to the needs of those witb the necessirny financial resources.
Poverty, however, is a not a complete explmintion for poor he al th. The poor are not a
hom ogeneous gro up. Marti□ an d Henry point ou t that poverty is t he only characteristic
that t he poor share for the ir cultural orientations, val ues, beliefs, practices and need'<
vary greally ( 199t: 523).
Culture and health
C ul111re is, broadly spe;iking, a wayoflife; it is t he t o taUty of who w e are as a p e ople.
1l is stable, wh ich mea ns that it endures over tim e and is passed on fro m one gen eration
to tJ1e Jlext. As such, it is obviously ru.1 impo1-tm1 t inn uen ce o n people·s hea lth . Culture
includes many things such as beliefs, val ues and customs 01· practices -how we socialize
or internet with others, how we relax a nd spend o ur free t im e, t h e food tliat we eat or
dn not ea t. how w e p·repa rl! our food , how we t reat ,md r .1re few pregnant women, h o w
we del iver babies and take care of n ewborns , how we cope with our problems, l1ow and
when we see k help, am o ng many others.
Culture has positive e ffects on h ealth. An example is the val ue t11at we F ilipinos place
o n close family ties a nd social re latio nships. Fa milies, relatives and friends are a m;-ijor
so urce o f financial , emotional, instl'Ufllental ,mcl social support, espcciaUy d uring cris is
20
s ituations. The.-;c relatio ns hips conlribulc to our s,!nse of emotional we ll-being and
m e nt al hcnllh.
Some peo ple hnvc beliefs ;1rnl prndiccs thnt adversely nffccL henllh. 11 is, howev~r,
diffic ulL to b.;ol;11e Lh c cffcc.:ts of <' 11 I Lure becau se nf the co m:LIrrcn t in rluen ces o f poverty
and i V,n or:111 (:u. and the in,1clcquncic;; oft he hc,1ilh care de livery sys te m .
Environment and health
The e nvirunrne nl plays .t direct in/lucm:c on the health of people. I'or exam p le , it
provides breed ing sites for im:ccl vccto rs of tlii;cases li ke malaria, d cn~uc und filarias is,
which a re ,;till m ajor he;1lth problem :<: in some p,trls of t h l! cou ntry. An un sanitary
environ 111~, 11 L i:,; al:-o a majo r fac.:tor i11 lh.e ca usutio n of d iarrh eal <l iscas e.c; such us chnlc ru
and typ hu id fl.'vcr. ll is lite brcctling gro und o f animals and insects that harbo r and
t mm:mil microorg;111 i~rns. l'vl,1l.1ria, dengue ;i n ti fila ri,tsis ct re sti ll m,ijor problems in
many part.s of the co1111tr_v.
Jn th e en viro n me nt could he foun d toxic substa nces s uc h as lead, mercury, asbestos,
pesticides. lobaccu,solvent." .ind PC13s. These could adversely affecth um an ·r eprod uction,
the br..iin ,111cl i111m1:ne <;ystcm i111d C<.Jul<l cause c;111ct'r ( N ecdle111;m and La nd rigan,
i994). Tohac.:c-n partit:ularly is a majo r t h re.i~ lo h ealth because i t co11l<1i11s over 4000
chem icals (in.cludin~ hyd rogen cyanide. sulfur dioxide. carbon m onoxide, ammonia,
fornrnld ch~·dc, nrsen ie. bcnzc-nc, chromiu m , lead, ni trosamines. benz:opyrene, nico tine,
cndmi tUTl ,md c;1rbon m onoxides ) many of wl1ich a re irrilanls . carcinogens and
mu tagens. 1oxins rmcl s ubsta nces I.ha t increase b lood pressure, pro mote h1mors, affect
the heart and brain, dam<1ge th e hmgs a nd cc1use kidney and reproductive malfunctio ns
(f,'rarnework Convention on Tohnc;co Con trc)l Alli,mce, Philippines).
Th e increase of carbon dioxide, m<,!lh nn e an d nitrous oxide (mnong oth er gases) in the
eartl1's a tmosphere has dep leted t he !">7.(m e layer. The deterioration of the ecosyste m
has bee n implicnled in the ra pid inc rease of ca n cer cases and other hea lth problems
th roughout t he world . Specifically, there is n rise in cancer-cau sing ultraviolet radiati on,
surface ail- temper::iture and carbon dioxide.
The denud ntion of our forests lrns cHrectly and indirectly resulted in many healtb
problems. Rivers have dried up or are extremely p olluted, thus d epriving many people
of their m::ijor source of djetnry protein.
The Interna tional Physicians for the Prevention of N uclear War estimates that millions
of cancer cases will result from the nuclear testing cond ucted in the p ast. The WHO
also estirn.ates about 20,000 deaths a year in the world d nc to pesticide p oisoning
alo ne (Philippine Breast Cancer Ne.twork, 1997).
T he s o-called El N i1io and La Ni,ia phenomena wh icl1 have b een caused by in~ults to
the e nviron m ent have caused thousands of death s due to disasters (Nash, 1998).
The state of the world 's envi ronmen1 is tl1e direct t·esult of the interaction of a n umber
of factors su ch as Ludustrializ.ation, governm ent policies, poverty a ncl an un caring
attitude towaxds th.e environm ent.
Politics and hea lth
Policies reflect the priorities of governm en t and the ,·alue syste m of p olicy makers.
The health budget is the m ost concrete expression of tJ1e go\'ernmen t's p olitical ,.v ill.
Many F ili )'linos do not hnve full access to basic health goods a nd services because of
t he sevcrclv limited health cnrc financi ng. In 1999, t he amo unt spent for health wa s
only 3 -'-1% ·of t he gross nationa l product, lower than VlHO-r ecomme nded 5%. This
21
tnrnslates to the fact lhnl c1lrnost hal f of health expendj turcs is o ut-of-pocke t; jn
olher words, lh e "financial burden on individual families is heavy, lea ving a ccess to
care h ighly inequitable" (NSCB, 2002). The sever ely lim.ite d heull h budget is ,ilso th e
biggest hind.ranee to th e fu!J imple mentation of weJ l-n1ea ning policies s uch as national
heallh insurance.
·
There n.re a number of lnws th at im pacl o n people's beallh directly (such as th e salt
iodiza tion law a nd food fortificalion law) and indirectly sucb as Lh oi,;e Ul at affect t heir
purchasing power (mi11 imum wage, e.'f()ctllded value-added lax , encccgy law, e tc.), family
aod social rchitionsh ips (e.g., laws protecting wom en and children). environ ment, and
access Lo education and employment opportunjties.
There are also laws that affect the delivery of health services - - tbe LocaJ Goven1ment
Code, National Healtl1 Insurance Act a nd th e professional practice acts of U1e differe.nt
professions (mtrsing, mich,~fcry and m edkine).
HEALTH CARE DELIVERY SYSTEM
A health care delivery system is the totality of usocietal services and actj vities desig ned
to protector restore the health ofindividu::i]s, families, groups and com.1ntmit:ies (Bant,1,
1986 in Cookfair. 1996:66). II includes both govenw1eul a n d non-government h ea11-h
facilities Q1ospitals, clinics, diagn ostic.: cent ers, health centers), programs, services
and activities (preve ntive, promotive, curative alld re habilitative). Preventive h ealth
car e is a major concern of th e government-owned health centers wbjJe curative c;ire is
pro"idccl by hospi tals, both government and private.
·
The health care delivery system is affected by poJicies sucl, as RA 9439 and RA 9502
(refer to Annex A2 for a listing of laws that impact on people' healtl1 and t he health
ca re delivery system)
Public health
P ublic health is generally regarded as a responsibility of government. One of the
most guoted definitions of public hea lth is t hat of Winslow (1920): '.'Public health is
the science and art of prev~nting disease, prolonging life, and promotin g hew. th and
efficiency through organized community effort; for the sanitati.on of the environment;
the con1rol of communicable infections; the education of the individual in personaJ
hygiene; the organizati on of medical a nd nursing services for Lbe early di.ignosis and
preventive treatmentofdi.~ea se; and, t he deYelopment of the soc ial machinery to ensure
everyone a standard of living adequate for the m ainte na nce of h eal th, so OL·ganizing
these benefits as t o enable every citizen to realize h is birthrigh t of health and lo n gevity"
(H anlon and Pickett, 1979:4).
T oday public health could be defined in terms of its three cQce functions: assessment,
policy development and assuran ce. Assessme11t is the r egular collection and analysis of
healtl1 d,1ta. T hese data are used for program plannin~ and policy develo p ruent. Policy
deuelopmenl involves advocacy and politfoal action to deve lo p policies in various levels
ofdecisio n making.Assurance is makingsurethathea lth serv;ces are effective, availa ble
and accessible to the people (IostitlLte of Medicine, 1988 in Clark, 2008:87-88).
Related to th e core functions of pu blic health ther e a re ten essential h eaJth servic es
(ASTON in Lu ndy and Janes: 2001: 8 75) wh ich are: (1) m onitoring l 1ealtb status to
identify com m unity health problem s ; (2) cliagnosing and i.twcstigaiin g h ealt11 pi·oblems
a nd haza rds in lhe community; (3) informfog, edu cati ng and empo=ering people
22
about health iss\lcs; (4 ) m obiJi;,:ing co mmu n ily p artnerships to identify and solve
bea.lth prohlem s; (5) deve loping pnlirir.'> :m d r,lans tlwl su pport iml ividual, fam ily
and community effo rts: (6) enforci ng la ws ~111c.l regulat ions th at protect hea lth and
e 11s urc s;ifety ; (7) li nking people to need ed person.,11,eallb se rvices ,11rcl e nsuring the
p rovision nfh eal th ca re tlrnt is o t.hen,; se 1111arni lablc; (8) c 11s uri1111, com pete nt public
hea lt h a nd persona l heal th ca re workforce; (9} C\'alua lin g c ffccti"cm~ss. accessibility
am.I quality of perso nal nnd populatio n-based healt h sen:iccs ; ,and , ( w) rcst,;a rclii ng for
new ins igh ts aml m novative solutio ns Lo h ealth problem s. Public hea lth nu rses s houlc.l
p articipale in these cssenti,1I henllh ser vices.
The Philippine health care delivery system
This section prescn ls some of l.lJe major components o f t he Phili pp ine bcalth care
d elivery sys tem tl1.it constit ute l.11e conLex L of communiLy heal th nurs ing-t he
Department o f Hea lth , l\•lillcnn ium Deve lo pmenL Goa ls. Medium- Te rm Philippi ne
Developmen t Plan, Health Set:to r Reform ;\gen da. FOURmula One fo r Hca ltl1, Natio nal
Objectives for Heal th and local health ca re system (dc\'olu t io n of health services).
Department of Health
The DO H leads tn e fforts to im prove tbc ·h L:ulth o f Filipinos, in p onnershi p ,\ith other
governmen t a gencies, t he p1;vat e sector, NGOs and communities. \IVith the exception
of a few governme nt age ncies (such as the University of Lhe Philippines on<l Armed
Forces of the Ph ilippines) a nd ,1 ffluent cittcs (E;uch as Man ila. Makoti a nd Q u ezon City)
operating their own health facilities, the DOIi remains to be the national govern m ent's
biggest health ( particulal'ly curative) care pr ovider.
The DOH used to have control and supervision over all barangay h ealth s tations, ru ral
health units and hundreds of hospitals thro ugh out the country (special a nd s pecialty
hospitals, medical centers . a nd regional, provincial. district un d municipal hospi tals).
Today, only t he regional h ospitals, med ica l centers, special and s pcc.inlty hospitals and
a few re-nntiona.lized provincial hospitals ar e dir ectly under it.
The DOH exercises rcgu la tory po wers over health facilities and prod ucts. lt t akes t h e
lead in the formulatio.n of policies and standards related to health faci lities, health
produ1>ts and health human reso urces. It provides LGU s th e n eces;;ary support in
m a naging their local h ealth system. It also implements a n umber of hel'll lh programs
(Refer to Annex A3 for a listing of DOH health programs).
The DOH has undergone transformation to be more responsive to its post-devolution
functions. One of the major changes at th e Cen tral Office is t he c reation of the Burea u of
Local Health Development, w hich is concerned with locnl health syste ms development,
health care financi ng p rograms, quality improvement p rograms, inter-sectorn.1 (p ublicpri vate) coordinatio n a nd local projects .
The direction being pursue d by the OOH 1s guided by the
M lllen~ium Development Goals, MedhJm-Ter m Phllippin·e
Developme-nt Plan, Health Sector Reform Agenda, FOURmula
One and National Objectives for Health,
23
Millennium Development Goals (MDGs)
The ~ ncem to improve people·s h ealth is universal b ecause there is a strong
corre.lat1on between h ealth and d evelopment. Poor heal th is n conseq ue n ce and
cause of poveny and un derdevelo pme nt. Pove rty a lso breeds d espair a n d turm oil.
T o address these proble ms, th e United Nations spearhea ded the form ula tion of tJ,e
l\llDGs ,~ith the corresponding targeLs. These goals are: (1) eradicate extreme p overty
and hun ger: (2} a chieve universal primary educ-'ltion; (3) promote gender eq uality and
empower women; ( 4 ) reduce c hil<l mortality; (5) improve m ;iterna l heal rh ; (6) combat
HlV/AJ DS, m ala ria and otJ1er diseases; (7) ensure envfronmcntaJ s ustainability; an d ,
(8) develo p a global partnership for development.
Medium -Term Philippine Development Pion (MTPDP)
Chapter 1 2 of the MPdium-Terai Ph ilippine Development Plan 2004- 20 10 spells
out the p riority strategies to meet the basic n eeds of the poor_ The following h ealth
priorities were identified: ( 1) reduc.1:ion of the cost of m edicin es; ( 2) expansion of h ealth
ins u ra nce partic.:ularl_v for indige nts through pre mi u m s ubsidy; (3) .strengthening
na tional a nd local health systems through the implementation of th e Health Sector
R eform ...\genda: (4 ) improq;ment ofhea ltJ1 care m ana gement s ys tem; Cs) impr ove m ent
ofheaJtb and productivity through Rand D; and, (6) establishment of drugtreatrn en t
and reha hilltation centers and the expansion of existing ones.
Specifically for public health. the plan provides for tbe strengthening of health
promotion aJld disease prevention a nd control p r ogra ms: (1) achieve and maintain
fufl•, fmmunized d 1ild,en cm·erage to 95% : ( 2 ) achieve a nd mairttain sputum positive
TB~= dmec.1cion rate o f,0% and cure rate of 8.5%; (3) w iden the choice a nd rea ch o f
family planning ser,;ces and increase the prevalence rctte of men and women/couples
practicing responsible parenthood using ei th e r modern, natural or artificial m ethods
to 60¾ by 2010; (4 ) contai:n HIV/ ..\.1D5 prevalence to 1% or less for groups at high
risk for Hf\. infection: (.:;J reduce malaria morbid ity rate by 50% from 48 cases per
1 0-0.0 0 0 populatirm in 2002 to 24 cases p e r 100,000 population by the year 2010;
(6) jmplernent micmnutrie nt fortifieation of foods; and, (7) heighten advocacy for the
p rCJ'.ision o; adolescent heal th ser vices including sexuality education and cou n seling.
Health Sector Reform Agenda (HSRA)
Tov:ards the end of the twentieth cenbJ ry, the DOH has come up with the HSRA
1999-2004 that incl uded the fo!Jo,..ing refo nns : (1) prO\ide fiscal a utonomy t o
government hospitals: ( 2 ) secure fundin g for prio ri ty puhHc health programs; (3)
promote the dE"\·elopmem of loca l health systems and ensure its effective p e rformance;
(4) strengthen th ie capacities of health ri::gulatory age ncies; and (.5) expand the coverage
of the ~ationp;J Health Insurance Program.
FOURmula ONE for Health (F1)
The FOL.Rmula OXE ·.,·hich is the imple mentation framework of the HSRA, has three
goa ls : O':'Uer health ou tco mes, more respo nsi ve hea lth systems and equitable health
care financing. The elements of the strat egy are: h eaJtb fin a ncing, h ealth regulation,
health sen ice deliYery and good gove rnance. Accord.in" t o th e Secretan• of H caJ th F1 is
th<: guiding philosophy and strategic app roach of the DOH (For ewor d: NOH 2005:8).
I
24
...
National Objectives for Health (NOH)
The :-J(JH :2005-2rJ1<J is an importa.nt tloc ument that re-Jkc..1:S the i\IUG'i. MTPDP,
HSRt, ,i nd Fi. It includes a stalcmc:nt of vis io n, m ission, prin ciples. )?.oaJs an d objectives,
ke\· iuc.i-. larg.:ts. inc.lic:.itri rs and sl ntlcg ics l•J hrin g the hea lth sector tn its desir<:d
ou.tc:om.:.'> (http://www.do h.gov.ph/ noh).
Till' t:i~irm o ft he STO l i is" hcalth fo r all Fili 11i110s- ,md the mission is toensu reacct:.ssibility
nnu qvalitv of health care to impro,·e the quality of lifo of all Filipinos. e.,-.pecially the
por,r. Tlw hasir.: pr111cip/es arl!: ( 1) fostering a i,trong and healthy na fion: (:l) enh;im:ing
1..he perfommm:e nf the health scc:lnr; (i) ensuring un ivcn,:il ac:cess trJ q uality essc nti,tl
healt h care ; anti. (,iJ impmvin~ rnac:ro-econornic: anti sncial comlitio11s frJr heu cr
healtli g.si11s. T h!! g<1ol~ .ire: (1) better hc;1lth uult.:1Jrnes: (2) more n:s pv n ~ivc lil·a lth
~\·stem: ,1 □ tl, (;.i) mr,rc L-q uitahlc health t,1rc financing. Th,· medium-l<:n11 tJ/.Jjectiul!s
a·rc tfl : ( 1) ""'cure i11crEOa,-,ed. bct1era11d ~usw i11ccJ in,·estmcnu, in 111:,Jllh : (~J assure Lhe
qu,ilit-y and ,iffordahililv 1; f bf'allh goods a nd servi ces: (:3) improve th e accessibility
and nv:-iil;ihil ity o f hasi<: and es.,ential bca ll h c.t re for all; (3) Imp rove health syst1::ms
pcrfonn ance at the m1tiom1I and local levels.
Devolution of health services
One o f the most sig nificant laws th at rad ic.1ll y d1a.nged the landsc.ipc of health
care de livery in t.he country is RA 7160 o r more co mmonly known as the Local
Go,·emmenl 0:>de. The Code aims to: transform local go vernment u nits into selfreliant comm uni lies and active partners in the attainment of nationa l gorus th.rough
a mo re re.sponsi,·t: and acco untable loCc!I government s tructure instituted through a
system o f d c t:e11Lr..JjzaLjon.
Throughout the country, there are about 79 pro\inces,113 cities, 1,496 munici-pa lities.
and 41, 943 ha rangays. (http://www.doh,gou.ph/kp/ statistics / no_cities_prou).
In 1993. health sen ices were de\'oked or transferred from th e Department of Health
to the local go.-crnm e nl uni u, -- all p n,,incial. district nnd mu nicipal ho"!) itals to
the p rovincial gm·emments and the rural health uni rs (Rl:!Us) and barangay health
stalions (BHSs) lo the municipal governments. In 1999 there were 2,381 RH Us and
11.39:{ BH Ss (Baut.ista et al., 2002:t9).
Each province, city and mun icipality has a Local He.il th Roard ( LE-1B). This body is
a gootl \'enu e for making the local health system more respons1\·e to the needs of the
people. Tt is mandated to propos e annua l budgetary allocations for th e operation and
maintenance of health facilities and servi ces " i thin the municipaJjty, city or province.
At th e prmincial le\·el. it is composed of the: governor (chair) , pro,incial health officer
(Yice chair), chairman of t he Committee Oil Health of the Sanggunfang Panlala"igan,
DOH representative an d NGO representati\'e. At the city und rnunjc;ipal level, the LHB
is composed of the follo\\ing: mayor (chair), municipal health ofncer (vice chair). chair
of the Committee on Health of the Sangguniang Bayan. DO A representative an<l NGO
representati\·e.
Al the municipal le\·el, many pu blic bealth nurses hnve been appointed as DOH
representati\'es. This means that they ha\·e been retai ned br the DOH. Ma ny of
them. howe\'er. perform dual functions- th ose of a p ublic. health nu rse und those of
a DOH representative. l'\•[any of t he local go\'ernruent units -cannot afford - to hire a
25
~ pl,1t\·111t•nt. 1 lw 1>()1I h,,s. lh l'n.•fo rt•. n lli,wt•d 1h1:- "<'I - up H;.. . , fo r111 of supp nrt lo low111 uu11\· 111\1111\ 1p·1h11.--..
Tl11 -.h,ft w tlw ll ,11lc•r.<f11p 111 lw.illh ,-:11v frn 111 t h .. n11 t 1un:r l i;<wer11mt·n1 In 1h,• 1.C Us
h.l', 1,•-.11l1,-.l ln h"1h 1h,· 1111111•"·,·mcnl a11tl tlt•h•ri,,ralio11 of lwal rh rrn·r delin•rv. Some
L(:\ ·-. h.iq• 1h,• p,,htic.tl ",II ,111cl linnn,·i.11 1·.1p:ibilit~· 10 s11pp,wt 1lwi r own llc:;11 11 c nrc
~,-.t,•111 whik utlwr- do m•t. ~,n11,• U:t ts ~"'" th,·1r 1'1 l ~s :--c: 1;; ,;:r lanc.·:- in n,·cordancc
"llh R.\ 0 1- i " l111, m,.-.1 ,In not.
0
ll ha~ 1'«-"<'ll ,~t.rhli-.tn-d l h.1l ,tn LGt;·s financial c-a p:rhilitv. a d ~·nnmit: n ntl n·sporn, ive
poht1t•,1l lc ~11..l.-r--lti p ,111d t·om muni1v c 111p,,wl•r111e m arc t lw i mp o rtant i11 g rcu io ul:- ofan
, fft·cth ,. loc-~11 h,·.tlth -.,-i-tl'm
,\lm c•«t two d,-. nd,~ .ifkr t h, tl,•,·oluticm orlw.ilth sc·n-i<-cs. th t.'rc h: n need to look into
it" 1111p,lt'I 1111 i"'"I'"-', 1a,.11th 11 ,... ubo import.int to know how P l INs pcrfon11cd th e ir
Joh<:. ho,,· till'~ µ,·n.·,•i, t! 1hei r mft.., an d h1Jw l hey ,;c w thei r profe... s io n;tl <l cvc lnpmcnt
i11 n dt"n"'°d ,.,.:l-up.
THE NAT IONAL HEALTH SITUAT I ON
Thl• n.11mnal lre.allh s-ituru,nn gin~~ us .in idc.i or the h ealth ~ih1a li on in Lhc
c-nmm1111111e:- \\here nur-.e<: \\ Ork. He c.1 usc of lhl' different to 11Jl t ions prc vni lin,:: in
thl'.,,. r ·nmumti,•-.. their he.11th pu·turc c.-.:pcc lt.'dly v;1ri1•s. Fo r examp le, i,;o it c- r i"' h ighly
pn-,·,lt 111 in th,· \Jo ,ntam Pm'1nl·e "hilc sc-his to!'ominsis is cmfomic in Lt.'~1 <'. T h e
loc;.J hc;,ith -.1111 1111111. tlwr.:-1orc . needs tn h c> co;tablis hed for each prvvi uce. city. :inn
mu nic1p~lit:
The "''"1 !-ectiun ~h cs a ,;i:neral dcmogr.iphic- :i nd hP:tlth profile of Filipinos. Il must be
T'f'£~ni1ed.. hO\\t, er. ll1al t.h c , 1?,:!ional d ifferr ncc.co in many impo rt;rnt socioeconomic
nrd ph} 11:;1I fact,J~ Jre t:r.m~lal••d to differen ce:- in the rcg ion:il hc;1lth picll.Jre.
Demographic profile
Th,• Phihppin1.~ r.inhxl 12" in the world in tcnns o flolal popul;ition w h ich was 88.6
m1lh11n ,n ,\IIJ:ll<;t inri-<llltp. 1 Wll"U-,C<!ll.'511.'i ,qrJl,',J'II) 'J11 i-. is p rojr c-t Nl to iocn:r1s~· f() 91,
RM(. "i <111 in ..;r110 (:-S.iri,,naf Ohjr•c-ti H."" for //caltl1. :.!OO!;.:.! 1) . Ac-r-nrtli11g lo t !J <: Prcsitlcnl
i11 lrrr 1'1illt o f ;,;,,1,.111 \dclrc'-" in .July :.mo8, th e c•H111tr_v·s ;i nnu;d ror1tla1i,rn gn,wrh
n, t,: ,, :> ,,4'\,. dr,"n (rnm the 2.:i6"°, in th <: 199 0s (111c l' h ilippine S t ar, 8/:3/08).
Jn :u,rq. 1lw a,,•rn~•• lifePYpt•c-tnnc-y :it h inh h "n" 72. 8 y cnrs for fem n lcs a n t.l 67. 5 years
fo1 111,tlc--. -- up from th, ;,~er.1.,:1• ,,f '11.6 ~N•r< for both -.ci.cs in 1()80. The c:o un lrv's
p upu l. ,111Jn i~ "'" ,.,uu;:, "•th -1 1 u·,1r<. :i, rh, · m t·cli:in ;,g,•. T h e d c-p1•ndc11c:y ral i<; is
6t.J \< li u h 111,•;i11, l h a t r,;i \01111 1-\ d,·1wmlt•11r,- (c,-14 yc:;i r<: ,,Id ) 1111d Ii ,1ld dt:pP nd cn ts
( ti_<; \t•·i r,. 11l<.J :m<l .11 ,o q•J :,r,• J,<•111;: upp<>rl< -d IH wo pt·opl<" ,1~cd 15-<,,i . ·11,i,·1y- seve n
p<>r-c-, 111 fr"",) uf t lw loltal po11ul.n ir,n art· in the 0-14 :1~:<' gro up whi t<: ::i.8'...'6 arc in lhc
1,_:; and ubm·t• ;i~, ~mup c:--oH. 20051.
J.n 21 i< ,o. I hl re we: re n hi•u t 2.-;5 1)(•oµ k• for eve,-y ~ 1u:irc kil011H't L' r o fr'h i Ii r,p i nc tCrTito ry .
..l\h-tn, Manila h m, IJw hq;hc.-.1 p11pula 1inn tlc-n,ily .111c.J C.1\1{ ha<, th e lowc!'lt (NOH,
::'[)(l~J
1iw f>')f)lll,,wm in th t! urhan :irca, i-. incrrn,-i n~ very rn p 1dly. F rom lh <' :;7% o ( th e
ltl!al P ,pufatfon rn 1984 (UNICEF, 198f>J the fi~l1rr incrc11-.cd to 48'.I(, in :too,1 (NO i i
2005)
16
-
Health profile
O ne o f Lh e iss ues roise d abou t hcal tb statis tics in the coun try is Lhe ir :-iccu racy,
co m p lete ness an ti rc lii;hility. Diffc rcm s ou recs s ometimes quote d iffeTen t fig urr-o;. ·n. c
inte n ti o n o f incl ud ing s o me sta ti stics in 1h is charter is to give a gene ra l p ic t11re o f the
e pid emio logit:i:11 pau em s a nd I r·e n d s in th e h eaJ1h of Fil ipi nos .
Births a nd deaths
'111 c c n 1dc b irth rate (Cilfl) in 2cm n was 23.1 per lO00 popula ti on while ll1 c~ c rud e
d eath i:nte (C DR) w.is 4 .8 p er 1000 po pula t ion. 13,iscd on these figures, t he rntc o f
nntu rnl increase in the co un try's pop ula lion for 1hc sa m e year was 18.3 (23. 1 m i_n us
4.8) for C\•Cry 100 0 pop ulation (NOH, 2 0 05).
Despi te ll1e decline in th e ferti lity of wo m en, th e Lota] fc.rtill ty rate (TFR) in the
P hilippin rs re m a ins h igh (3.1 birth s pe r wo m a n in 2 0 04. accord ing to lbc AOB)
co m p;ired tt> t he neighbo ring So utheast Asian coun tries. Rural women have m o re
c hildre n 1ha n u rban wo m e n. Uned uca ted w o m e n a lso have mQre c hildren tha a tJwsc
w ho arc wit h cvl lege e duca tion . Those in the 25-29 age gr o up have tlle hig h est fe rtility
ra te (NOH :tr;o5).
Be lw c c n 1998 a nd 20 03, the infant m ortali ty ra te (IMR) wa.,; 29/rnoo Jive b irths,
wh ic h it- ,vith in the \-\'J-fO global gual for J MR o f less llrnn 50/101Jo live births. T his
figure w<:n l down t o :t6/ w oo live births in 2004. The chi ld m o rt.:i l it:y rate (CMR)
h ch-:ee n 1998 and 2003 was 12/ 1000 live b iJ·t hs (NOH 2005 ) . Th e matem;i_l m o rta li ty
r;:i te (MM R.J was 2/1000 Live births (ADB. 2 006).Tbe re are m ore d eaths among m a l es
t ha n fema les. ·n 1is e~-pla ins Lh c "feminizatio n~ o f o ld age.
causes of morb idity and mortality
T h e fo ll o wi ng a re tbc lead ing ca uses of mor ta lity amo ng F ilip ino s : (J) hea r t disease;
neop lasms; (4) acciden ts (5 ) pneumonia;
(6 ) TB. all io rm s : (7) ill· clefined :ind un knqwn cause of mnrtaJiL-y:(8) ch r<Jnic
respira to ry d isease; (9) dia hc les rne lli t11 s; a ntl , (1n) certai n conditions originating in
the peri nat:.tl pe riod (P hili ppin e Hc:a llh S tatis tics 2004). Mo,;t o f t h ese discai.;es are
highly p reve ntable .
(2) vasc ular s yiacm clis:ease; (3) m a lig nant
Dci;pilc th e im proveme nts ln the field of public health, many of the common causes of
m orb idity can be p re vented e as ily by improvin g e n vironm e ntal sanitation an d personal
h yp,iem: a ml 1h ru up,h health e du ca tio n . In 2004, the leadi ng c11 usc.<; of morbidity were:
( 1) m: u tc lo wer resp irato ry t ract infec tion (RT I) and pneumonia; (:!) bronchitis and
hrum: li iuli lis; (:!) aCllle wa tery diarrh ea; (4) in flue n za: (5) hypertension; (6) TB
rc ,.,-,ir11 1ory; (7) c hi ck1mpox; (8) d iseasei; of the heart: (9) m a la ri a: and. (lO) dengue
fcvr- r (P MS 200 4).
Infa nts and children
·11,c lead ing cau ses ofrofant mortality in 200 4 we re: ( 1) bacterial sepsis of newborn:
(2) res piratory dis tr ess of ne, ,,bom; (3) p ueumo uia ; (4) d iso rders related ro s hort
ge..<;t;1tinn ;ind lnw hi rth weigh t 111)! cb;ewh e re c lassified; (s) congenital pne umonias;
(6) co nienital m alfonn;i lion of th e heurt; [7) neo na tal aspiration syndrome; (8) 01her
con g('n i 1nl nu, lform;Hion ; (9) in traulc.:rine liyµox.ia an d birth asphyxia; (io) diarrhea
an d gas t roe nte ritis of p resum ed infectio us origin (P l IS 2004).
1 1al r1utTil.ion is ,·err cu m m on am cmgch ilclren, par ticularly protein-energy malnutrition.
J11 2 00 1, 31% c h ildren under 5yc;ir<; old were u,iderwejght (AD B, ~ooo) The Philippines
h :is nne of the.: high<e'>l blind n ess rates i n th e \•:oriel. ll is estima led that 17 children
becom e perma ne ntly blind eve ryd:1y ,1 nd lack of Vitamin ,\ i~ thi? primary catL--e o f
27
tlw i r lil andn• ._., (1'011. 1•)<1<1) , lndi ,w d•• lic·i,•111-y w h k lt r(•s 11ILs In 11wn 1:tl and j~rowth
r<•t :11 tln 11on ,., Clllll ll1Cll1 I ll r,•111.II••... 1., ., ,. 11 ,·c•a r,.. o ld and :.1hCJV(! , a nd i 11 pn ·gn1111l U t ttl
lac·t:1t 111i-: rnntlwr,. (N,, tlo n .11 NutriLion <:crnnl'i l, t</<JtJ J .
A n , n,c,~i" t ,,•riou.-. lwnllh n 111n•rn ,unon g t 1..- .vo1 11 1~~. aec ordinR l n I h e Vv I II ) is I lie Iact
1h :1 t :111110,;t I in <'\'l't)' :~ l'ili pit w nd1,1t-»1·,•11l o.: 11g1-<l 1:1 tu LS ~=1110k1· l'i i.;11rel les (f ' nn·:tll;i,
:ioo7 )
M aterna l mort ality
l\ h tll' r 11:1I nw n .11i1, i< 11 m:n11r iucl ic.1 lor n f a \\u 11 w 11·,- h ,·:ilth s 1n 111s. II i,, <li!li r11:d h y
t lw \,' I HI 11 '- th< t!1·t1tlt nJ ti 11•t1 rr11111 u•ltill' J>r<'!J" " "' ,,,. withi11 ,'/ :! days of l<"r111iT1ut in11
of 111rqm11wr1 rrr, ,,,,•,·r11·t 11( t/11' ,Jur 11tw11 u nti
~it (' vj rlH: 1n·1·y 11,11/C'!f .fi-tn11 <lll!J
c't11rs, n·lut, ti ro. ur cwµrt1l'<If1•1l ''!I tlw 11r,,y11t111n, or i t s 111cu ,c19 ,•111, ·11/. 1>111 /l(l t .frr,111
CJrrirfrn t"I nr in.-idrnta/ cu,, , ,~. Tiw rn atl•r11af mort a lity nil c i n 2 000 , w,.o.: 2 / 1noo I ivc
h i rt 11_, (/II rn. 2 1106 ).
,1,,.
'I11c lt-adin~ rmt'-''' nf nl'l! t' n1a f mortali t} in :t.004 w(•re: ( 1) n r 111,r r·omplic nt io m: ,·cl n te tl
l <l p r c~u rm r~ t)('(' umn~ 111 the ro U T'-l' vflalHir. , lt·l ivc ry .,nd p 111>r prrium : (:.!) h y pr·rt 1•n Ai r,n
C'•>rn1•lit-,11in;: f'"''~r1. ,n,"·· ,·hildh1rth ;111d pue.rpcri u m; (;3) p osl pnr1 11m h c mnrrh ;iJ.tt•: (4 )
p rt>~nanr) "'' " :,h.,n1,·;• 0 1111.,,m l.'; and. (~) h e m o rrfw )';c in curl~· p rcitnancy ( .:!00-1
Phihprini ll,•.1 lt h ~tal1-Lic. ).
M a te m ;il m o rtality ~hould fl<• ,·i<n~r d w it h i n the grea te r co ntcx1 o f w o m c n'i; h e a lt h.
Anal~, ,~ 11!' " "m•·n·~ ponr he:ihh ;in<l ma lt:n 1~,J 111o rt:ili ty shoul d c1111s i<le r t he ' " 't' r a fl
,,od nl. r,1lt 11 ml. J)n,I 1'<-·1111,11nk f.'11Vir1111 men l. The wo m a n who <lies frn n l p rc•~11 ;1n cy·
relull'ti ,·.:111,,·< ,. rn<>r,. J,l«•b 111 ,,., p i>U r, "it h lo"' r d L1c11 1io11;if st a t us . :r 1111 rf1ipara,
:wrl ;11 11 •11w '.;!11rt• tik , J\ ,h,· 1·ome" frmn :on are a wh,•rr· I h t· n11 1enalal !>cn·it.·c " ciro
in:ic-, , <•t lilc· irnn,p•1n (;,·i lit1<•<. arP poor; s upply tJfblood fo r l r ~rns ftr ,_i,,n j., ina deq1ra lc;
,.,t.."ll dn, ;;,. , up p li, ..; a nd L~~11ipm<>n l .ire no t 11\';i il rib fc; and adcq u al cly sk flled h e lp in
labor and dP)f\•1·r:, 1• nt>l nYallab l•:.
Elderly
Prub.1bh 1h,· mu-:1 commr,nlv doc-umen1e d p rt>blc m s of n lclcr p-eoplc nr<· !hose
wla t,•rJ 1,,· t hr ,r h ,•:dt h . ;,i:cr,rdi~g IO th" !)() 11. Ih e d<lcrl y s u ffer fr<J m Ih e Md v 11 bl!:
bu rd ,•n · nf ci••;;<' n• r:m•:,· ,,nd communir:1bfc· dis t':l'..,;s. ' Inc· f<"ad i ng ~ 11,-.cs of murl, iu i ty
a mong ,,Id,, fY 'tlfll•· ;,r, infl11(!!17~l . rnr•unwn i:, and TIJ. '/'Jw lr·:icli rlg ('.:.l\JS(!t, ,,r 111,11-ialit y
are c~1r,Jj,,-,-,..,ntl;,r d 1v•a~, .... pn r-11rno11i;1, m:1fi~n.in 1 n e n p l:, <.ms, Tll, C O l' I >, di:1bc: rc .c;
mel!Jtu-;, J!llt.!Tfllnt.-.1 ,n.:if u It•,..,., nc ridPn l .., ~, n<l inj11ri1:,,, n,·ph rit is , 11c ph r o li c i.yn<l r o n ic
and n"phm,1s ,u,,J v •ptiu:mia ( PHS 20<,cJ i n :s'Oli :.m o5).
TI1,; prc,.ilt•m , ,,fn11 l nli,Jnal cii• h r'i• n1·ydisor<lcrs n m m1g o lde r peo ple is hii;.h: nn c niia,
4 5'" "; rh1«m1nr d 1•1u·u n,·. 1:;',• , :incl nhfJ ll ;nin. 12%. T ht• n · :He m ore r,lclcr w o n1cn
( 16 ",', J th:rn old.·r nRn /11' ,J "hn ~, rr 11 nrl1·rwr·ipit (N;11i,,n:J I l le;1Jt lt 0 1,jecti,·cs, 1.44 ).
According M th•• Food .ind -S u 1n111,n R,,, a r•·h l n «ti t ute (2 00 1: 21 } LJ, ~· prcva le 11cc u f
chmnic ,..n t·rzy dcftcit-ne> 1:< h1~h.-r in f<·mA lr, tlwn in mll fc-,;, ;,nd th e :-.cvcri ty i n c n.msl!S
u ith a~e
·
fo 1995 th l·n· wcr,· 345 ooo .,,,0,,11· ci t 11t•n<: ( 9 .2 % ) wi th so nw l vp(• n f (l io;;1hility. Lo w
u,11~ arn< m i.: ,-fdc-rl .1 ,~•r,m ,·n ( ,1,, 1'J/, :,o.; c o mp::irc d
lo 3',,......,.; nmofl_i: dJ..rf~ m ,·n). Thc <, th,:r tvp,·, 11( di,;1hil1ty tli ,, t olrl,·r p,· t) pk s u ffer
from 1,"c n • ,lealT16s (partial and total), poor lwanng, h lin <lnc,s ( p ar1 ia l a nd tu t a J) nnd
pa ~ll i,,i!> (?-: so, :,_(,c11 ).
v1,1on ........ th •· rnu -1 •·11mrnon l"'-)X't
Lifestyle-re late d diseases
The p;it tc, rn s of mo r bid ity and rYHH1 a li ty lt~1V<s changr,d siY,n i/ic:mt ly. While infectious
di,-,r;:1<;e,; r• :11111i11 t u hr· tlw main t :iusr•<; rif rn1,rbi<l i1y, c-ardiov~1<;1·11l 11r (!j,_,,:,~1· s. di:,betes
mcll itu.s, c:,nc, •J', 1111d chr,,n,c rc:sp,r:,torydisrc;;sc.s, th e 'if>·C1.JIJ•·d i1fc~tylc disca.scs. have
beco m e I he l1·:,cli11~ c;, 11 s<:s ,,f d ,;;,th,.. WI I() r,-..t11n a l •$ thHt ho% ,,r ;,JI d c:,th~ are tlue
lo c:hrnni,· disP:tS1•,-., Eii~li ty p cn;c nt (f$11%) o( L11csc· r,ecu r in 11,w- ;i 11d rnit.ldl<:- incrime
co untri,~s lilw t he l'h ili ppines (WI II J, .<rto.5). By 2 1,2n, it i,-. t·~ ri rw,r c:d th:it 7~% •>ftotal
dc::t t hs wi ll ht: 111trih11t1•d tn th e rnajr,r nnn-r-,,mmuniC'.ahlf• di.<;r.:1s1•<; (Wnrlrl I Jc;,l t h
/\ssc mhly , 2004).
l'coplc·s Ii fes tylc (rart iculnrly th ei r unlicalt11y die t , sedentary work and Incl< of exercise)
ha.o; hc~cn identified I r, he: th e rnoj or rc11S()J1 why th ey dfo from the diseases which used to
be asso cint c<l with cJcvc lopcd cnu nl r ics.
Cnrd iov,)sc ul;,r di sensc~ C<Jmprisc 25% of the lolo l dcitlhs. Nine 17ilipinos die of
cnrd i{lv:isc11l:,r d ii,a,:1~a: e very ho ur·. Di;ihclcs m c ll it us, " ·hich is rr~ardcd as "the biggest
hc;.1 11 11 cata sll'ophc th1c world has ever seen .. (C.,s lillo. 200:3) is found in 4 out of 1-00
Fili p inos. N,;t surpris i11 ~ly, nw re d ia be ti cs :i re fo und in ud,an a reas (6.8%) than in
ru ral arc.i l> (2 .5%) (FNJU ).
Ca nccr is I he most dreaded ,,r 11 11disc.ises bec,111s e of its very high case fa tali I:) r.ile and
the lori,: su ffering LJ1at pati c11 Ls expcr·ic nce. The leading canc<.:r sitei; amonv; ma les arc:
lung. liver. c:nln n/rect11m. prostate , leukemia, s tomach, nasoph.irynx. non-Hot.lgkin's
lyrnr h nma, n rnl 1·nv11r :ind l:1rynx. 1\ mn n ~ fomalt'.:S, these a rc: breast, ce rvb., colon/
r C'ct 11m. luni;, ovary. thy m itl. leukcmiH, Jiq• r, nte m s and ,;tr,m nch . I Phi lippine Ca ncer
Socie ty. 2008). In ;iddition to li festyle, a major factor in the 011i.~a1ion of m al ignn nt
n ec,plasm s is the drastic change in th r:, physic;nl e nvir1111meot nnd gr eater e xprJsure of
people lO cl,cmicals (such as po lych lori natcd b irhcnyls c>r r CBs), rndia1ion nnd other
carcinogen ic s11bst<111ccs (Cone,:wus; Need leman and Landrigan. 1994).
Infectious and commu n icab le di seases
t\lthuugh the m11nhcr of d c;iths £mm infectious d ise.ases hns decre;1sed, many of
these arC' -;; Lill majnr puhlic health problems in the cou ntry Cholera and typhoid fe,·er
is s till a com m rm m·r111-rPn1•p in m;my part <; nf tht.:: cow,Lry. Tit" number of panuylic
s hl'.llli~h pni:;cmini ( more oommonly known ;is rnd Lide) continul!S to in crcas~ b~cause
of 1hc rlcgrnclntion of the country's bodies of waler.
In th,: pas l fc-w yca ri,;, t h e re were infcctinw; diseases lhal have emerged such as the
:-;cnry sever e acute respira tory synd ro m e (SARS). SA RS has highligh ted the f;ict that
the t rn11sm issio11 of infcctiou!' di!'eases is fn.cil it,1ted hy the increasi ng rhysica l mobility
of people and ease in u·.iveling frnm o ne coun try to unother.
There is a steady increase. Llrougli relatively s low. in the number of HIV ..\b s eropositive
C!;lSes in the co un t ,·y- 2,454 c.,ses rrom .January t982 to February 20.06. HN/AfDS is
no lo nge r j ust associa ted with hmnose,, uality. Al >tml one-th, rd of the cases were O FWs
(seafor·c rs, dornes lic helpers. e ntertainers and heallh workers). Abo ut three-quarters
(74'.)(,) were males. T he mode o f lraos,nission is prim;1rily (9:~%) thro u~h sexual
int ercoursc ( DO 1-1.. 2006).
The in ct·<•asc in olhl:r sc-. uall y tnmsmi t1cd di s(•ases (STDs) :;uch a,; :,-yphilis a nd
gonorrhea is due tn u11 lrn mpcre tl pro:-tituli<rn in m any areas of the country. Prosti tution
h us nlways been identified as o ,•onsequcnce of poverty. STDs (and 1.hc n c"• ly emergi ng
d isca;;c.:s) furth c r hurd c n the health care system which at the mome.ni coul<I nm cope
ad equately w ith the lea ding cnuse.s of m o rbidi ty aod mortality.
29
Tuberculosis which was the n umber o n e cause of morta lity about so years ago
co ntin u e lo be n major killer of Filipi_nos. TB pi-cvulence in 2003 wus 458 per 1 00,000·
popula tion (ADB, 2006) a nd this proble m is made wori:; e by the res istant s lTains of th e
TB microorganis ms. Unfortunately, TH wm J1ot s ignificantly decline over the next 1.wo
decad es (ADB, 2004). Leprosy, too, is sti ll a p ublic health concern in some parts of the
country.
Schistosomiasis co n tinues to affect hundreds of l:'larangays in 24 endemic provinces.
Rabies incidence in the Philippines is one of t he highest in tl, e world. It is estimated
th ul about 12% of the population arc chronic ca r riers of hepatitis B (DOH). The
significan ce o f tb is figure lies on th~ very close association between hepatitis B and
h ep atic carcinoma.
Tluee fatal and debilita ting d iseascs- m aJn1ia, filarinsis a n d dengue fever a r e hrougl1t
a b out by the vector mosquito. IVJalari a .is e ndcm.ic in most p r ovin ces i n th e country.
Filarias is, on the other ha nd, is endemk in the Bicol Region and some provinces in
R cgiun 10 a nd A luvlM. I n the past few years, the r e has been a s ig n ificant incre ase_ in
the incidence of dengue feve r ( DOH).
Mental illness
Mental illness is the third most common form of disability, after visual and hea ring
impafrments, accord ing to a d isability survey by the Nation al Stat is.tics Office in ::woo.
Almost 2 deaths (t.8) per 100.000 poputatio n result ed from suicide a n d self- inf)jcted
inj udes. Jn anntber s u rvey in 2004 , 0.7% of the h ouseholds included have a family
member with m ental disability. The incidence o f mealal illness is repurter.lly b jghest
among older age groups. Othc1· vu loerable g r oups a re drug u sers an d those who could
not cope wit h strc.-sses of daily living (NOH 200s) .
PRIMARY HEALTH CARE AND HEALTH PROMOTION
TJ1 c practice of community health nursi n g is g ui ded by the philosoph y, goals ,md
stra tegies of p rimary heallb care and h ealth prmnotion. In t h e ir search for more
effective st:rategi es am.l interventio ns, commu n ity hea lth nurses s h ou ld also learn from
the lessons o ( Alma-Ata an d the differ ent ,cha rte rs of health p ro moLion. A m ajor Jesso n
from ;ill of th em is that meani ngfu l im p r ovements in the socioeconomic determinan ts
of health a re required to h ave s igoifica.i.1t nmproven1en ts in people's health.
Pr;mary health care
I n 1978, reprp_,;eatativesfrom 134 coun t ries who attended the International Conference
on Pri mary Heal tJ1 Care in AJrna-Ata, USSR s igned the Declaration on Primary Healtl1
Cn1·e (Pl rC) because they believed that lhe g lobal h ealth situ a ti o n was unj u s t . T h e t·e
was a wide gap in t he health of underd eveloped and developed countries a nd even
with i.n countries.
Com muni t,, hea lth nu rses subscribe to Lhe belie fs art icu lated in the Declaration,
specificall):: (1) The promotion a n d pro tection of t he heal th of the people is esse ntial to
susta.ined econo mic an d social rlevelopment and contrib u tes to a better q u a li ty of life
and to world reace; ( 2 ) The people have t'h c right a nd d nty to pn rtic ipnte individ u ally
an d colle(;t;vely in the p lann ing and im p le m e ntat ion o f t b e ir h caJ tb ca r e; (3 ) PHC is
premised o n tlJe sp irit o f social ju!-licc; a nd, (4) PHC is an integr al part o f t he co u ntry's
health system and o f th e overall social a nd econ om ic d evelop ment of ·the com mun ity
((WHO/UN[CEF t9 78:2-4).
30
PHC wns viewed as the approach that could improve the health situation throughout
the world. It was defined 11s "essential health cnrc based cm practical. scientifically
sound nnd socially acceptable methods and Lechnolo1,,')' made universnlly accessible to
individuals and families in Llui! community th rrmgh th eir full participation and al II cost
that the community c;in afford lo maintai11 :1t every stage of their development in the
spirit of self reliance and self determination" (\-\THO/UNICEF p. 16).
The essential clements of PIIC include: cducntion about pre\'ailing health problems,
inclu ding methods of p revention and control; promotion of adequate food supply
and proper nutrition; immuniz.-1tio11 againsl the major infectious disenscs; provision
of safe w11ler and basic saniwtion; maternal and child hc111lh care, including family
planning; prevention and control of loc11lly endemic diseases; appropriate treatment
of common diseases and injuries; and, p r ovision of essential drugs. Although these
. we re identified decmles .igo, Lhesc a re slill reflective oft h e n eeds of most people in the
world, particularly in developing countries.
Realizing that health and illness are multi-causal and could be addressed only by an
integrnted effort, the CHN works with o ther health workers and those from other
gove rnment agencies and non-government org:mizations (NGOs). Mullisectoral
linkage ensures that the different facets o f health problems are addressed. (These
concepts 11re elaborated in other chaplt:rs of th is hook.)
App ropriate technology is used in addressing people's problems for many reasons.
Herbal medicines and acupressu.re which have been proven to b e effective, -have the
ad vantage of safety, acceptability and affordability.
Three decades after the International Conference on Primary Health Care, access
to basic health services has not significantly improved for certain segments of the
country's population. Vlhy? The nnswer lies on the poli tical commitment to primary
health ·care wh ich "implies more than formal support from the government and
community leaders.... For developing cou ntrics in particular, it implies the transfer
of a greater share of health resources to the under-served majority of the population.
At the same time, there is a need to increase the national health budget until the total
population has access to essential health care...'' (WHO/UNJCEF 1978, in Werner and
Sanders, p. 18).
In addition, many people (health workers and communities) have not fully understood
the essence of community participation and have not developed the n ecessary
competencies to participate more effectively.
Nurses should do their share in making basic health services available and access ible
through advocacy and p roper management of health programs and services.
Community participation should he ensured in all the phases of the nursing pr ocess
and other community he.11th nursing processes. Nurses must be com petent on the use
ofparlicipntory npproach to engage clients/community portncrs to look, think and act
in o rder to address illness realities a nd barriers to quality health care, hy enhancing the
competence of client-partners to unclcrsland, ana l~1.e nnd carry out options to address
hopelessness, apathy and helplessness, they can sustnin their m otivat_ion to change
the cur rent reality in order to out health and health care in their hands (i\lnglaya,
2008). The participatory approach is descdbed in Chapter 5 antl pursued ,,;t11 specific
examples in Chapter 18 as pa rticipatory action research on family empowerment for
malaria p reventi_on and control inn baranga)' in Abra Province.
0
31
Health promotion
Almost ten years after the Declaratio n of Pri mary Heah 11 Care was s il!,ned, th e Ottawa
Charter o f I-l eallh Promotion cam e o ut of the Fi rst ln tern ationaJ Confe ren ce <JII He::dth
Promnti on in November J986. T he Charter defi nes healt h promo tion as ~Lh t.: pr()(;c:-:s o f
enabli ng people to increase conlTo l over, and to improve. their health". l t identi fied li ve
priority action areas: builtli11g h ealthy public policy, crcu tin g :rnppoi-Live e nvir o n m en ts,
su·engLhening community actio n. developing personal skills a nd rcorieiJl in g health
services
111c Second I uternntionril Conference on Health Promotion tha t was h c lr1 in Adelaide,
south Australia in 1988 focused on healthy public policy. I-'ou r priority nrew-; wc:rc
identified: supporting the lwa llh of women, improving food sec urity , sa fc.:l.v nncl
nutrition, r educi11g tobat:co and a lcohol u se and creatin g suppo1·tive envi r onme nts for
health .
'fhe Thi rd Jnternational Conference on H ealt h Promotio n tlH1t w·.is he lcl i n Su ntls,·a ll ,
Sweden centered on sustainable development and e qui ty in crea tinli\ supporti ve
euviro.nmc.n rs for health.
The.Jakarta Declarnlion on Leading Health P rom o tion in Lo lhe 2 1"' C e u tury whjcl, is
tJ,e output of the Fourth Internat ional Confere nce Oil H ealth PrrJm11Lio u he ld in 1997
identified five prio rities for action: promoti ng social responsibility for health, i11<.: re.1::;i 11g
community ca paci ty and empowering tbe ind ivid ual , expanding a nti cnn "ol idatin g
part nerships for health, increasing _i nvestm en ts for h ealth developmen t a11d securing
an infrast mctu rc for health p romot10n.
The Fift h Globa l Conference on Health Pro m otion ( 2000) examined the con l1·ib uLi ons
maclehy hMlth promotion in improving th e health a nd qu ality of life of people living in
difficult circumstances. It called for the strengthening of the science anc.l ar Lof health
prulllotion and strengthening politicaJ skills and actions for health p ro m o t ion.
Recognizing the changed glol~a l context for health promotion, t h e Bangkok Chai·ter
of Health Promotion io 11 Globalized 1-Vorld which was adopte d duri n g Lhe 6 ' 11
Global Conference on Health f>romotton in 2005 focuses on the nee<l Lo adclress Lhe
determin ants of health in a globali7.ed world thro ug h h ealth promolion . Com;eqoently,
it exp .inds the definitio n of heal t h promotion to include the determ inan ts of healt h:
Healt h promotion is th e procc-;s of enuhling people to increas e con trol over th e ir health
and its determ inants. This is done by strengthening in divid ual skills and cap abilities
and the capacity of gr◊u ps to cha nge th e social and eco n o m ic co nditions that affect
J1ealth (Tang, Beaglehole and O'Byrne, 2005:884).
'J11e Charter recognjzes thatorganizedand empoweredconinnmities nre higl1 ly effective
in detem1ining their own health, an d are making go"e rnmenti; c'lnd t h e p r iv;.1 te s ector
accoun table for the heal th co nsequences of t11eir policies and practice.<;.
About U1irty years afte r Ll,e Alma-Ala Declaration and twenty-two years after t h e
Ot-tawa Charter. the re arc ma ny questions t hat still n eed to be asked . 1s the re enough
political will to insli tule m ean ingfu l an d lasting structural ch a nges tl, at d e>not o nly aim
to im prove J1ea.Jth b11 t to effectively address the socioeconomic and othe1· determ inants
of lieaJ tb·? Are t he com munities compc t.cnt, con fident a nd co mmitted enoug h to
actively participate in matters t hat affect them? And th e q ues tions to be a nswer e d
by community health nurses are: Do nurses en ga ged in practice do so Jn acc.ordance
32
v,ri.th the beliefs o f primary h ealth care ,md hen Ith promotion·! /\re they committed Lo
help cataly-.;r,c change in their c111111111111it ic~? :\r e th ey willing to share power with the
comm unity :md trcot them as p a1'lncri; ;md not j ust as recipients of health services?
Are they willing Lo learn ho\\' to \\'ork ,,il h th r~ c:nrnm11nily as partners?
CHNs should take a ffirmative actio ns to h...tp com rnu nit ic:s a1tai n 1he: gm1 l nf PHC and
]1ea]th prnmotion-imr>rovcd henllh n nd qua lity of life.
N U RSING PRACTICE IN THE COMMUNITY
Nursing practice in th e c<>mnrnnity c nt;1 ils th e utili~atirm of a number o f processes
to respo11d to the hcnlth 1u:cc.ls ancl problt.:111s of clien ts, m;111agc hen lth progn1111s nnd
resources, nnd infltwn c:e clccisions tlrn l :ill'c cl l he deli ve ry ofhc:illh and nun:in~ servic.:c.:s.
And to he cffcc:livc. c:n1111111111 ity healt h nurses should ;rnhsc.:ribc to LIH! pri1wiplcs of
equity, participation, and in vo lvemen t oflhcir dicnts in 111aki1 1)!, dm:bions 11ho111 hc:1lt h
care. As Leon.ird pointed 11111, ltt:nlth L':1111101 he im proved just hy mere p rovision of
health s ervices. NurS<;:s and dic11ts shrn dcl h e p;irt 11crs in work ing fo1· the ac: hicn,m,m t of
the latter's health go,1ls (2000:95). Clwptc r 5 cl:1hornt cs on the p:irtncr ship appro.ich
an d the parLicipa tory ,1ctio11 methodology from a nursini;; perspcctivc.
Table 1. 1 presents lhc different processes that arc important i11 conlrihu ting 10 the
attain m ent of the go;ils of co111mu11 ity lwal lh. There arc lhn.:e major targets or foci of
nursing ac l ions or pmccsscs- c lic nts. hen Ith cnrc un it uncl political lc,11.len,/dcc:is io11
makers. The processcscngugcd in byCHNs inc:lude: n ursin)!, p rocess: progra m planning,
implementation and evaluation: henlt h educ:111 ion : 111:111age111cnt and i- uper\'ision;
quality assurance; research; nnd, ad vor.acy c1nd p olil iail :icl ion. Lc;ic.lcrsh ip cuts across
these processes.
-
F.ocusJ.tanzet
, Gllents _
'.
,,
:
.
• NursJng process
.
,
Processes·
• Program planning, fm pleme ntatlon, monitoring and
,,
evaluation
• Health edu·catlon
~ '
.
'
- . lijealtn'.care unit (health
center)
-
.
• Management-and super:vlslon
• Quality assur:ance
• Nursfng.researi.h:/,health systems research
- - -
I
Political leaders/
1,
-
• ~dY0Cl!CV and politic a I action
decision -make rs
'
- .
Table l,.1 Processes In community health nursing
A comm on element in all of these p rocesses is critical t11inking because t here are
no hard and fast rules to use with diffcirent clients an d siluations. Even so-called
standards could not capture all the 1x,ssible situations or circumstances in lhe field or
workplace.
33
Critical thinking in community health nu rsing
Because of thecomplcxil)1 of problems, issues and concerns tJ1attheyface in t heir dayto-day professional practic11, nurses need to th inlk criticallv. l>andman and Bandm an
(1995:7) defined critical thinking as the ''rntional e:rnmi;ation of idens, infe re nces,
assumplions, principles, a rgume_nts, conclusions, issues, statemen ts, beliefs and
actions". l11is means that mirses shou ld not accept as true o.r co rrect somell1iug s imply
because others say so or continue to do certain things because these l1ave bee n done
by their seniors.
Critical thinking in nursing means U1at nurses sh.ould: (1) use the processes of critical
iliinking in all of daily lh>i ng; ( 2) discrimina te amo ng the uses and miimses of la n t~uage
in nursing; l3) identify and formulate nursing problems; (4) analyze m eaL1ings of
terms in" relation lo their indk atio n. their cause or p urp ose, and the ir s ig nifica nce;
(5) analy1.e arguments and issues in to pre m ises and conclus io ns; (6) exam ine nurs ing
assumptions; (7) report data and d ues accurately; (8) ma ke a n d c heck in fe re nces hascd
on data, making sure that the inferences arc, al least. plausil>le; (9) fornm la le imd clnrify
beliefs; ( w) verify, corroborate, and jus ti fy claims. beliufs, coucl usio ns , dec is ions and
actions; (u) give relevant reasons for beliefs and conclusio ns; (12) formufale an<l clarify
\'alue judgments; (13) seek reasons, cdtcri a, 1111d p,rinciples that e ffect ively justify value
judgments: and, (14) evahmte U1e soundness of conclusions.
Nursing process
Nursing process is the main framework or guide in n ursing practice ru1cl the
means by which nurses work with clicnt-partn.e rs to enhance wellness or address
the healtb needs and problems of lhcir clien ts. Jl is a log ical a nd systematic
way of processing information gathered from d iff'erent sources and translati ng
intentions into meaningful actions or interventions. There are five p hases:
asse.~sment, diagnosis, planning of outcomes and in te rve ntions, imple mentation
and evaluation, The nurse starts with the establishment of a working relations hip.
'111c nursing process by type of client-parlner is well illustrated in specific chapters in
the book.
Establishing a working relationship
The relationship between CHNs nnd their clients lasts for m onths or years; it d oes
not end after tbe resolution of a health problem of the client. Particufarly in mral
communities, PHNsare either personally related to their clients or the latter are friends
or acquai ntances.
Establishing a working relationship based o n respect, tn1st, s hared goals and cla'rity
of expectations results in posi tive outcomes such as good quaUty of collected data,
partnership iu addressing identified l1ealth needs a nd p roblems, and satisfaction of
the nurse am! the client in wu.rking loge LI rer.
Assessment
Assessment is the process of collecting, organizing a nd analyzing dat a/ inform ation
about the clicnl. The CHN should collect nor just q uantitative but also qualita tive data.
Qualitative data gi\'e a more in-depth underst:tn<ling not j ust of the cl ie nts' health and
nursing problems but their lived experience. Qualitative data represent the clients'
perspective while tl1e quantitative data are collected from the nurse's poin l of view.
34
Tab le .1. 2 prese n ts t h e basic d a ta/ inform ation that need l o be collected b y ty pe o f
c Hen t-pa r h1er.
Ln a:ssessing p opulation groups, other data s hollld b e a dd e d , par lic ul.u:ly o u lbe ir
con text. For exainple, assessment o f worke rs s b o uJd a lso foc1,1s o n f:ictors snch as n at ur e
of thei r wor k, imrne diotc physical and social environm e n t, exposu re lo occupat io nal
health ha7.a r ds and h c nltJ1 r esources.
A s sessment
lndlvldua l
Famlly
Com munit y
Heal th Status
Knowledge, attitudes
and practices (KAP)
Adaptation Propess
Pattern
Lifestyle
H elp-seeking behavior
lJ till:z:ation of health
services
Family structur e,
charac:ter,stlcs .ind
dynal7'ias
Socioeconomic and cu,ltural
characterlst1cs
Environmental fac~ors
He;:ilth stc1tus of each
l:)emographic, c;ultural and
soc:loeconomlc: variables
Snvironmlc'rrtal factors
1-1<.>al th nnd lllhCS!\ patterns
Commun1ty resources
Community compet ence
Examples:
• Parrticlpali on
• Mechl n ery for
focllltatlng Interaction
and dec;islo,,-maklng
• Articulateness
n 1ember
Values and practices on
health promotion/
ma fntenanc.. and disease
prcv-e nbon
Compelenctes on famlly
he,3lth care
• Conflict management
.
Reasons for t he failure of
p>ast health programs
Ta ble 1.2 Assessment d ata for lndlvldua l s, famllles and co mmunities
Diagnosis
Diagnos is is the id entification of the clie nt's wel ness stl'ltus o r n eeds an d p r o blem s
based on a n analysis of the d ata /infonnution gat11ered. A CHN formulates a nursing
diagnosis. Nursing diagnosis was d e fined in the 121" North Am erican Nur s ing D iagn osis
Association (NANDA) Co nfere nce in 1996 as " a clinical judgme nt about in di vidual,
fam ily or community responses to a ctual or poten tial hea ltl1 pi:oblerns/l ife processes"
There wer e 165 NANDA nursing <liagnoses in 2003-2004 ( Danie ls , 2005:221.;
1513- 1514). NAN DA·s focus , h owever has b een at t he indi,vidual ral h e ,- than co1nm u nrty
level of diagnosis. Refer t o t h e Typology of Nm·s ing P roblems in Fa1nily N ursing
P ractice (Chapter 2) and the three catego ri es of community hea lth nursing p1·oble m s h ealth st a tus problem s, h ealth l'esources p roble m s and hea lth- r e late d p r oble m s, jn
Chapter 7 .
Planning of outcomes and interventions
P lanni n g is a logical step-by-step process in designing a p lan of action to accomplish
s p e cifo.: goals and objectives (Allender and Spra dley, 378). Desfred o u tcomes c ould
be in terms of a person's hea lth, k n owledge, attitudes and practices , a n d a b i lity to
cope ,-vith problems. ( R efer to Ch apt e r 3 for developing family n ursing care p lan and
Chapter 8 for p lanning for commu nity heal th nu rsiug programs and s ervices.)
Obje ctives of care which reflect t h e d esired outcomes, should b e s p ecific, m e a surab le,
attainabl e , realistic and bave specific ti me frame (SMART). The presence of SMART
35
objectives ,,;\l d cfi n ild~· faci litnt,, cvuh mt io u .
Nursing inte rve n tion!'- should: (1) lw appropi-i,1Lc and responsive lo Ille c·omliti1m o,l)l'Ohlcms of tlw c lic11 1 :111tl slH1uld co111i-il.,utc LO th(: a1r nin11wn1 of Llw o li_il'~·I h •~:s: ( 2)
he c ,·idence-hased and n•flccti"<' ~1 fnun,rn~ s tandard s:(:,) h e c.: u ll ura ll_v ~:cns i1ivc and
,\ pp rnpriatt' It> th cdic11 1·~ p e rsona l l'irc11m:;tancc~: a nd , (,1) e11ha11<:C' llw c·npa bili t~· and
cmpowcrinR pol1•nli:il nt" clie nts .
Som e of th e m o.~I common nursing actions or inte rve nt ions inn commu.11 ily selling :1n•:
provision of n11n;i11 g care, counseling , U<!al th eduv:i I ion. c apacity-bu ildi nJ!., L'oord i naling
a n d making r~frrrnls.
If the focu:, is ;i co1umu11ity or pop ulation g ,·oup. :-:ys tc m:1 Lie in tt•rven I it'll u s u;1ll_, takes
t he form of a prnjcct or progra m. Com111u n il_y hca ll h p r ogra m s invol"e Lhc diffenmt
levels of pre\'enlion - primary. sccu11Llnry and ter tiary (l'cfcr to C hapter 7 ).
ln the Jighl of l h l' nnrsi ng proft•ssio n·s efforts to s ta11dan lizc 1hc lan)!. u ug t· th.lt n11rse:-.
use, th en;> arc olht>r 1ax0110mks i11 udclition to t he N ANDA-- N11r:-<ing l n l c1-vt'11Lio11s
Chi:;si1kntion and ~u rsi11g Oulcomcs Classification (Da11 iL'ls. 354-5). C l l N s shcn1lcl b1•
familial' w ith lhes-e taxono mies and use thei r ni;.c n cy·s r eeom rnendcd t:lassifica t io n .
Implementation
In tlw nur,;ing process. the im pl<!'nien ta tio n phase co n::;ists of do in g or ca1-.-)·i11g n111
the intl'.1'\-Clllic>ni-: sµec ifi.ed in tlw <'an• plan in p H1·t rwr,-;hip with c·l i0nl -p,Jrlm:n-- Hllll/o r
other rncmb~rs of Lite team. 11 im·oh·e~ ,~nhnnri ni,: c-li<--nt- pn rt 1wrs· :thilil_\' Lo 1111lcu:; h
thei.r empowering put1:ntial for \\'c!ll nes,;. preven t ion . 111;111a1;,• 111C'nt o l' con l n .,I o 1· J •<·al I h
problems. It. ioc.:luJI)~ the use u r pnrt ic ipolory acti o n 11 1eth nd nlogy le> 111 :L, i111izc L'lie111 pa,1 ncrs· cxperit:nces 011 ll\c ~1ook- think-;ict·· ire n 11ix•e <'-'1)C r ie n tin.J knrni11g cycle.
Clif•nl· part ne r compe te nce is ;1ch ie \'e d I h rough .idcq u atc opportunities fo r f)n n_:I ic(•
sessions rui<l feedbae.k..
Evaluation
Evnluntion µhase of the nursing process is u planned. nngoi11g. r 11rpnseful a c tivity
in 1,•hjch Lhe nurse a nti the client-purtne r d c tcnn inc I ha client 's p rc,µ,rcss I,;wa rd
acMevemenl 11I goa ls And outcomes. ll als(l involves e.xu m ining the ol her sl\:!ps of
the nursin,\ process. As .'~ lfaro-Le Fe \TC (:'.!002: J91) ic:uc.:d nctJy e..xpl t1irn,, eva lu,tli n.~
n u rsing care includ es analyzing nursing i nputs ;inti cl ient- partner n ~aliti es in c.,;1cli
step oft.be n ursiDg prnress ( r-ig. 1.1) . Ev.1lna lion is an important nspect or Lhe nursin g
process L,._.causc cnncl11s inns drnwn from tllc e val u:ition de t(o!.rm ine wlwt her Ili e 1111 rsi n g
illterven tions shrndd b e le r m i111.1L t:d. c::011 ti1111 e d or c hanged/ m o difi c ~I. Ev,dua1irn1 is
continuous. Evalualinn done wbilc or immediately after implc111c11tiug a n11 rsi11g
inlerventfon em1b les th e nu rse and client- parlncr lo m:ike o n-Lh e-spv l muuili.:;,t iuns
in an inte rvention {J{n:;.ie r ;md others , 2004: ;i 18).
·11,e focus of 1:val11::ition in the care of individ ua ls a re: qua lity of life, fl.1nc tiomd ,;!al us,
patien t sati sfaction. cu mplinn ce mea s u ,·es, and im pacl o l' c:duca Liomd i u I c r vG n tiorn;
(Alfaro- Lc Fcv rc , :wo6:23 4 ). Tlwsu rtre the brcJ.i<l arnas con H1ined in Lh e nb_iecli\'c!' o l
n u rs ing cnre. ln family he alth nursing, the n urse uelen11ines the exle nl l u w bicl , the
family eould perform it s health tas ks lo 11wi11 Lai n wellness or to addn,ss s peeific h e~dt h
threats. health deJ-icits, ro nesel!ahle c-risi,;: / st ress-poi nts.
In eva lu ati ngprov.nuns. Lheevahwlor look<. into t he inputs, processes a 11d/01· oul con H; ~.
Inputs are the importan t resources the progr;im canno t do without (e.~ .. I ron a nu
Vita1T1i11 A for .i n ut rition progrnm :cind va ccines ror ;i n immunizaliuJJ p,-ogr a m).
36
l' r n,,,,.-<.<C':< 11rc imporl:1111· ac tivit k-s of the f>l'OAT":-tm . Th f• o ultT>m es o f a prn?,ram are
rn11p11l:<. cffe l'I S :r n cl im p:11·1. n 1111w ts ;1r,• t lw sp,•<"ilk p rc>< h1.-~s n r s <·1-vkcs w h it'h ;Jn
nf'ti\'i ly is cxpc·elcd to prmh1c-c• !'rnm ils i11 p11 1s to adlit!\'C its o bJcc li vcs. /;'[(cc/fl arc the
l'l~Ulls o f lhe 111'!-' of prn.iL'l'I Oll t pl llS. ITIIJ )(I C: ( is l h c O II IClllllC o f pro~um e ffects and is
:111 <Jsprcss ion
broad er. lo 1w,- ra11ge p ro!-!,r:1m ohjcc1ivcs.
ur
EVALUATION
l\sse,srnqnt
J. Deler111111e
whether there
,1re changes in
he;ifth status.
2. Make sure that
esses:s n1ent data
,., re acr.urate and
cumplete.
Diagnosis
Pla nnin g
lmr,lementotlon
1.0eterm1ne
1.Determine
if p~oblem/s,
requiring
n ursing care
arc reso lved,
Improved or
con tr.oile d.
rf thE'
1 .Analyze how
the plan was
,mplamented.
2 . Dt!termine
vJh<1t fact ors
:ire re tared with
the success In
lmp lementtng the
plan.
2. Con~ider' if
there ere new
p roblems.
i ntcrllentions
are approprl.ite
.ind adequate
tq <1ch leve
client
outcomes
2.Speclfy
th e client's
status base·d
on expected
out comes of
c iire.
3 , Specify what
fai:tors cmated
problems or
ba rriers to care.
Fig 1.1 Application of Evaluation by Phase of the Nursing Process
Documentation
[L i,; nut e nou gh to :issess, <fo1gnose, p lan. imp lement and evaluute. CH Ns sho uld
d ocumen t a l l th e things t ha t they <lid a nd the corr es po nding o utco mes. Their
dnct1mea1,1tio n s hould ind udc th e fo llowi ng: client assessment and hea lth need s/
probh ·m s idcnl iued, inte rven ti o n~ c::i n ied ou l, client response to interventi ons,
outc:-u1tH.s o f i11ll'n·culions on <l rutu re plan of care (Clark. 1999:209).
l n the h e;1 ILh 1.:enle.rs, it is als o impo rtant for t he PHNs to document what they do,
w h e t her clis.·111-t;cntcred , pro.g1·am-rebted or un it-centered. They sh ould d o cu m ent
th ei r inn,w:tt inns, tb cLr pmticipntion in multidisciplinary endeavors nnd thei r e fforts
in sha ping policies or influe ncing policy m n kcrs.
O f llt1;: djffer en t r es po nsibilities of t he CI-IN, documentation is conside red b y many as
lhe least p r iMi ty; ii is an nd clitional '·burden". H o w ever . no matter how it is \i ewe d by
prat: Lil ioncrs, cinr11menl ai-io11 i s still a n impn rtnn1 cnrn pon enl of the nursing process. It
sen'!'-" a 1111 m be1· of rnncti o ns, am ong whi ch a re : ( t ) it scrYes ni:; a ··proof· of th e t.hin king
and 1!1wis inn-1m1king th at n 1irse.s do; ( 2 ) i t co11lrl protect t he n 11rsP frnm n law,;uit (it is
ge nt•ra lly believed t hal w h at is n ot written w as not don e); (3) i t ){i \"l!S d ecis ion m akers
an id ea o f tlw wu rl,;lo,1 <l o f I1L11·ses; nn d. (4) it provides inform ation 1h,.11 cou ld be used
in n:s~arch .inti q11.:ility a ,;sur,111c;e acti,, iti es a n d fo r lrai.Jti.i1~ purposes.
37
Program planning, implementation and evaluation
T o nd d ress Lhe needs and problems of the co mmuni ty 01· s pecific popu la tion g roups,
Cl-rNs, 1011,eth er ,,ith ot her hc,d th worker.:; participa te in tl ,t:: planning, implem e n t ation,
m o nitori ng and c>,·alua lio n of he;1lth prpgrnms. (l'rogram p lanning implem e nlalion
and evnl uation .ire cfo;cusscd in t:ba pte:irs 8 nn d 9)
Health educatio n
H eallb cducntio n isoneoftl1c s tT,1lcgies ofh ea ltb promo tion nnrl a major function and
in tervention of a Cl JN. G nat.:n and Kre uter d efi nc h ealth educa ti o n a s "any co mbinatio n
ofl carni ng expe rie nce1S J-,sign ecl to focil'i tnte voluntary actions conduci ve t o h eal tb tha t
people ca n take o n tlll' ir '"ni incl ivi cl uall_,. o r collectively, as citi;,.cns lo o kin g afte r th eir
own henlth o r as dt,cis,on ma ker:s looking a fter the he:, lth of o the rs a n d t he coJJ1mo n
good of the co1mm1ni t< l199 1, in ~'lec1d c. 1997:156). T h e go nls of h eullh e duc., liun
incl ude : ( 1) c.lien r p.o rtid pati11 11 in henl t.b d ecis ion 111:iki ng; (2 ) increa sc,, J po te nti:i l to
com ply with ho.11th rec:o mmc nclations; ( 3) d e\'elopme11t o f self c.J T (;? s kills ; ( 4 ) i mp roved
clieJ1I an d family coping: (5) increased pnrticip,Hion in con ti n uin g care for s p ecific
cond itions; and. (6) adoption o f healthi e r lifes tyles (JCAHO in Cl,1rk, 2008:263).
Management and supervision
CHNs i11 different levels pe rfo rm diffei:-ent m anagem e nt and s upervis o ry func ti o ns. A
general dd-inition a nd descriptio n of man age m e nt function s m ay be th e sa m e but th e
scope .ind le\'el or acthilics done m ay b e diffe re nt for ench leve l o f n,an,ige m e nt.
Quality assu rance in commun ity h e alth nursing
Toe pro,·ision of q mtliry c..ueis a profossio 11:1J re.sponsihili l)'· I t is not e nou gh Lo ensure
the d e.li"el')· of ba~ic heal th services a n d implemen tati o n of public health progra ms.
CH?\s. rogc-tbcr witlt olhcr health workers s hould e n s ure th e qua lity in h ealtJ1 (and
nu rsing) care. ,\!lender and S prad ley, ( 200 1 ) ide nt ifi ed five rea son s for do i1.1 ~ qual iL)'
measuremen t and im provem e nt io commu n ity h e~ ll h nurs in g: ( 1) pro fess io n al s clfr egtJlntioa of c linical competence; (2 ) ce rti fic;ition a nd accred itati o n ; (:3) legis la tio n
and regula tion: (4) reimburse m e nt; and, (5) C:C)nsu mer d e mands .
'
For a m ore detailed d iscussio n ofmam1gement in publi c heal ti 1, r efer lo Ch t1 p le r 17.
Research and evidence-based nursing practice
T o improve the quality r,f nursing se rvic.-.es in th e commu n ity, the re is a ne ed l'o ado p l
evide ncc-hased practice. Evidence-based practice is tJ1c ''con scient ious in lcgra l·ion
o f be.,;;t r e.~e:i cch e,; dence with clinical exp e r t ise and p:Jlic nt v.:du es aml n eed s fo r the
d elive ry o f q ual ity, co,;1-e ffr:c.:li\'<: h1:ol1h ~ re " (Sacke lt und As1;1>c.:ia tes . 2 00 0 i n Burns
and Grove. :zc,07=50 0 ). E,,den<·e-ba.scd rwr.'ling, the refo re, is" tJn: procesi. b y w hich
nu r.:es m nJ:e clinkal dcci,;in nq usi ng lh e be.~t av;iil:thl c research evidence, th e ir· clinic.al
e>.1>ertise a nd pa tien t prefere nces (U ni versity of M in nesota. in S impson, 2004 : 10 ) .
There i,; a nef.'d. th e refore. for Cl INs to e n gage o r pnrti6p:1te in resea r ch. T o b e able to
int ~grat e tJ,c• best resc:1rch evid.,nce into practi c1·, they s hould h a ve wo rkin g kn owle d ge
o n research con cepts a nd processes and s kil ls to be a h ie to critiqu e publis11e cl r cscnrch
rep ort s .
CH Ns also <.'Ond uct research with the co mmuni ty to gen e rate kno wled ge t h;1 I U1e la t te r
can use 10 inilue nce policy a nd decision m a kers. They ca n s erve as resource ·p ers o n s in
38
th e commu nity's rcsc.1 rch activities.
Research in community hea lth serves a n umber of purposes, among whid1 ore: ( 1)
improve our understanding of elicnts and their specific contexts; ( 2) provid e data
needed frn· prugrnn1 a nd policy developmen t and cvnlLL.atfon; (31 s upprn-t ad voeacy
and lobbying for speeilk pc.llicies; ( 4) improve the delivery of l1 ealth service.s and
im pleme ntation of existing progr:uns; ( 5 ) improve cos·t-effective ness of programs;
an d , (6) project a good im age of nurses.
Advoca cy and political a ction
Advocacy is an et hic;il and professionaJ responsibility. The American Nurses
Association (2007, i.n Clark, 2008:6) defines ad vocacy as .. th e act of ple ading or a rg u.ing
in favor of a cause, idc:-1. or policy 011 someone e'lse's behalf, w ith a focus on develo ping
th e com m un ity, syste m , individual, or fa m ily's capacity to ple;;id th eir own c;rnse o r act
on thei r own be ha lf'. Po licy advoc:ac..-y is a very important modality for influencing the
l,eallh o f p eople (Williams, 1991:619).
Community hcaJth nurses arc in a very stra tegic pos ition to speak on iss ues that
di rect ly and indi rectly impact o n the hea lth of th o community. But in doing :advocacy,
th ey uphol<l a cJie nL"s nut onomy, wh ich m ea ns that th ey reserve for their clients the
right Lo make th e i.r· c,wn c.lcc:i.sio ns . They just Lr;rnslate am] ::u-ticulute tli e prob lems,
as pirntions. he,alth and illness cxpcdcnces, t he perspectives and positions of their
c lients, particularly those w ho are vulnerable, to health p lanners and policy m akers,
unti l s u ch t ime that the clien ts can do these for LJ1emselves.
Nol too long ago, the preval1en t view among n urses is t hat politics is outside the
concern of nurses a nd it is "unet l1ical' lo engage in politica l actions. Politics, t hen, was
associated wi th '·activ is ts" w li o w ere viewed negatively by 1nany nurses. Today nurses
getting invo lved witl, politics are uol frowned upon anymore.
0
Being politicHI m eans spealdng up and rneeti.og ,v;th politicia ns. Nurses should aJways
be adcquutcly prcpared-witl1 accn rate a n cl up-to-date data/inform ati(ln, researches
and sou nd 1.1ss11111pt ions an d reasoning; b etter if th ey h ave well-written and engag ing
position papers.
Political nclion requires a good working kno wledge on the workings of tbe political
syste m and the dynamics of policy-making both at t he local a nd n ation al levels.
COMMUNITY HEALTH NURSING I N THE PH ILIPPI NES
Mus i of the cC)mmunity heaJtb nurses in the P h ilippines work in heaJth centers as
. public healtJ1 nu rses, industries/companies as occupatio nal health nu rses (company
n u rses) and school nurses. Few of them work with non -government organizations
(NGOs).
T h e roles and functions of nurses are defined by the nursing law (RA 9173) and
standards that are developed by profess ional associations such as the Philippine
Nu rses Association (PNA), Occ upa ti o na l Mea lth Nurses Association of the Philippines
(OHNAP) an<l th e National League of Philippine Government N u rses (NL PGN) and
agenc.ies such as tbe Department of Education (DepE<l).
39
I I
I
I l
Public health nursing
I
PHN5, togetl1cr witl1 the oth er members of 1he healtl1 te.1111 , arc t he implementers
of th e luc:11 ~ovcrnmc nt units' mand at e in pn1nmting and proter.:ting t h e heal th of
their <·011slit111m 1s. They parlicipnlC' in the pla nning, i111pleme nt ;llion, monitoring
aml cn1lu:1 li11n or t ht• LOU'~ 111•:tllh progrnms. They HC1' n;; proi;.rnm 1·<w rdin r.i tors of
hcalt l, progra1m,sud1 ~s EP I, T B C:1nllro l Pl'Ogn1n1. Lcp rns,-Cmitrnl progr n m, e tc. T h ev
also deliver nursing services 10 indivithia ls in t he hea lth ccn tcri.;, :,;chno l5 a n d h ome~,
incluclini; he.i ll h t:dut:11ion. The fum·l ions "'.1~1 ,tc~ivilics o f PHNs contained in t h e
resource manual Trc1i1d11g C11ul'sc on S1111eru1s1011 Jor Lhe Public lfrullh Nt1l'se ( l 99,i)
are lis ted on the foll01\ing page,;.
PH~ FUNCTIONS AND ACTIVlTIES
Monagemerit
1. Plans ~nd organizes the Jl.l.lr&lng.senllc;e of the health UFllt .
1.1 tdemil!es problems ralatell to clients, re:;ourcei;, program
Implementation and .service delivery.
1.2 Prepates the nursing servtce plan.
2. Participates.in t he preparation of t he m unlclpal he,alth plan.
3. Participares In the l111p/ementation of the municipal health plara.
,
4. Implements the nursing service plan.
,.
,
,
:
4.lCOordlnates with the different health units and related a-ge'ncles ~nd facilities.
4,2Delegatesthe task to the mldwive,, ff,nece55_ary.
,
.\'
, .,.
s. Monitors and eval11ates tile lmplep,eDta~oJ1 ,o.f th~' J'lursin•g ·se~vlce plan.
.,
6. Initiates chal)ges for the Improvement\o~ services. '
7. Manages-the RHU In the a.bsjnce of tile r ut'al health physician (R\-IP). ,
rralnfr1g
·
·
··
Participates in meeting.the trainIns needs of midwives, st uoent ¢Hllate;,; and ot.h e r "
tTalnees.
·
,
l. Ptioriti;es Ifie identified needs of rural he.11th mldWlves (RHMsJ that can b.e ad dres
"".,.... In
•rM • " ~
'
2. Or1111nlzes ii 5tilff develcpmenJ program for ~HMs.
l Condu$a staff educationprogram 0< GOA¢hlnB
4. Evaloates effects of tral11"11 on wort perfarmance,
.
.
,
·
,
Sed
sei:,,on.
Supervision
Supervises the l!HMs:
. ''
' '·
'
I
l .form1111tes uuper\lisor¥ plan.
1.1 ldentift§fKtor~affetlln,.tf!e ~ J ~o•and-,Jol). satf~adtlon ot;the
mldwlw!s
:lJ''
1.2 Identifies the needs.-of.tlle ~ ~fa;.:liu ~lon In mlatlo~ to:
congruence betweefi~~a~)~~J1~n1;1I t'oaJs, work situation , 1
motivatio1'JDD,al~ ~ - atlo1'1,.knp.wledge, skllls ahd;'.atti;u...
andperforma11Gen r.,1t~i~._:?."'~·••.i.~,,
l ,3 1dentfffespto,j~
.'
.
'
lA lijeotilie,gb
5tlpe1Vfslon.
1.5 Determines1ndl'cat
40
"es;
"
ervlsorv Visits.
.
-
-
2 . Implements t he supervisory p l an
2.1 Conducts su p ervisory v1,;i t .
2.2 Reviews objective~. target< and norms with midwives.
2.3 M (i)r:ivates the midwlvPs lO Improve performa nce.
Gives recogn rh on for good r,c:rl orman cc: a r1cJ,
•
Provides the midwives opportunities to reollze the.Ir own potcnrtal.
2.4 Provid es technical ~upervlslon to midwives.
•
Ens ures that techn iques and procedures are done according to standurd 5,
targets aro monitor ed, and car e Is prov,de.d and recol'dect
•
Guides the mldw1,,cs in the formuk1tion of barangay health ,pl.:i ns;
•
Reviews bar.inr.u1v health plans +ormu l.;1ted;
•
Monitors the 1mpieme1~tatlon of 1:1,e bar;ingay health plan;
•
Identifies gaps, neecJs ;Jntl problems in tl1e lmplementatior, of lhe
baraqgay health p~an; and,
•
Guides the midwives In instttL1tirtg needed corrective n,easur es.
2.s Performs adm1nist ralion and lc.idershJr, ,1c:twities. Pr ovlde~ adm1nisl ratwc
support:
•
lnterp r-ets pol1cies, guidehne,s. mcmofrlnda and other administrative
issuances; assesses·supp ly o t st'oc:k l evels;
•
fac1lllates acqu isition of logistic requirements; and,
P;llocat.ei; and distrlb1.1tcs suppllcs.
2,6 Performs activlt'ies related ro pel"Sonner man a gement.
•
!nltiatesand part;dpales•ln activ ltfes to promote p erso'n a l a11 d p rofe&Siona
growt'h Caif midwive:.;
•
•
•
Evaluates the perl:orman.ce of midwives; ensures adheren ce to Civil Servlc
Rul es arad Regulatjpns and RA 6713;
Initiates an·d reco'mmends personnel actf0ns such as promotions,
transfers, recommendat10ns,for awa·rds, al'ld other recognition; and,
Reviews and lnjtlals·dallytime reco rds (DTRs) and midwives' reports.
3: rvi.onl tors ~nd eva lua!es midwives' per formance 1n the i mplementation of public
health programs.
3.1 Prepares and utilizes appr opria t e rnonit.orlr(g and evaluation tools.
3 .2 ·Conducts r egular s uperwlsory vislt:s.
,
3.3 Provides feedback t o the. R HP and midwives.
3.4 IJtjl izes results of .monltorthg and evaluation Lo strengthe n supervision .
.3.5 oo·eum!?nts findings during monitoring. and ev;itu ation.
4 . M a intains records and re ports.
4 ,1 Reviews clln lc records and reports .
4 ..2 Va ll dat!es- the completeness a nd accuracy of recl)orts .
4 .3 oveFsees proper and systematic fillna of records :and rep orts.
Prov,fsion of ijealth a n d nursing care
Provid es health a.nd nursing ~are to indTvldua1s, families and communities.
1. Identifie s health needs an(! problems of indlvlduals~ famHle$" and communltr'es.
2 . Fo rmu lates Individual, family -and community nursl ng/healt h ca re pls.tn ,
3. Coor dina tes w ith rn dJVJdual groups and age ncies for resour ce assistance In
i mp[em enting the h ealth car'"e plan.
4. lmPcle ment:s health care plans. for lndlvldua1 s, families and the community.
5. Eva luates nurs ing Int erventions and e t he.r- components of care pr ovided to
individuals, families and t h e communitv.
41
ftf, edUJmton-,
ad:lvltJes.
th edt.tc.ldc:ln Btdvitles on the capablllties of client~.
PSJ orpn(zatfor,s. other agencies and communttfes
8"1.Wati.ble within ~nd outside the community a nd wh ich can
e fn:IR~rnentatron of lndMdual, farn;ty and community health
to other he;1lth personnel, health faclllty or govemment agency.
~~ .JXJH. Trafnlng Course on Superv;slon for the Public Health N11r~e
~roe Manual. 1994
Occupational health nursing
Occupation11] he,1ltl1 nursing is ''aimed at assi s ting workers in all occupations to cope
with actual and potential s l1·csses i n relation to their work and work environment. It is
primarily geared at helping workers attain and maintain optimum level of physical and
psychological functioning " (PNA-ANSAP, 1982).
Book IV of the Labor Code contains provisions on health, safety and welfare b enefits
for employees. Section 4(b, c, and d) of Rule 1. states that if a com p a ny has more than
so workers. the services of a full-time nurse should be provided. A comp.a ny nurse
wbo is a r egistered nurse, shoul d p referably l1ave training in occupational nursing
conducted by the DOH, University of·ttie Philippines Manila College of PubUc Health,
or any organization accredited by the former.
The major considen1tions tn occupational health nursing p r a c tice are laws (such as
PD 856-Sanitation Cone of the Philippines), policies and standar ds (e.g., Department
of Labor and Employment, Department of Health, Social Security System, Philippine
Health i nsurance Corp.o ration and Employees Compen sation Commission) and
professional standards s uch as those developed by the OHNAP and the PNA.
The standa.rd job description or statement of the duties and responsibilities of
occupational nurses has been formulated by the OH NAP. The duties and responsibilities
are grouped into four headings --curative/pal1iative, preventive, educative and
admLnistrative functions. The mnjor a reas of concern of occupation a l health nurses
include: emergency and palliat ive care, fomj]y planning, co unseling, immunization,
environmental sanitation, wod, safety, disaster prevention and con-LJ·ol, orientation of
new employees, and dissemination of bealtb inform ation/ health educat ion. In s mall
companies, physicians are either totally absent or are just worki n g part-time. Because
of this, nurses are ,Llso in charge of a n u mber of administrative functions (OHNAP
I
I
2002).
School nursingSchool nursing aims to promote the h ealth of school personnel and pupil/students. It
aims to prevent health -problems tbal could h i nder students' learning and performance
42
of their developmental task;;. l lt•11llh. in this partleulnr instance. is considered ns an
important resource in cduration.
The major con;;itlcratiom: in sdwol nursi11� practice i11clude l:,ws such as the Child
and )'outh Wdfan• Co<1e ( l'D tw:,) and Letter of tm<I n1t·tinn 7(J•I [rlcrlnrin,.: the School
°
Health Pro�ram th,• priority pro)!.1'11111 ol the nnlionnl i;ow ·rnntt.mt); policies and
standards ,,f the lkpa11 n1cnt ,,f Ed11c:1 I ion ;u1J the t Hl I I. and .sl:lncb rds nf the 11 ursing
profes.'<ion. And probably nmn· import.int i ntlu,·nc,·s an· I It,;- scwioN·onn111it: rca.lit ies in
th esc:honll'. home.'-, co11111111nitir;:. nnd l,w,11 gm·L•rnmrnt units (1.<'ills).
Jusl like workt·rs i.n their workpln,:cs. :<chool ehildren who nn: in school ;ire 1,;c111·r.illy
well. For this reason. llHlst of the :1et i,ities of sdu,ol 1111rs1·s arc fnc11st•cl 1111 hculth
advocacy. health promotion. di,,,•asc 1')rc,·1•n1i,1n and ('arl_, , d,•t.."<'Linn 11( di,;<!r,s,·. More
specifically. mirst•,-; p,·rform: r 1) hl·:ilth and 11111ritio11 :1,.:s1·ssmc11t. s<.-rct•11i111;, :111d l'.:lse­
fin<lin,;: (:!) ln.'al111l!l1t pf l'llllllllVII ail llll'lltS and :II l<'lHlini: to l.'llll' l").:("llt'.)' C';1St,'1,: C:-1)
counseling and he,1lth L'dlK':llion: (.1) 1111r::;ini,: proccdurc:;;: (5) supen'isi(>n ufthc health
. _ ,;chonl: and (6) reforr,1ls nnd foll,iw-up,: of pupils and personnel.
and safety o( the
On top of these. the nurse rna11agc:-< lhl! sc.:hool clinic, nmnitnr:-: ;111(1 evaluates hcallh
progr:,ms and projccls,
For 11 detailed prc.�entation of the nctivitics vf schvul 11111"ses. rcfur lo Ch.ipter 4 of the
NLPGN 's book l'ul>licllealll1 Nursing in the Philimii11es (:2007).
<;OMMUNITY-BASED CASE MANAGEMENT
W'hile there is no clear agreement :thnul thr dcfi11itin11 nnd romponcnl aclivilies of
case numascm,mt, it.<. Ust.! i:-: bused nu the ussumption that people with eomplcx he,ilth
problems need :1ssi:;tnnce in usin1-: the hl!althc.1ri- s�,slcm dfr,·tivrly (Rheaume and
others,.1994). Casemanagcmcut isnhou td10iceandc111powermcn1 for people. To achieve
these, case managers ncJ.?<l to be accessible and act ns people',; advoc:itc (Thornicroft,
•
1991). Bergen (1992) divides 1-ive tlisti1u:1 phases of ca$c finding. assei-smcnt and need/
problem identification, desi)!.n and implementation of ca1·c pac.ka1-:cs, monitoring or
reassessment, which lead to the last ph.asi: of case doslu-c or repetition of the cycle. The
responsibilities of the case mana�er, are, therefore, to assess, ,uonitvr. nrnluall r plan
and nctivate intesventicm::; and coorclinntP. hc:1lthcare services to the indivi<luali z.ed
needs of patients and tl1cir families (L::thridgc and Lamb, 1989: Gibson anJ others,
1994). To achieve this, Meisler and M idycttc (1994) specify live roles of n nurse case
manager: manager. clinician, consultant, educator and resca.reher.
.
A manager's role involves financial accountability in terms of evaluating and monitoring
costs and resources. As a clinician, the nurse case manager develops and manages plan
of care for a specific patient trpe or population thrnu)!.h cnordinating with hoi.-pital staff
for the discharge. plan and the rest of the team for th1:e hornc-base<l <:are. As consultnnt,
the case m1111ager collol)oratcs with the multi-disciplinary le.am, sen.:cs ,1:; a patient
liaison, offers clinical support nn<l expertise, coordinate.., consnltatfons and encour:iges
ptltient and family pnrLicipation. The cducntor's rnlc inclmlcs explainin g the use of a
patient's care plm,, involving tbe entire team in the total i:wocc,ss of c,q1·c and updating
the team of practice cb.an gcs. As a researcher, Lhe cusc ma11np.cr rontinuously monitors
and evaluates outcomes and costs.
Case management aims to acl1ieve quality and access wh.i1c nutna)!.in g cost in a seamless
healtl1 care system. It is a systernatit 11rocess llrnl hopes to achieve cost effective, high
quality, comprehensive health service." for clients across a continuum of care.
43
Sl;<:tm•o;u wilii CamSt;arn11::1
5·
/\_n<l ersnn. r-;.T. (201,oJ. "A mndcl to �idc practice:- in ET A.nclcriaon and .I
McF:1r lnnc (Eds) C:rnnrrwnily us l'c1rtner. :i-·• c<l. Philadelp hia: l.ipr,incott.
6.
Arroyo, G.M. (:mo8). "Stale of the Nation J\tldres.-;~, The Philippine Slur.
8/o:',/oR.
7.
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and Stmtcgics. A�ian Development Hank Ecrmomicsand Research
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8.
•·,\ 5 tidc in human development"', �wloriaL Philippine Star. 2/28/08.
9·
Har1dn1nn, E.L.. &: Bam.l111an, B. (1995). Cr·iticul 111inking in ,Vl/rsing. 2•• ed.
Norw�ilk. Connecticut: Appleton and L;inge.
,.knk Charter for He:1lth Prommion in a Clobali1.ed \.\.Qrld. Si-..1:h Global
Jo. g, 111 "'
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1 1.
g,,utista.V.l\., Legaspi, P.E.. Santi.ago, F..V.. & .Juan. L..J. (2002). National
and f.,r,,al Covcr11mc:111 Roll!S in Public Heu/ch Under Devolution. Quezon
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,
1Jc:111ehnmp. T.L., & \,\'alters, L. (Eds.). (1994). Contemporary /ssue1; in
-· Uioe
tltics. Bdmont. Californi:i: 'Wadsworth Puhlishing Company.
I ••
l�j-
Bergen. A. (1992). Case management in community care: concepL,;. practic�
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J 1/1ilippilf(: f)aily Inquirer. August 30.
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J-lculth. 5"' ed. Upper Saddle River. New .Jersey; Pearson Education, Inc..
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:.!l.
Dnnicls. R. (2005).N11rsin9 FuindamentuL,;. Curing and Clinical Decision
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46. Me isler, N., & Midyette, P. (1994). CNS to case manage r: broadening the
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49. National Economic.Developmen t Autbority. J\fedium 7'e1·m Development
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50. National Economic Developme ntAutho rity. Medium-Term Dcueloprnent
Plan 2 004-2010
51. Natio n al League of Philippine Government Nurses. (2 007) "Standards of
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Philippin es. Manila: NLPGN.
52. National N utritio n Council. (1994) Philippine Plan qfActionfor Nutrition:
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54, N eedleman, H.L., & Landrigan, P .J. (1994 ) . Raising Childre n Toxic Pr ee.
New York: Avon Books.
55. Occupational H e alth N urses Association oftbe Philippin es. (2002)
R efer ence Manual. Post-Graduate Co111'sc in Occupational Hea lth and
47
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(l
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Dc:1ucha m p, T.I ~. &. \ V,d t,·~ . l.. ( f,:cl,.) ( t •N I l. <"c •rrr,·nr1 -, wt.11·11 Js -:u,•~ irr
Rirn•thir:.<. Hel rno 111, ('a l, for111,, : \\',1d -.w111 I h 1'11 h l1 ,(1111r l ·11111p, m J
1:3. De r gcn . A . ( 1992) . Cai:c· mana~ em, ·n: an r-1t11111u11111, . c.1r ,· n llRL' pt:-, pr.rc t 1,:,·-.
nnd i111plic:11io n fnr n11r.-:i n~. ,l r>11n1,il "' \ ri1•rr1w1·, I s,11-,,111,1 1-. 1 ,uo- 1113.
14. Bu m !;, N .. & Cron•. ~ .K. (:iocr). 1 ·•rrli ·r s t 1w,l111t1 '\'11r,,im1 l frs t"t1r('l1. r;11/l<fi119
a11 Hr1irlc·1wr- fi(l:;1•d l'l'lll'tic·,·. S I I.mu,•. \l,, ,o nn 1·'. l,,·, u·r
15. BuLl t::r . .1.T . (2CtCH ). l 'ri,wif)f,, P / ll, •rilrlr h/111·tH i1 u1 nm/ ffn1lth
Prvmnrio,1.:1"' ,•d_ lklm1m1. t .\: \ \ ·.,i1,\, 11r1 h Tlw 111-:on l.1•.tm l11~ .
16 . Castillo , R. { 2003). T lw hlAA•"•l 111',dth c.n ,,.,tmplw lht:: world ha-. ever !.ecn .
Philippine Ouilv l n(luirC'f". Aul(u,t :1n.
L7 . Clar k. :\!..I . (20 08). Cu111rnu111t11 l fcci/1/i .Vrirsitr~, .. \tlt·ocuc:11Jo r l'np uict tion
H calrh. S' ' ed. Uppt!r Saddle Rh·er, NL'" ,kN y· 1•..,ar;,)n l-:<luc.111o n, J n c.
18. Cla rk. :1-l..l. ( 1999). Co m mu11i1µ 1/,•a l rfr ,'\·u r s inv. 3 ' t:<l. Sln m fu rd,
Conne,:lk lll: A p ple ton a nd l.·tn~W 19. Cone, :\I. (2 0 0 5) . Sill'n t S now. 771, .. S/vu: P <>i.~u 11i11!J O.,( t J11u \ n •tic:. N i;;" Yc,rk:
Grove Pre$S.
20. Cookfair, .J.M. ( L99 6). •Vursi ny Cc~rr! in zit.: Comm unity. :.i...i ed. SL Louis:
M osby.
21. Danie ls. R. (20 0 5 ) . Nursing F11in d C111h:nra ls. Ca r-i11y cmd Clinical l)€'cis-io n
Maki ng. Singnporc: Thomson/ Ddma r Lea ming.
45
ETHICOLEGAL ASPECTS OF COMM UNITY HEALTH NU.RSING
T_h e p ractice o f co mmunity he.n lth nursi_ng is guided by a n u mbe r of legal nnd ctl1ica l
pnnc1ples tJia Lce nter o n the wel fare o f cUents a nd p ,-olectio n of th e ir rjghts. CH Ns arc
in a po,-ition lo in nuence o ll,e rs to respect ::ind prolecl these rig hts . Nursing practice
is lega l i f l he practili o ncr works w:ithin th e b o unds o f law: it is ethical if th e nurse
upho lds ethic.:,! principles s uch a s auto no my, b e ne (i cence/ non mal efice m.:e, jus l icc,
fid elity an d veraci ty.
Nurses s hould at all tim es .-e:spect th eir clien~· rigl1ts s uch a s th e riglll LU b e infonncd
a b o ut their condition an d tren lme nt o r any health interve ntio n tlrn t n eed s t o be do ne.
The ,· are e ntitled to acc ura te a nd adcqnate inform ation so that the \' could mak e a n
info.rmcd dcc.ision. Cli1mts' refosaJ (e.g., 1,pecific F P m e U1od s) s hould n ot affect their
access t o o Ule r lle:tlth s.-,-vices.
Clie n ts han~ th e rig b t to safe ;ind quality care and nurses can e nsure this on ly if they
are co mpeten t. CH~s. t herefore. b;ive a 1·e spo nsib ility to u pdate t he mselves on th e
la·test d evelopments in health core a nd in com m u oily he alth nurs ing , They s hou ld read
ne"· books, p rofessio nal j o urn als , manua ls ond o ther re lated materials ; and, a ttend
semina rs and confereuces tha t could e nric h tJ1 e i1· pr ofes!;lional prc1ctice. They shoul d
be updated on tbe latest Prnfessional Regulatio n Co mmissio n (PRC) g u idelines o n
con tin uing professional education (GP E).
Clients sJ10uld be treated respectfully at a ll times. The ir rig ht to p riva cy , particularly
du ring meclical or nursing procedlu-es s hould be res pecte d . Th e ir health records are
tre.1ted confide n tially.
r n p rioritizi ng healt11 sen rices a nd activi ties, h ealt h worke rs in genera] s hould be
guided by l'hr p rinciple "the g re.ftest go o d for tl1e greatest numbe r ''. Ano th er p r inciple
that guides th e pro,·is ion o f healt h services, pa r tic ularly in gove rnme.n t -o wn e d health
faciJitY is distrib utive justice. In a ·•micro· setting. t his could mea n "fair. e quitable and
app1 ·opriatc distribution " ( Beauchamp a n d W alte rs, p. 26) of services a nd res ou rces
s uch a,- m edicines a nd m edical s upplies. J'ri m aril)· beca use resou.rces are li m ited. PHNs
s hould be g uided by the e qui ly rule. that is, ( assuming th at t h e n eed is t he s ame) th e
sca rce resources shcrnlcl h e given t o tJJe one w ho is in greate r n eed. "Need" is d ic ta ted
not only by one's hea lth condition but a ls o by his i nability to p ay.
CHNs c.lo not only d elive r needed health s ervices, they also hum anize th e h ea lth care
delivery system as well.
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49
CHAPTER 2:
ASSESSMENT IN FAMILY
HEALTH NURSING
PRACTICE
Araceli S. Nlaglay a
FAMILY PERSPECTIVE IN COMMUNITY HEALTH NURSING
PRACTICE
Communi ty h ealth nu rse>s io 111::iny purls o f th e world lw ve b een u s in g th e fo1Tii ly
persps.>etivp 111 a<ld rl'!'." individual cl ie nts· he;ilth nccdt. or prvblcm s and en han ce
fa mily functjoning for grriw t h and dc,·clo 1m1e11t. cop ing- with il lness or los;.. m 1Jbi 1i7.i n g
r~"VUn.'e$ :ind mainrnin ing a n e n,; r o nmcnt t hat s u p po rt wellr1e,:s a nd health. Eve n
in the western ,,·nrld. lik,• t he USA. wht•re m a n aged ca r e s~·stc m is lJic: stn.1ct,.ire fo r
pa tient cnrt' d,•l in--ry (such a.• bcallh rrrninl t:mm ce organi7.atio n s and i11dcpe11dc nt
prnctjce a.-osociations) renewc,d foc us on the fami ly is e m e rg in g ::ts ins ti tutio n-b:ised
hea lth = re js sl1-,'lljJjcantly decre;:i.si ng a nd h o me care is r"1 pid ly gro";ng .
·111ere an• sc-..:?ral reasons for foc us in~ o n th e fam ily in co mmuni ty h eal th nurs ing
prat-ti.".<.'. ba,-c,d ,rn it" chara cteris tic as a n npen :md developi ng syst e m o f in te ra c r-in g
pen:on:ihties. with a i,,,n1ctur e and process e n :1dcd i11 rcla1it1nsh ips ;imnng incl ividtwl
mt·mber-;. regul:lte<l b\' re!i,:mrce-; an d s tressors, a n d cxic;ti ng \,;thin tlw la rger
oonrnntnity (1'1aurer ;.i;,d !'imith 2005 , p. 2 75 ). The fam ily prr-venL-;. 11,ene rat e.,;,
LOlc11-atc:< and co rn ' rt.<s h<'alth pn>hlt:c11s u mon g iLs membe rs (Fn: e m:.111 a n d He in rich
198 1, p.81'1). It is a pow"rful in flu e nce o n va lu es. b eliefs and practices on h c;il th llnc1
illnes:-. Fo r t•xam ple . based o n st udie.., o n d iabc te!i (C:1m phell 1987 ) , pw11 <lia b.:tic
contt·,,I •~ a_,.,~·.ia tt:tl w iLl1 chronic fan; ilv contlil'l :mcl poor org~ini;,,a t iu ll. b ut th e
s tu die~ dj:s-aRr~'t" a.,, t<J w lietJ11:r tlt ~c fa milies h:.ive low l) r hig h co he:-io n. Ouhamel
(198-:-) t;>x.,mined fr1mih· interactio n ,md li vp c rt e rn~ion and g enerated :1 s ig ni fica nt
hyp<1 thcsi~ that hypcrtc.ns h c 11alicn lS Sllflpt:ess an ge r a nd h ostility . ·n,c s 11pprc'ssion
of th~e foelinp, l~d.s to unrc.snlve:c.l 1110:rital cn nfll c t:, thal rccip r, ,ca lly re in fu1-c-<' I h e
s u ppre;;.-:ion o f iin~cr a nc.l ho<:t ilitv. Ikea use th e fnm il yoper ;1 Les as a sys te m. dysfu m :t io n
in ;, m t;>ml>e r na,w lw , e lat<·d tc, disturhn n ct.: in t hf.' \,·holl' f:.1111ily , Fam ily i11fon11;1 t io n
and part.ner<.hip ~ffe ttM·<l in trat·king d 11w11 t he occurrence and inciden ce o f discnses,
c rir i,:;ll in pn.:,\.'11ti ng th c,;p rcad afc,m1 11111nic., b lc: ,:w,e.<: (J\ l :111 1·e r& S m ith . p. 274 ). ·n1e
fam ily is a c ritic,--u rcFou n·c in m ai nta in ing h ealth and d e li very of l11.:a ltl 1 care b ecau se il
is tlw loc1 1s ,,f dc•ci.sion - 11rnking 11n use o f m nn p o w (•r n nd eto n ornic i-11ppo r t, e.<:pedally
during ill11c.,,_~ o r cr isis. The fa m il v c;111 b,: the n-ic,s t ,·ffr-c-l ive ;, nd c,fflt:ic:nt link w ith t h e
cnlin · L·o111mu11ily if orga11i1.ed a,.:'1i1Jn a.11d p;,rtnc.:rship ,11·r, ,,, he· r•s 1:ihlishc·d lo c re ate
a n cl ::.u.... 1.ai11 :m c• nvironment t I, ;, I pro mot e l1c:d thy Ii fc.•,tylc ur ca rly .::i~c Ii nd i ng, prompt
and ;1pprupriat!' t rea t m cn t nf d i!<em:C'cS. C h apt e r 18 d t•sc- rihcs a t hi11y-111u11th l!X p c rienee
wi th familir:•s in ,J n1ral ,illage in 0 ,111g lns 1\.-1 u 11ic- ip nli1y. Ab ra Province. w h ere fr1 milies
c n ..--alt'd mccl1ani sm.s for m a laria prevention an d co n tT'Cil u si n~ 1hc part.ici p a t.ory act io n
methodolog y.
50
Fa mil y h c;1llh n un; in g r,e rs pcclive inc lud es two v it1ws: th e fami ly as u n it of ca re and
tJ1c fo 111i ly ns con text or s e lli ng of in d ivid u a l c lie n t ca re. T his c hapt er a nd th e next two
cl rn r,tcrs will c()ver cnnct:pts tha l elucitlaLc on fa m ily hcallh n ursi ng r nic tice focusi n g on
the fa mily (ll> a function in g un it a nd clicnl- pa rlner. T h ese con cepts a rc a lso applicahlc
tcJ indiv id u a l d ic n t care) wit hin tltc famil y us co n text or set Ling.
FAMILY NURSI N G PRACTI CE: TH EOR ETI CAL PERS PECTIV ES
F a m ily 111.n-s ingpn, cti<.:cem p lwsizcs th e need to underst and lhc be h avio r o ft he. fam ily
as a d yna111 ic. fu nctirrnini:; u n it which affects its capabilit y to he lp itse lf a n d mai n t a in
sys leni integ,·ity, 01· its rc;,d incs:. to w url< wi th Ll w 11 u1"'!<e in c u Lam: ing wcl.lness o r
::icldressin ~ p rohle1ns 0 11 h ea lth and illu e~. T lw o rc t ic.i l framewcJ rks prvvidc direct ions
hy w h ic h the n11rse c;111 o rg;,n ize o bse rva t io ns . focus in q u iries, d esig n tbe a r pHca tio n of
th e n u rs ing p rocess in r:.unj]y nurs ing p ractice :rnd commun icate ren.lities :-111d o u tcom es
of care (M e le.is 1985).
T h e F ami ly Sys t e m s Theo ry views rhc fa mi ly ns :1 living snci11l sy/;I Cm v..i thin a
co n lcx l in whi th 111nll iplc envi rnnmc n lril a d in ns o r fudo r:<; m:cu r over lhe life r.ourse.
It is cn m p o.~f'CI of in1 crrcla1!.!cl 11 n rl in tcrcl e p c n dcnt ind ivi du.-i ls wh o a re org.inized in to a
s in g le 11ni1 so a'< In at ta in i<peci fic fa mily functio ns o r ;;o:i ls. \ Vi thi n th e fam ily syst e m ,
lh e fa mi ly m r mh!'rs in te ra ct as a f11nctir:ma l whole. '171c h ch.wiors of diffo rcn t m e m bers
are co m p lc m c nl;iry or recirrocal, in volvin ~ g ive ,tnd t,1ke. ;ictio n o r reaction . The
in te rrelatio nships in a fn1nily sys-le.m a re intrica te ly tied loge I he r such that a chan g;e in
any vnc pm·t inevi tably 1·c,; l1 lts in clwnµ.cs in th t: e n tire i;yslem . T h e in terrelat ed ness
o f cu rnpuncnls i11 th e fa rn ily s_q;te 111 !;LYE'S rise Lu n e w q u a li ties a nd c h n ra ctcristics
thal n rc" function of th a L i11terrc l:1tcd11ess ( Fr iedrnn n 1992 . p. 118). Th e family as n
system h as h o u n d a ries o r fi lter in g m cch n n is ms (i.e. nor ms , va lues. nt-1 ii u cl es a n<l rules)
whi ch re~u l:i te the a mou nt and flow o f ,11n crg_v. inf() rma tio n , resfl11 rccs aad s limuli to
a nd from the cxtc·rna l Cll\'i ronmc n t. nr herwern fomi h· 111Pmbers as s u hsYstem s w ith
separate bo u mlnric:< aficd ing each o the r a n c1 1hc fa m ilr :system a, a ,vh~ lc (Clcmen Stone & o th e rs 200~ . p. 18 1). In 1,c-a llhy fom il~· ru n c-tinni n~. in pu ts (i.e. c ne r)c\y, sti m u li,
rc.sn11rcl!.'> a nti in fn rm a lin n th a t tht• fn mily system retei,·t:s a nd p roces!'.es) a re screened
so that th e rm u ily takes in w ha t is nc<'dcd frn m the e n viro n men t a nd ass im ila tes o r
mo dilics ii ln pronwte i ts ow11 s 11..-.;val a nd growth (Frie dma n 199:!, p . u 9). T h e fa m ily
;is:, s y~ le m h;1~ lhe p r0 pe nsity 111 evo lve. and grow so Lha t as g rowth ta kes pince . th e
sys te m becomes m o1·e complex. a rti cu la IP :111d di f;crim inate (11 Ii n uch cn 1974 ).
T rn 11sadic mal µruccsses ur i11ten11: tic111s a rno ng fo mi ly m em bers. whc, nccu r,y position /s
o r roh:/s. promo te o r iJ1hi b iL fnm ily ru,wtioni1111, tCle m e n-Sto ne & o tlwrs 2002 . p .178).
The ln tc ra c tionnl Ap p ro ach or Syn1b olic lnt c rac timrn l Fra m ework ,,ie ws the
fami ly as 11 11 n ily of i11L.:r;-1c ti11g pe rs nrn1HI ics \\'huse arli o m; a re h;iscd n n m ea n ings th ey
d e rive from inlcrnclinn~ 1111d la ken in an eve r c hanµ.ing proct'sit of new interact ions.
n e w int e rprc lalio 11s. and ne,,· m ea11iu gs:. Sym bolic: com m u 111\:<1Lio n 1-1volvi n g fro m the
s elf .in c1 Lh c c1n-iro11 mc nl helps in tl i,; t111a ls inle1-pret a nd select th e e n v ironme n t to
wh ic.:11 they n :sp q nd. T ltis frn m e work iJ ent ili L·s huw relationslti ps with oth ers a ffect a n
indiv id ua l's fu nc tio n ing. The 1 ntc r;1ct; onal Approa ch em p h a s izes the a ntecedents
and consequences of s u ch p rncesscs .is commun icatio n , d c,·i:;io n- m nk in g a nd p rob lem
i;olv ing: tnn ll ii:1 m11nagcnw n lj n ~$Ol11ti c1n: re.1i:tin ns Ln «tress; an d <Jlh e r fa mily
s il.u:it io n, infl uen<·C!rl h~, l:1m ily int·e rac1io ni, and in le.rilcli ve p rocesst:s ( Aldo us 1978;
Hill a nd I l,u1s en 1960 ). To und ersta nd the fa m ily"s beh ,wio r a ncl n::alit-ie:;, th e nurs e
m us l ;;co th e c xp1,!ri,111ce fro m th e fa m ily's point of vie w, slri viug fo r s h a red m ea ni ngs
throug h cons ens us .in cl feedba ck
The D evc.lopmcnta l A1>proac.h views family d e ve lo pmc n t t h ro ughou t its gen e.ration.a1
life cycle, higb lii;hti n g c ritic:1\ pe rio ds of family g ro wt h a nd d ev e lopme n t across the life
51
('Oun--.:- ( Hill & 11~ 11$ ('\\ lOhO: D\\v'!'lll & ?- li lk r 108;-) . It h e-I p;: prt't:lic t wh n t ,1 ~iv..- n fn mih·
is <''-l'e ricnd n!! nl nn:,, p nrlic-ular l im e. \\.hilt' t lwn' :u~ .sodn-,•c-onomk. c ultural m1d
c thni,· v nri:iti(,n:< in tlw fa mily lif,, c~·,·ll'. t h,, 1kvl'h1pm,' nl n I appn1:1d1 c a n g u id..- a n :1 l~·.si~
c,f a~;:c,;.:,nw n t ,bu r ,·lal,-<1 ,,, t11 .1111 ici1,:1 t,'<l p,'rincl:: nf tt nu.su n I d,•111 :1 n d.s on t hl' f:1111 ih·
in l C\'1 11:' or rl'Sl)\l !Y,'$ l11' :1<lju1-t 11w11t :lS tlw f:1 111 ily ~''''" t !in 11,~h ,i 11 ,·mOI in11 :1I )'rtl<'L':-S
t 1-..1 nsiti, 111 an,i drnn ~c in tlw fami ly :<t:1111,- n·qu lr..' d to pr11n•,·d i11 tfl ,, l1 r,, c~·..i,, ( ( ·11' m (• nS t o n c & n th e n, ::!Ot1:.!. p .1-0). 1\1 illu;:t r:ll e. i11 th ,• lif,· ,·y,·k !'lag,· ,, r 1:-unili,.., wi t h young
chilclr~•n , the k,•~ p 1;n,·ipl~ of e111t11ional pn,-•,~,__._ of t m.nsi ti,, 11 is ,H'l'<'!Hi11g n,·" · 11 w111 lwrs
intt> th,: fam ily s~-:,tc111 as thc C\mpll' :1d,im-1s to m ake spac;.• fo r t.:h ild(ren) :mdj .. ini n ~ in
chil dbearing . fi n ancinl :111..l hou,-chold tas ks (Carter nnd 11 lcGold rick 1988. p.15).
of
Stru ctural per-:-pcc lh'l' specifi~ family ch:irncte.-i::ti cs such ns m e mbe r role.~. fa mily
fon11s le.p.. u udt':tr. sini le pare nt. hle 11dtrd, e,1 c n ded). powe1· stn1ctn rc>s (C.f!..
matri ard1al . pat1;:1reh:1 I). cnn1111nnic ati u 11 p rocesses :1 nd va ltw l<YSWtns \\'hid, pro , ;d('
order lo fam .ily interac tion:-- a nd intc rth:]ll'th.1 \'nl re b tinnshipi: :111d ;..crve lo 111·f;an i1.e
p e rfo rm a n ce of roles :111.d fu n ctio ns ( Frie cl m :m 19<.:>8).
Usi ng l h e.· S t ruchtralVunc tionul pcrspcc;tiYc. Fri i:-dm:rn ( 1998) ;:p pt:i fi<'.s four st ruclurnl tl imcns io n :--:
role s tnK·ture. value system , ..-omnntn ic-:i ti0n prm:es!'c:-. and p o wer s tTU c tu re. S h e
ide ntifi es five funcliu 1rnl a n: as: affect;ve fun c rion. socialization a nd family pbccmen t
fu nc tion , re producth·e functio n , ct.:ont1mic fu.n ctit)n :i.nd b c n llb cnr <' nin c tion. Ue nll a m
(2003) gen cr:it·cd m ore precise concepts a n d , ·:1riab l~·s on I he s l rnc-rnrn l ,111<l fu n c t io nal
fram ewor k through he r pro fessiu 11al nu l's ing prnd ice a nd rese:\ rch findi n gs fro m th ree
qualit:lli"" studi es abo ut family ht>allh ,111wn ~Appn lach i:m ra mi l ies i 11 two south eas tern
Oh io coun ties. !ihe devcloped the F:1 n1il_v H L•al l11l\'lodd .1slrn m e wnrk 1·odescribc. e .\7)lain
a.ad predict health o utcomes and m e:ins Lo circturn,erlbe t he bounda ri e s o f house h old
production of h<!.n hh. de fi ned a s th e d y nam ic process th.rou g h which h o u:sc h o lds
cuml,ioe thei.r (i nt e rnal) knowledge. n"sou rces. and bch:n·ioral norm s an d pa tterns ,,;th
avajl;,ble (exte rnal) lcchnolog.ics. services . information .111d skills to re;.;tore . m a intain.
and promote the health of their m e m bers (Berma n. Kc n d:ill and Dh:ittaclrnryyn 1994.
p .2). According to De nham. seve n functional pn.Jcesses (p.1 2 5) a r e u s ed by fom ilies
to incor pora te information, rnlues a nd beliefs io t o be h a,; or, activi ties :rnd ro11t;n es
relevant to famil~· health. They involve ways family mem bers intera ct 1·0 po-rc nti a tc,
negate, tl1re aten. mediate nnd enhance indi vidual an d fa mily h ealth . Denham s p e c.in cs
these fonetional processes ns : (1) carcgiving; ( 2) cathexis (em otio n al bond betw een
indhiduals :ind fu mily): (:3) celebration (ta n gible forms
.sh a red m enni ngs); ( 4 )
cha nge (dyn:imic no nlin ear process im p lying .ilte ring o r mocl i{S;ng th e form, direction
:.ind o utcome thru alte rnativCJs): (5) commu n ication (pdmary ways to sociv lize children
about he alth bcUefs, values, attitudes aud beha viors a nd use in fornrn t ion. knowledge
and a c tio n s opplicnule to health): (6) connectedness (ways the fam ily as a s ~·stem are
linked togeth e r) : (7) coo rd ination (coope rnlive s h a ring of r e;::o urccs, s kills , ,1bilities,
and information within th e family and with the larger contex tual environmen t to
optim.ize i ndividual's h eal th potentials, p otentiate t h e h o use h old product ion of h ealth
a n d adticve fam ily goa.ls). The fam ily hea ltl, model specifi cs fam ily routines as basic
structure whi ch pruvic.le 01·c.ler to famil~• membe r 's lives a n d serve ro o rgan ize heal th
vvitli in the ho uselto ltl where individuals assume in terd e penden t 1·el<1 tionships. r oles,
fu nction s and p urposes. Den ham 's fa m ily routines (p. 184) iuclud.e: (l) ,;elf- care
routi n es {patterned heha~;ors .rela ted to usunl uct:i,ities of d:.t.il_v Ji,, ing experie n ced
across the life course . sucl1 as di e tary, hygien e , sleep- rest, ph~",;ic.-1I a c ti vity and exercise.
gend e r and sexuality); (2) safety and prevention (pert ain to healt h protection, clise ase
preventio n , avoidance a n d p articipation in h igh - risk beha v ior a nd e fforts to prevent
unintended injury :icross th e life course, su c h as iuununiza tion s lalus, abuse a ud
violence. s moking . alcoh ol a n d s ubst ru1ce abuse); (3) m enta l health behaviors (ways
by :''~i ch individua ls and families a ttend to self-efficacy, cope ";th daily s trnsses a n d
ind1V1duate, such. as self-esteem, personal integrity, work a n d play, s b:ess l evels); (4)
of
52
i;,111ih- ,·,1r,• {d.1ily ,h·ti, 11i,•s. l 1.,di t in11 ,1I l,\'lrnvi<•n• .11111 s pc,·i.d ,·,•l,·hrat in 11,; that ~in·
111,•.111m>=, In d.uly Ii f,· ,uul pr,n,,k .sh., r,•d ,'nim m,•111.11l ,•:1s11 r c nm I lm p p1 Ill"'<" for m nit iplt•
llh"lnl.,.·r-.. '-lh."'h .,, t c' l.1\'Ht it Hl !h"I h i t it•,, , :, c.H ilttl,. \.·•·l,·hr11 Iinn ~. I r:u '1 l i,111,. , pi ri t tt :t1 HtH.I
n.·hJ;:!.i1'l l ... pr.h·t it·,·~): l.-;) 111 t1t•~'." ,·a n· Ih ;1,-.. h., ,,·hi,·h t111 •r11 h,•r..:. 111a k•· d ,•L·i~i, 11 1~ rl• l:1t t'd
ttl la·nlth 1.·.111• nt't'd,. du,n,,· "ht•n. " ·lll•I"•... :uut how lo ..__.,,k :,;upp, ,nh •· fu~., hh ~ervit·'--•:,;-:
.,n,I d,•1t•rmi1w "•"" to rt"'l'<•nd Ill 111<·, l..-111 dire, ·11\',·~ 1111<! hc., lt lt 1111nr111:11iu 11 ): lh)
nh•nt h1.•r , ·., r1.•~i , in,:. t 'H\ , ·~ t. . , ,, hh"lt fo 111 i1'· tth•1u lh•r-. :h '1 ., ~ i 11 h•r: wt h ,, •·ar•·~~i ~·\•,~ 1u·rn~~
th,· liJi• ,·, •111 ,,. :i, I h,•1 ,n,·1.di r ,· .-1111,1 n·11 a nd n il<•l,·::-,·1•111,- 11h11, , I h,•, t11 h , 1'1:11,·d i, ku l:;.
p.1rt1np:ll,· 111 lw.1lth .rncl il1111•,-, ,·.1r,· 11,•,•d ~ .i11cl ~11ppor1 111,•111h,·r~ 111 dh1du:i l l'f>llli1w
pat1 ,'rtt-.,. ~u--·h ~\ ... pn\, 1..:;itl n ,q 1.•;,n• d11ri 11).: ilh u •ss. ~,q,pc,rt,, •· 011•n il1r •1 \11..·t inn, nntl
n w111lw 1 1111,·::- ,ind n.•sp1111, ihili1 it•,- l . \., t,:,,i,· ,:1n11·111n•s. l l,•1111:11 111'/o.l' l,1111, lh,11 l,1111 ily
rrn11in.::< ,in• h.11'11 ual l.1 mih p:i11<•r11, ,,n l1L•nl1h a n ti h1•:il 1h ,·.1n• "h1d 1 pn nHI,• l"r llw
furnih nn l1 f"'tu.·il lll ,,ay t,, nr).!:Uii ll' int1.'l'a~tl\•t· p rt>L'l'~~es to c..·acr.· uut f; 11 ui h · (unctio n~.
1
,\n :1daj' l,Hirn1 , ,f tl w F am i ly l h·nlt h T :i.<:I, ,: P c•1·:,:p c-c.:t i n · (i11i 1i:1 llrn 1111·q •lut11!71.:d br
F n ,;•(·1 11au 111d 11,·111dl· h 1q~ l. pp. , ,. 1
11f") ha!-- IWl' ll ut ili1Pd :t , l •pc..~rntiu11:,l lr;11nt·"·, ,rk
in Jtun 1h · ht."al th o,n·.-.it, ~ p t.u:til"t• ( B.ult ,11 :111d ~ t;,g b vn 10-H. ;\ldnlav; 1 J(), l - . ..1, u1.1} a ~
11 p n :dse mc t hndnl,,i,;_, 111 in lq;ral<' 111,· ,1pp li1·:1 li« 11 , ,I 1h,•n1·,·t 11·.d l''' ''"l'<'•·liq•, w lii l'11
Ct..1 11\-pr~,· pa rlk1 d:iil) ,)1t h ,,-. c-nt 11·:1I 1n1l' 1
11i l. 1111 il_, P"'rfnnna nn · nt furH·linn , lo ;1I L1i n .
s 11s l a in . m:11 111:i III n nd rq:.:1111 1nd" ah ,.,I :t lld l.11111 II' h, •, ii I II. Tl11s ,, p.-,·a I 11111.il Ir:1 m,' w<>rk
i~ b n;;..:d l'l ll tltc p rin,•iplt • th nl 111 ttl'rl\ ·r c,, 1u- lu.. ·, e \\.'t..• 11111.•~"' :tt 1u. •11g fn1 11 ih tnetu lu•r:-4 :ind
rerhwe 11r 1• li111 i 11:11,• f:i111i ly lll'11h h p rohh•m,-, lh,· f:11111h .,,. "f1111 (' l iPni11 ~ 111\il p,•,-f,.n u s
t h e fol lt,wini:, h,·11 l1h t a:<k~: (1) r1·,·ni.:11i~L' t h,· prt'S<'IH'<' nf II w.-lln e,;,.-. s 1:11l' <•r h,·a llh
c n11o i 1io11 o r p ,·nb le m: ( '..! ) mala · cl,,,.,..,.,,,,. 11h11111 tn l: i111: 11ppr,>pl'ia1,• h, ·.d1 h 111·1wn lo
m n in1ai 11 wellm~~::: or 111:111:ig,• t lw IH•: 11111 prflhl.- 111 : en p r ,wid,· 11ursi11,.: t' ,1r,· 111 t h ,· :<i<·k.
d isnbkcl , d ,•11t'1Hl..-111 or at -risk 111,•111lwrs: ( .J) m :,in lai n ;1 l\n n n· t ·1wi1·n 11111vn1 n1 11, h 11·1"l'
10 he:1IL h 111ai11 Lc 11:11H' t' a n d p,." rs n n :d d,•ydc,p111 c 111: :·111d l :;) 111ii i:~,· t·•1111 n 11111 i ty r,;,;1>111·<:cs
fur hc:d lh ,:,re . T l, is o p enllirnmi fr:11t1L' \\'o r k was 11;:\'d in t lw ,•arlr pm-t ,,r 1<1-ns m:
b asis li.11· i:i,emmlli ng. c;, lq\11r i1.i11).\ .md f111 111iz i11g :\ T y11ul ogy of N11 r :- i 11 i; l'ro h h .-1 u s
i a F anti ly Hcu lth N 11 t·s i11 J,1 P r a c t ice (T :ihll.' ::.:.:.:) , Tht· firs t lil•ld - t e,:t._-cl t1·po loKV
was p ub lished in 19 78 hy lfo ilw 1 nnd 1\l a).\l 11y a. T h roug h the yPu r s t h r typo lo~v lws
b een npcla l ed. specifica lly in 1994. 1997. :2ou:1 aml '.!Oll<J. T h is .:hnpt .:r pres ,·nt!:- t h e
typology ,is p:11·1 nf t he disc u ssion on fn rm ulnting l hc nursi ng d iagno.s.is in fa mi ly
n ursin g p r acl ice.
In conclusion . th e System s F t·am c wor k. t he l n tcr a c t i o n a l and D c n -,Jo p n , ent rLI
Approac h es , .incl t be S tr u c tu ra l-Fu n ctio n al n~o dcl nre c.x:imptc..~ nf m ajor
theo re t ica.1 p e rs pective;; which dcscrihc . e xpl:ti11 a n d p rcd k:l fam ily bcha1·iur critica l
t o u ndc rs l:rndi ng th e fami ly as a fu nctioni ng 11 n i1 and 11 -; ., di en l pnrtncr. l'n r l icula rly
in assess men t , t h e ni·etical pcr-apt•ct iv,•~ p rovide a s vstc m n t k gultil' for t h e 1111,s e to
id en t if:-,· w h at ;isscssm c nt dau .in· 1WC'd ec:I a nd h ow t o g.:n e rale, ,;un nu t , or,:;a nizc and
a n nlyz.e large a m o u n t of <lis parnti' da ta a h n111 the fa mi ly (Fi-ic d111.1n 1<)')'.!, p .;;9). The
u n iq ue l1ehriv i nr of t h e fo m ily as a fu nt.·tio n in g u nil l'Xpl ai n s t he rcalit ie,; :111d d.,i:1 ree
o f npe nn e~ to change as c lient nnd p:wtne r o f' t he n ur,;e in fa m ily nu r,;in,L\ practice.
T h enrc tic,11 frn m c wo r ks whkh C'(p lni 11 a n d predict this u niq11<• bcli.1\-iu,- uf Lhc L'.u n il y
provid e direct io n s o n h ow t he n u rse o.::m , ,·o r k " ; 111 tlle fami ly ( as fu 1H:l io 11 in,L\ 1111 it :111 d
clie nt - pn rt n e r) by e n h a ncing ils syste m e ffr-ctivcncss i n ,: u;;taini ni:: n::>'ourcc/c11c q ,,'Y
ava ilabili ty a n d 11sc fo1· ,,yst e m c han ~c- ,ind f.icilitali ni-. bo u ndary dlidc n c::y in :1 l10 \\; n r,
a cces;; to exte rna l su p po rt o r u_se of infn rm :llic)n In pn.1111o lc w,: ll n .-,;,a, ,ml1:1ncc g rowth
a nd developmen t. cre a te a n e 1w iro 1tment for a h ealth y lifest:- le. or man;i~e h cn ll h o r
re l ated problem s. Respect for fa m ily 1·,tlucs a nd re;-1d i11es,a l u umlc r:s taml and m ai, i , n i7.c
u s e o f fomily ru ll:!s. n orm s. a nd fam i ly ntlil udcs (as \:U1t1po11cn1s ur fa 111 ily b o u nda r ie;:
aud fil tering m ec ha nis m s) arc essci1 Lial in creat ing dficic n l, se mi-pe r m e ab le fa m ily
system bo un daries thro ug h a work in~ re l" tio nship based o n tr ust and gui ded by clear
53
and muttrnlly c.stablishcd g,()n\.s a nd expectations. W ithin a n n tmo::-phere of r es pect ,
trus t and belief in nn E.'~ali tnrinn robti onship to en hance th e fomil y"s e mpowering
pot ential , th e fa m il~·-n ur.-e p artne n-:hi p c:.111 maximiu e.,1leric nti a l learning processes
such as creating option:::. decon 1--'truclinr- mindset,; llr c urn:nt 1,·orkh·iews by anal~-✓.ing
meani.u~s to gain new insigh~. and / nr rc,1rdt:'1i11g p:H!Prns a nd n,•lat;o n ships in original
w;,,ys that result in fresh rn..-nnin~s, exp ando:>d ,,·1 1\"S of t hin king. :.111d d iffe r .:! nt ,·alues
t o di,;l·o,·er nt''' inte1-pretalions (tnd e,q~lanntiom: for " ·hn l ,,·as pre,;n 11s l~- thou gh t of
as fixed :md absoluh· l Dt•nham :.!t1 0:~ pp. 1~ . 2;6 :md 280). C hnpters :~ a n d -1 focus
011 how to facilitat e these proct:'sscs or crt•al i11g. d,-,·on:<tmr- tinf.. and recons t ructing
e.,-perienc.-.s. meauiugs. difforc nt valul"s arnl expa11<led w-ays of thinking to h elp Lhc
fami.ly systematically handle the chall<!nges of going Lluough beh;nior c h ange.
NURSING ASSESSMEN T: OPEIRATIONAL FRAMEWORK
Nursing assessm ent is t.he fir.;l m ajor p hnse of th e nu rsing. process. I n fam ily h e;,il th
nursing pmctie:e. Lhis im•olYes a se t of actions by \\'h ic h the nur.se de ten 11ines U,e ,;;talus
of the farni l\" as n client. its abili ty to mai n t"in itself m; a sy~lem and func non_i n g- tlll_it,
and its abili~· to m ainta in wellJJess. pre\·e nt. control or resoln: p 1·oblems in c>1·der t o
achieve heal1J1 ~md w ell-bei ng among its m~111ben;. Datu abou t Lile present cow.lit io11
or st-Jtus of tJ,e family nre i;ath-e red and anal~-.:cJ lmsecl 011 how fru n ily dynamics .
realities. possibilitie:- .,,,d ,·11lnernbilities generate the antecedents or fa ctor s associa ted
\\iLh health nnd ill ness e:,,perie nre5. Ut ilizi ng Lhcoreticnl models to unde rstand
the char.icteristics and beha,ior of the fa mily as a functio n ing unit and cli.en t. the
operational miruewo rk for assessment. ;:is described in th is ch apter . focltse.s on_ types
of a~e..--sment dnta t u ge-nerate. method a nd tools to collect t hese data, a n d fin ally,
application of the Fami ly H e alth Tasks Pe rspective in determini ng family health
n ursing problems associated " ;ti, speciJk health cond itions or problems.
Nursing a!'Sessment includes data collection. da ta a nalys is o r interpretation and
problem defi nitio n or nursing diagnosis. Nursing diagnos.is i:- t he e nd resu l t of two
maior c-.-pes of nursing assc.-<smco t in fatnily nursing practice baserl o n the fra m ework
us~d in. this book. These are: (1) fir,:t-level assessment: (2) second-level assessm ent .
First-le \'eJ assess me nt is a p roct;"SS whereby d:ita ::ihout the current h ealth stntus of
inch,..;dual mem bers. the family ns a ~ -$tem and its environment are compared ;1gai11st
norms or standard s of persooal. socfr1l a u d em;i:ou,nental health a nd inlen\ctions/
interpersnnnl relationships ,,ithin the family system. As end res ult of data analysis
during the first - Ie,·el nssessment. specific health con ditions o r problems a r e ide ntified
and categorized as: (1) wellness s rate/s; (:c1) h ealth t hreats; (3) health d eficit s; and (4)
stress poin ts or foreseeable cris is sit11a ti o ns (see T;ihle 2 .2) . Second-level assessm ent,
on the othel' h a nd, specifies t he n ursing problems that the family encoun ters in
performing t he health tasks wi th respect to a given health con dition or prob lem, a nd
the cam,es, barriers or etio logy or the family's in;ibility to p erform th e health task.
These two le\'els of assessment sp ecify a hierarchy of two sets of <la ta and their nn alyses.
They reflect depth of data gath ering and analysis on what health conditions or problems
e.>.ist (first-levd assessment), and why each health condition or problem r elated v,rith
maintaining health or wellness e:-.ists. The latter is stated as ex pla nation a bout the
family's problem related lo mai n tainiug health/wellness, m an aging h e nlth problems/
illness experience, or pro\7iding a home environm ent conducive to h eal t h main tenance
and personal development (second -level assessment) .
STEPS IN FAMILY NURSING ASSESSMENT
There are three major s lcps in nursing n~cssm cnl ns applied to fa m ily nurs ing
prnctice : darn collccLio n ; data analysi:;; ;;i nd form ul nt ion of diagnm;is. Figure• 2 . 1
illustrntrs t hese ,;teps.
Data collection for fir.;t-kvcl fl&;cssm cnl in voh·cs gathcrin~ of fi\'C types of tl;ila which
gen erat es ll1e categoric;, of h ealth conditicms or proble ms of t he fa mily. TI1csc dnta
include:
I . Family slrudurc. clrnractcrislic;,; :111d d~,,amic.'.s :
2. Sociu -1..'<'<)1HJ111 k and l'tl lturn l c hnrndc ristics:
3. Home and c11vi n111111c 11 t ;
4. H ea lth s tntus uf ~·ad1 member; and
5. Vn lucs ;rnd practkl'S on h ealt h pro moLion/mai ntcnancc and disease
prevention.
Second -level nssessmPnt dnt.i in clude those thnt sp1:cify or dc.-.cribc t111• f11 m ily's
realities, percep tions about :md :1llitudes r elated lo Lill' assu m ptio n or pcrformnncc of
fam ily h e-al th t.:1sks on eac]1 health condition o r prnblcm identi fie d during th e first- level
assessmel\t.
Da la an alysis in,·n l,-cs sc,·eral s ub-steps: ( 1) Snrlin~ 11fdata fur broad calc):\Ol'ic..-. such as
th ose r elated with thl' healt h st.l tus or p r ;1r t ii.:1•s of f;11nily llll' lll lw r,-: or dat:1 abo ut h ome
and environ ment:(:.!) Clusicri n~ ofrdnt(•d c ues 10 d ck·rmirll: rd:r lio ns hi ps hct wee n :1ntl
am ong uala: (3) D is t in!!,1.1is hi 11g r elevant fro111irrc h-vn11l llal:1 to dt'dd c wha l info rm.it inn
is pcrti ncn l to un<lerstnmling l hl' :-it11ati o 11 a t hand bmsccl o n s pcci~i c rnlq~orics or
dimensio ns ; (4) lck nl if~·ing patt ern s :s11d1 as physiologic function. dcvc-lop m c n tn l,
nutritio nal /clietarv. copin g/:iclapt a tin n or 1·nn111111 11il';1tio11 nr i11t.1 rac tirn1 patte rn s nnd
lifestyle; (5) Rcfating fam ily data to relevan t clinical/ n·s,·:11Th fi nd in~s a nd comparing
patlerns wi th m1m1 s or :;tan clnrds nf hcrtlth (c.J:(. nul ritio1111l in take. i111111un i;,:Hion
status, growth :ind devck,pm cnt. J1ocial nnc.l econ om ic p rntludi\'it~·. environmental
h eal th requisites) family func tioning an rl assu mption nf hen1th tasks; (6) lnterpr.:ting
res ul ts based on h ow fom il v charac teristic.;<, \','\lu cs. a ttitudes. pe rcept ions, lifo:;tylc,
communication, int eraction . decision m.iking. o r role/ task pe 1·for111ance a r e as:so ci:iled
w; tlt sp ecific bealU1 co nditicins or problem s identified: a nd l7l l\u1kinp, i nfe ren ~es or
dr:'lwing conclusions ab1)Ul lhe n::asum, fo r t ltc existe nce uf lhe healU, condi tion o r
pro ble m and risk factor/s relate<l lo non- main te na nce o f wellness sta te/s w hich can be
attribu ted to no n-per-t'o rma ncc of fa m ily hea llh tasks.
The last step in family ntrrsing assessmen t i11volvcs 111.ikini; a <liagnosi:.. This incl udes
t wo types: (1) defi nition of well ness stat e/ poteu tiul or heal Lh condition o r µ rob le ms as
an end product of fi rst -level assessme nt: .md ( 2) ddin it.io n vf fami ly nursi ng problems
as a n end result o f s ccond-]c\'el nssessmc n L The fami ly nursing vroblom is s ta ted as
an inability t o perfo rm a sp ecific health task and th e reaso ns (elio lo~v) w hy t he fa m ily
cannot p erform such t ask.
55
•
•
•
•
Recognize Need to Use Data basC'd o n Evidence
Ensure Ac~unuy arid Re-llabHlry or Da ta
Check for Inconsistencies
Complete M issing Information
• Use
PROBLEMS AND FAMILY
NURSING DIAGNOSES
COfflpl"N1e..
h1t-11fit•-.ic1N•~i
.,.,....,,.
...
-IOel - Dllbl
of.
• Mollie;
Fi~r-t~vrl A.sseum~n t:
Define the Hel>lth
Condition_s/Problem.s
(aitt•gorlzed .,_., w@ llness
states, h ealth dcffelts,
health threat s, foreseeable
crises os s tress points)
.5e.cond-level As:Sessrnent:
Deline the Family Nur$in11
Problems/Diag noses (Table
2,2J ~ Statements of:
Famlly's Inability to
Perform Health Tasks on
each Heah h Condition/
Problem specifying the.
B•ttie.u to Performance
or Reasons ror Non•
pttformeni:e of Family
Heal th Tasks
quacv of
56
-
DATA COLLECTION
The nurse is concerned nbout two im po rlanl t hings to e ns ure effective :ind efficie n t
data collec tion in family nursing prnctice. F u-stly, she ha s to id e ntify the typ es or kinds
of data needed. Secondly. she needs to specify the methods of data-gathering and Lhe
necessary tools to collect s uch data.
Types of Data in Family Nursing Assessment
What data are needed to arrive a l a measure of th e (amily"sabili ty loacbievc healLh u nd
well-bei ng am ong .its membe rs, while itmau1lains itself as a syste m a nd as.i fonc ti oning
unit? Based o n theo reti cal frameworks which d escribe fam ily c h aracte i-is l;c.s, explain
and predict fa mily beha\':ior. two t)1)es of dat.i are needed at two le\le)s of assessm en l in
fam ily nursing prac tice. As shown o n Table 2.1 (."'-ssessme nt D ,t la Base) th e following
constitute the first type of dat.i taken during the fin;t-level assessment:
1.
Fa m iJy slrnct u re, chara t.: ltH"istiQ; a ml tly n.a m ics- iii cl ude fa mil y co I uposit ion
and demographic dala , type of family form aocl stru cture, d ecision-making
p atterns, interpersonal relatio111ships, interactional patterns /in terpei:sonal
relationship:; (sucl1 as presence of dyadic and tria di c boundaries which
ll ave the po tential to alte r membe rs· diverging health beliefs, kn o wledge
and beh:tvior) and communication patterns or processes affecting fami ly
related ness (e.g. ex pression of fee.ling5 or e m o tions p articu-1;:irly related
,,:ith addressing conve rgi ng nnd diverging motiva tions or perceptions,
such as tl u ring conflict) cons(stcncy and co ngrnem:c bet".vee n intended
and received messages; and, exp licitness of m essage for approprintcncss,
effecti vity and efficiency of the co mmuni cation p rocess r elated with role
perfonnance, indivi<lual me mbers' health and family system integrity.
2.
Socio-economic and cultural characteristics- include occupation, place
of work, a nd income of each working member; educational a ttainm ent
o f eacb family m e mber; ethnic background and religious affiliatio n;
family t raditions, even ts or practices affecting members' health o r fa mily
functioni ng; significant others and the rnlc(s ) the y p luy in t he family's life;
a nd the relalionship of the fa mily to th e la rger commu nity.
3.
Home. a nd e nvironmen t- include information o n housi n g a nd s Stnitation
facilities; kind of neighbo rhood and ava ilability of social, l1ealth ,
cor:nmunication a nd transportation facili t ies in th e communi ty.
4 - H ealth status of each member - includes current and past significant
beal th conditio n/s o r illness / es; beliefs anc.l practices con dudvc to health
and illness; nutritiona l and developm en tal status; physical assessment
fine.lings And significa nt result,; o f labo rat ory/diagnostic tests/screening
procedures.
5-
Values an cJ practices on he:aJU1 promotion/maintenance and d isease
preve ntio n- in clude use of promotive-p revent ive senrices as evidea_ced by
immun izalion stat us of at-risk mem be rs and use o f other heallhy life.style
re lated services; adeq uacy of rest/sleep, exercise, relaxation acthities,
stress managemen t o r o ther healthy lifestyle pn11;tices; o p por tunities
which e nha nce feelings of self-worth. self-e fficacy and connec1ed ness to
self, o th e rs an d a higher po we:r; essence of m eaningfulness.
57
I
A t o o l for gath e ri ng this a s sessmen t diltu b ase CADB) is p r esen ted in Ta ble 2-.1.
Thro ug h lh is AD B, the n u rse ca n id e n ti fy ex:istiug and potenti ahve llncss s t atc/s , h ealth
threat.,,, .bc ri lth d efidts and s.t.-css po inl s/foreseeabl e crises in a g iven f,i 111 ily .
Each family has it.-.; o wn ,., ·uy of be ha ving l'c1w n rds o r resp()ncling t o s i h 1.iti o n s j n th e face
o f th ese p rob lem s. The o th e r l:\1Je o f clnta rnke n d u ring the sec o n d-l eve l assessment
re flects the exte.u t to w hich the fam il)· can perform the health tas ks on each h eal th
con d ition or p ro blem identified. These dat:1 inclt1d e :
1.
2.
3.
4.
Th e family "s pe rceptio n of U1c c o ndition o r p roblem;
Decisio ns mride an d appr oprial·eness : i f n o n e , rensons, and
Actio ns tak e n ;in d rt",; ults: if n o ne , rea sons; and
Effects of decisio ns a nd actio us o n othe r fa mily m embers.
Data-gathering Methods and Tools
Therearcsen'!ral m et hods of dat;1-g,1t h c ri11~ Llrnt Lh e n u rseca11 selet·l from, d ep ending
'l1-1 e
c riti ca l point fn the c ho ic<.> is conce rn for :1cc ur:1cy. valid ity. reli:1bil ity . a n d acl e ri u ru:y of
;i;;sc!<smt·n I J:1w. Poor qua Iity / i1tmT 11 r.1le and i, 1adeq u a tc d ala t·a 11 le ad to i ,1 acc11 ra h•:ly
d e fin ed hc :1lth ;1111.J 1111 r.;ing p r o hlcm s which , i n tu.rn, lead to poorly design ed fnmily
o u.1"'$ ing c11 re p lan.
on nvaila hililY of rcso11n·es s uch ;1s ma tcri.:i l, m anpower , tim e a nd facilities.
To e nsu n" quality a&<es~,nenl d ata, a co m b ino1ti on o f m e tho d s a n d sout·ce.s ca n provid e
cross-cl1 ecks nnd cfata valida tio n . T o ill nsh-a te. a comoin a tio n o rinter view, ob s e rvation .
ocu lars11 rn '.'"· direcl e;,.-;1m inatio n ( ph_vs ical a s s essment ) . use o flabo ra to ry o r di.ig n ostic
lc.~ts and n icnrJ re \-iL'W ca n bc u tili:r.t.·u i..., ~e n t•r·a tc lir,; t -le,·d nssess~n ent dr-i t n u s ing t he
toul. : \ssessn1c n t Dat:1 Hust.• for Fau1i ly N u r s iJ1g .Pnict-.icc (T a ble 2.1) .
The foll<lwiug :ll'C b rief d csLTi p li ous ot co1111111m melho d .s o f ,gath ering d .ita about a
fam ily. its lt,·u lt h sta tus and .stat e of f111wt ioning:
1.
ObscrvtHion. This m e thod of data co llectio n is do ne through the use of
the .St' II SOI')" ca p .1 c i tks-s ig h1_ h c n rin g. s m c lJ and touch. 'fhrnug h direct
o b.sen-;ition . tlw 1111r sc ~ath c n, i11for111:1tio 11 a b o ut the fom ily"s s tat e of
being :ind hdrnv ioral rcs ponsl' -"- T he li .u11 ily "s lwn ll h st:it11s can he inferre d
frc1111 1lw i< iJ:; n s :, nd .symptoms o r p1·o ble n1 a r·t•ns re fleer e d in tJ1c follo wing:
ii, t;o n11111111intlio11.
i11l ~•ract io n
p a11·c n 1s
a nd
intc 1-pe1-s o n nl
rdati onshirs cxpc~ t1:d. used ;ind to le ra te d by family m embe rs;
h. l~ol1• p,·n ·cp t ions/ tn:s k nssump lio ns by e a ch m e m be r·, incl uding
d el"ision-ru:, kin.g p.itt,c-J•us: 11 ncl
c. Con d itio ns in th e ho n lt' an d e n vi ro nme nt.
Dntll g11.th crcd t hroug h this m e t h o d h:n·e th e :1d va 11tage of b eing s ubje c te d t·o
vnli cl:itio n nnd re li11bility testi ng hy o the r obse rve rs .
.2.
PhysicnJ Exnminution. Sig nitica111 data about Lhe health s tatu s o f
i11div id11nl f;nn ily 111e 111h1~r.'i c·.1 11 he o hta inc cl I lirough direct e xamina tio n .
This i,- d1 11w 1hr1)11gh ins p ccl i1)n , pa lpati o n. p e rc ussio n , m1scultn t io11,
m t•a s11rc 111c111 rif ,<p ,.•d(ir uvdy pm·t:.; a n d n : v ic w in g the hvdy sys te m s . His
('S S1•111iul for t lw 11111·s1• to l1n v1• I '1C' skill in pe rformi ng physical a s s c~s m e nt/
i1 ))Jlf'11i:<al in ,, rcll•,· lo help llw fo111i ly h u n wa rc o ff h e h c:tl t b s 1.itus o f its
1111•mlK•r:.. Dula gcncrntc d fr11111 ph~•sic:11 I 11ss css11w111 fo rm n s 111>s 1.1ntive
p,11"1 oflirst -lc ,·cl :iss, •ssm t'n l whi c h may indi c:;ilc presence o (h ea ll h deficits
(ill rwss s lates ). Th e ll:c hn iqnes employed Juri11g the phys ical e xamination
process are d isc ussed e xt e nsively hy l3 kkl ey (2007) and Ilnrlrnusk:ts ,
58
Stoltcnberp;-,\ llen. Baum;urn, a nd D:irling-f'is h c r (2002).
3 . Jnterdew. Another m aj or m ethod of tlala-gathcrini,: is the interview. O nt.-!
type of in te rview is com p le li n~ a healt h his tory for e.tc h fa mily m e mber.
The h ealth hiRtory dc tt~rmine.-. current ill',1lth s tatus lin:::ed on :-;ignilica nt
p;1st hc,1lth histo ry t C,l?, d c "clnp nwnl ol ,H"CLHt1plis hmr11 ts . knnwn illn esses,
allc rgks. restora ti\'{c' trc,1l m c nl , rPs ide nl'l: in end e mic :1rcas for c ertain
disc;.1:,,p.s o r c'~ l"'""n.• s In 1-·01111111111k:1hh· rlisenscs): fam ily his lory (e.g.
gen et ic h ii,lory in re lat io n lu h ea lth :md ill n ess) and s,xia l history, s uch
.1s int raf)<!rsnnal and intcq)ersun;il fad on, :i ffcctinJJ. the fami ly member·s
social adj nsl m c n t o r vu ln e r,1bility In s tres:,; .mu c ri!,is (C le men-S lone anu
<1th c n; l 99 l, p .:;?7 1).
A secon d type of in t e rview is c.:olleclin~ tlaltl by personally asking
s ig n ificnnt fnmilr 111c rnhL·1·:a 111· rdnti \'CS qu c:ation s rq::ard in g h e.-i! Lh ,
famil~· lifc c:q wric111·cs 1111d ho m e L'11 vini111111.! ut lo ~,·nPrn ll' data 0 11 what
we llness cn ndi l in 11 / s a nd lwa ll h prnh l,·ms ,·xis l in lh,· fomi ly ( Fit"!<llcvr.l ,\ s.~P.~sm ,· 111 . $L'•· Tr1hl, · 2_!.! ) :i nd Ilw l'nn-cs pomli n;: f:unilr m 11 s ing
p roble ms for .:a..:h hl'allh ,·m 1Jitin11 n r pr0 h lo.:rn (Scenncl-lc,·cl As:;\.'ssmc11 t.
Table 2.2). "ns u riu~ 1:nntid,•11tia lily anti rnspeL"l for lhe fa mi ly\ ; ri~ht lo
self-clc tc rmi nation arc key pri11ciplcs It> considur during a ll phases of the
n nrs ing prm:e:;s.
The uu n;c can a ls o collec t in furm :ition rrn111 cnllr.agur.s wh o work "ilh
the fam ily llt'<·Ord in.; to the ir pnrt ic ula r scrvic·c spcci;1lti cs a s we ll os
sch ool p c ri;on ncl , emp loyers, sig n ifica n t olhc1·s an ti communi ty w orke r~
who can giw reliable and rr>lc v,rn t i nforn1alion o n l ht.> fami l~• s lire .111d
experien ces.
P n1cluct·ivil'y of lhu inlcn iow process d (1pcnds u p on th e use of effective
communicalio 11 lL•c hniquc:- tu l.'licil th e n eeded rc.<;ponscs-. One m ajor
prol>lc m t'lll'lHLILLL'rcd by prut t ii ion e r,: in gal h t•ring dnl a (,•.sp eci ally fo r th e
sccond-1,:,·e l a ~,-.cs:-;rn c nt) is h ow In d ctv rm i11t' wh crP the die n l i s i11 te rms
of p e rce pti o n o f the health t•n ndiLion nr prnhll'n1and th e p:ille rns ofrnping
utiliz1'fl Ill rc.-;uln • or 11ddrr.:.~ it. There i~ a lcncl r 1wy :111H,11J1. com mun ity
h ealth 1111 rsc·s to rP:ul ily ~in.! o ut ad 1·icc. h i.:a llh lcac·hings o r s,>lutio ns once
th ey ha\'C itlenl ified Lh<' h<•alt h t·ond it ir111s t 1r pr11blc111s. T hl•rc are , ·rlj· few
instance$ w he n they ddc r mi nc first the dic11l s pcrcr p tio n of the hciilth
co nd it io n or proble m .tllll rciim1rccs in clct11ing with it h e.fo re th ey take
at.:Livn or do nurs ing in lc r-·cnt io ns.
0
lntet·vicw ques6ons and commun ic;i tion techn iq ues m ust be guided
by theorelkal perspectives in family h eallh earl". Rl•specl, tru s t a n d
cot11iclenliolity are crilka l v,ilu es to 111ai11t,1i11 when t:onclu<"t ing the
in te r vie w. Confide nce on Lhc m:e of t:l\mmnn icn lion tec hniques c.:an
co m e a fter bcin i; fa m il iar w ith nnd b e in g L't.m1pete11t 011 the tL<;C of ty pes of
q11c.c;t io 11s tli:H aim to e-..p lrwc, valid il lt.•, t:larifr. offer fc(•db:1ck, e ncourage
vcrb aliwtio ns of lh ouv.ht s 1111d fcel i11f;S, and offer m:e<led support o r
rc ass11rnncc.
Second -le vel nsscs.smcnt cm1 be adeq natcJ~, done for each wcll nr._<t<; s tntc,
h ea lth threa t, h ea lth d e fici t or cri~is situntion by going throu g h th e
followillH s lCJJS with fami ly nicmbt.:rs who may n eed lo h elp each o ther
va lida te int erview d a ta un rc a liti«::.~ or experience.-; rega rding pe rforman ce
59
o f th e family lw11l th tas ks:
n.
D e te rm in e 1r I he fomii l~· reco ~ nize.'< th e e x is te nce of th e conclilion
o r p roble m. Jf the fa 111j]y d oes n o t recog n i ze th e p resence o f t h e
conditio n or p ru blcrn. e x plore lht: nms uns why.
Sn m plc int ervi1•" q ucs l iuns :
1.
\'\rhul cioe.:- Lh t.' fom il~• think aho nl the s ill111tio11/ condilion
of . . . ? (,\no ang palngay/ ling in ninyo s n knlngaya n o
k ondi!-; ,'Ull n g. ...
·n
\\'h a t do yo u ·think is the re ason w h y h e/she appears (e .g .
tli in. letha rgic)? Or. wh,\· d o y ou Ll1ink I.Je/ she is h c h aving
thi i- \\ :ff • . . ? (.-\J1<1 s:1 p::il:.ii,:a~· niuyo :mg d:.ihil;111 k ung
b n kit siya nagkn ka~u nya n ?)
iii. \\' ll nt do you thi nk is hap p ening to your .. . ? (Ano !'-a
pnln g ny n inyo :ind nan g ya y 11 ri sn inyong ... ?)
i\'. \\"hy d o Y OU thin k h e/sh e is .. . ? (Ano s:i p:ila gay/ tin g in
n iayo :rng d nhilnn niya .. ?)
u.
60
b.
If the family r ecognizes the presence of U1e co ndition or proble m.
determine if so111elhing ha s i.ltc!ell tlvnc lo ma i11 lt1 i n tl1c w d!J1 e,;s
"l:lte o r rl'SO l\'e llll' problem. If Llw family has 11ol ck,m.· ..111)1.h ini-t
:1b ou t it. dl' it?rmi nc u 1c reasu ns w h y . U the fn m ily h ;is u r>I\\!
so rnc tJ1i ns. ttbo ut the p rn blcm ur co nditi o n. d cu.•n11 in e i f th e
solu tion is cffectin~.
Sample int e n -iew q uest inns:
1.
\\11a t h as been don e to im p rm·e th e co ndition or si t 11ati o n ·1
(AmJ n a :mg ll,lgawn p nra mng bago an g ka lag ayan . . . o
m apai1;i a n<l p:1ki r amu am .. . ?)
ii. \lih:i t is t he family ',; pl:111 rcg:11·di ng this? (An0 a n i4
bin:th:-1 1:i k n g p a mily:i Lu11 g kv l c.li to?)
iii. \Vl,a t irnproyem e nt s in Liu: c.:u ntl i Lion o f . . . ha n : 1,een
oh,sr r-·c•d ? (,\ no ng m i-:,1 pa j!bahago a 11g inyo ng n:i p ans in
s:1 kal agaya n n i ••• ? )
iv. W hot dfJ ~,Ju think th e fo m ih- s ho u ld do :abc,111 .. . '? (J\no
sa palaga; 11in~·o a n g d:1r,t1 t gawin ng p:imily:1 lun g lw l
S:.t ' . • ?)
c.
De term ine: if th e f::1m ilycn c·ou nt cn;oLh e rprobl c m s in im plc na c n t ing
the int cr-·cnt ions for tlw \,·cll111~1,s s talu/illJ lcmli af. la c a lLb llffc:it.
hc11 llh deficit or c-ri<;i,;. \ \'ha t .ar c th ese problems'!
Snmrl, lnkr-·it·\•.' t p H·--t il)n.'I:
i.
Vl'hn t ,, ,•re• the r ro hl cms n r harr-i ,,.r s , •nc nunt c rc J in ... '?
(.-\ 1111-nnr, ;1 0~ 111yonp, nagi ng pro bfo:nia sa p ngp :i p:at u pad
n ~ m ga -;olu-.._\·on -;;, . . ':' ,,,. /\r111-:i no :1ng m g a m 1g ing
.o;ag:tb <ll 1) ha l:-1kid n a ng myo ng p.i 11rl\V,J :1111; ... ?)
ii. , v h :H do , ·0 11 think :.ire t li~· rTa-;0 11 s w lw th ere is m>
irn p rnvr: m;•,H in the r-o n d it i11n o f . . . '? · (,\1111 - mw s.t
pnl :11;:,~· 11inyn :,11;:. dnhib n fcung hak it w :il:a11g p a g lw bagu
ClllJ!. kalagJv:111 111 ••• '?)
iii. V,' h) d1tl nJ u .- .tup tloanr; wl int yo u 11_..,c-(i to c.ln r ega rdin g .
• . ? (H aldi nin yo it i11ii:;i l CJ hindi ipin:1p.p ,1t1J lny a n g ll a li
11inyong gin:iwn,a .... a .. . ?)
i\'. \\'hy d itl yc,u 110 1 C◄J r 1 l in u<.: do in,:;, w li ,1t we lta\'l! lli ~CLISSCd
reganli ng . . ? ( Bak.i t hi n di ni n )<> ipin,,gpn tu loyn n d a ting
v.
cl.
p u1a,;-usap,m Lu n g ko l sa . .. ?)
How did yo u do il? (Papaono n inyo gin a w.J i1 0?) Or how
nft c n did you do it? (Gaan o ni n yo kadalas g inn wu ito r)
Determine h nw the othe r fa mily m emb e rs arc b e having toward s
each other o r how tbcy arc affected by the heo lth condition o r
pro hl e m.
Sam pl €' in I cr"ie w questions:
L.
How are I.he ot h er members a ffected by ... ? (Ano ang
n aginµ e pck to ng ... sa ib,mg m iyembro ng p am ilra?)
ii. How an, Lue: c>lher members reacti.n g to ... ? (Ano and
rcaksro n ng ilnu1g miyembro n g pam i.lya sa .. . ?)
4
Record Rc,·iew. The n mse may galh e r info rma ti on through reviewing
cxis ling rccordi; ,111cl. rcpo11 s pert inent lo tb c c.:He nt. T h es<.! include
th e i11<livid1.1 tal d i11ic;,il n.:c:onls o f the fami ly members. lalm n.1Lory an d
diag110:;Lic report~, i111mu uiza li un record s. reports aboul the home and
c n,iro nment;il c<>nd itio ns. or si mil ar sOlLrccs.
5.
I.ahoratory/ Di a gn o s tic T e sts. An o lher meLho c.l of da ta collection is
Lh rnu~1 pe1-fo r111 ing lnbora tu,1,- tests. diagnostic procedures, o r o th er tests
in tegr ity nod f1Loclious ca rried o ul by Lhe nu.rsc h e rself and/or o Lhc r
h eall h workers.
or
T he Assessment Dnla B ase (AD B) is s upported and co mple m e nt e d by nthcr fn m ily
,1sscssmenl I nnls tn r-l i1·i1 gcn c n11io nnl inf<Jrmal ion ,ilJou t farn ily s tructure n od p ro cesses
(Acnngr:1 111). f.ient;i l d;iia a hont fami ly rela tions-hip with t lll' ex1<'nrnl c n vironmen1 nnd
ils resources (c,·omAp). a11<1 i111c rne tive processes a nd fomi l:, n ~lntinn s h ip problc,ms/
dif!i c-111 i-ks ,1 ml s tre n g ths (fo m ily-Ji fc elm m n logy).
Gc no,;ra ms j'.!,l"Hphic.n lly display infornrntion abo111 fomi l_v m e mbers and their
rtil:1tio11shi p,; on· r ,11 lc~1~1 th rcr gl' n!'ratinns. The Fan'li l y S y ste m s Th eory of
i\lu rr;1~• 11mwn ( 19713) is 11scd a s th e con ceptua l fra mewo rk for constrm:l.in g mid
:111:1lyz in,:; i-;c u o~rnrn p .11 tc rn s (i.c slructurnl, rcl;1tional an<l f1.111ctional lnfo rmalio n
:1ho 11l :1 (: 1111ily) , ·t!'\\'l'd h nriu► nlallv :1cross 1h11 famil y con lc~:t an d ve rti1;;,1lly th rougb
i;c11c r:1t ions. T he h r<,adlh o f th,~ current f;i m ily n m le xl capt ures the eonneelt!<l 11ess
of 11uc k m· :, nd cx lc ndcd fomi ly 111c111 bcrs w, we ll as e-i~uilicanl n \111-f;i 111ll y mt•rn licn;
wh o h;.-·c· c.,,•c r li ,·ccl wit h or p l:1yed a m ajor rulc i n the fam ily's life, in d 11di ng fom iJy
.sl rcngl h s :md \'l dn c rahil il ie s in ,·elation liJ Lhe ovcrn ll Sil u a ti o n. Depcndi nA o n the
le vel o l as~css111c11 t cn111 peli..:ntic:s oJ' th .:: n urs-,, no<l ul iUJ d crit ical events in th e Camily's
h i.~ lo ry art· assr,;sc d "ith i11 and Lhrougl1 li fe t·y.:11,; transitio ns, p la c.:ing present issues
in the c:n11lext u l I he fam ilv',; evo lu tio nary p a ll c rn s. Curre nt b e h avior or prnblcm/s
or family me 1nbers c::i u be ain,lyzcd fro m nrnl tiplc perspectiv es. Data abo u t th e in dex
p c ,-,;on (IP). I he µer,;un w ith Lhe problem or sym ptom. c an he , i e w1~d in tlw c:o nr ex-1
o r vad ous s u bsyste m s (s ui:11 as s ihl ini-:s. com plcmcnlnry an d sym rne l ricnl , rec:1procnl
rc l:11io11sh ip.s) or in rc l:Hion to Lile hrnndcr sut.:i11-c11ltu rn 1 con text (e.g. th e c:0111 mu nity
and s<1l' i;1 I i11sli 1t1Lio n s}. Family mr111bers nre i11 1ervicwcd ;1ho 111 1·h c p1·escnt siluHtion
in rclu1 i,111 lo the I he mes. mylh s. rule,; a nd emotio n a lly chargeti issue;; of _prevfous
gcncra li o11s, .s11,:;~t~sli11 i~ poss ible· 1·nr111cctions hclwt'C'l1 fami ly events. Patte rns of
p n •\'io1 1s ill m:.s.s a nd carli1:r .shifl.s in fo 111ily rclnt.innsh iJ.)s liro u1;hl about thr o ugh c hanges
in fo m il~· s t ru ct urc a ntl othcr c:ril1cal life clrn n i;,l's can easily be noted 0 11 th<:: gcnogra m ,
p rovi,lin ~ .i rid1 !:'Ourco: of inforrn:1lion a b o ut whal lead.s to c h a n ge iJ1 a paTticular fa mil.)"
(Mc<.;old rick mul G1::r);o11 1985, pp. ~-3).
61
A n ecoma p visunlly diagr:,ms the family's interact ions or relationships w ith Lhe e xten111 1
environment a nd its resou rc·cs. llsum111.:irize:c;o11 one page I he family stre ngth s, con Diets
and s t resses in r e lation Lo its inte rac tions witl1 ind.ivic.Jnal:; and agencies outsid e the
fami ly s_vstc m. As o ne of Lht:· forcrunncn< Lo use Ll w ect)m ap, Harl1mu1 (1978) used the
tool to l?.X:t m i nc b o undary m aint e na ru:e nspet'.ls of fr1mily functioning. The ccomap
dramatically il111slra1 es the amount of<:?.nergy used by a f:1111ily lo rn;i inta in its systelll,
as vJell as t h e presen ce or a b sence of situationa l s upports nncl other family resources.
]t helps i<lcnlif-y h ow family energ ies ar-e being usecJ nnd w h en r elationships w ith the
external environment -1re posi tively or negatively inOuc ndn)?, family fun c lion ing.
To ill\lstrate, if u fami ly's tlovv of ene rgy ns depicted on lht: ecomaµ 1·ellecls only an
o u tward d irectio n al process ( - ... -► -►), r-h c fa mily m ay ha ve difficulty p 1·oviding a
nu rturing e nvironm e nt fo1· family members nnd nch ieve ils gonls (Clemen-Slo n e n nd
others 200 2 • p . 194-195). The ccomap is p;irricuh1 J"ly usefu l wh e n the family is involved
with several co mmunity systems or when the fam ily perceives a lack of supp ort from
significan t others.
Family-life ch ronology helps cap:llre ~amily inL-eractiv_e pro~esses that J1ave_ e vo l~e d
(Satir l 6 7) . Ltcun hel p tl1t' fanuly ~<l e~lify th e ~trc~ gth s m fo,mly member re~atior~sh_1ps
9
over tim e and the need Lo a-llc.r farmly f11nct10mng to reduce s tress. By 1denttfymg
•latjonsllit• difficult ic:s wi tl,in the family, the 1111rse can focllitate the development of
re <
.,
.
b
Ii _,
d'
.
effective family proct!sses by e nc~ur~'.g'. ng mem er s to m" w11ys to 1scuss and ad<lress
their diffe ren ce:; io support of 111cliv1dual and fa mi ly wellness (Clemen-Stone a n d
oth ers 2002 pp. 195- 196).
Appendices B1 lo 83 describe how the genogram, ecomap and fanrily-life chronology
are constmcted.
DATA ANALYSIS
Utilizi ng tJ, e data gcner;1 led from the tool on AS$ess m ent D_;ita Base in Family
Nursing Practice (See Table 2.1), the nurse goes th rough d ata ana lysis. She sorts out
and classifies or jlroups dat a by type 0 1· na ture (e.~. wb ich are wellness states, th reats,
deficits, c,r stress points/foreseeable cr-iscs). S b e rclntes them with e.ach other and
determines patterns or reoccurring r-hcmcs among the d ata. She then compares th ese
data ,,nd the pottcrns or recurring th em es with norms or standards.
The standards or norm~ ut ilized in deter m ining tJ1e s tatus o-f th e family as a client o r
patienl can be classified into tJ1ree lypes:
Normal healtJ1 of indrvidual members;
Home and em;ronmental conditions conducive to health development,
and;
3 . Family characteristics, dynamics or level of fun ctioning conducive to
family growth aod development.
1.
2.
n orrmil health of members - involves the physica l, social and
Home 11 n <l environme ntal cond ition s
include both the phys ical as well as the psycho logical and soc-io- cu ltun,1 mi lie u. Such
n milieu considers th e type an d qu ali ty uf ho using, aucquacy of Jiving spac e, adequacy
of sani tation fnr ilitics and rcso1u-ces lm tl1 in tlte h ome ; incl t h e comm u nity, the k ind of
neig hbo rhood, psyc hological or socio-cu ltun~I norms. values, expecl;itio ns or modes of
lifo whic h enh:rn c(' h ealt h rle vc lopnll'nt a nd p revent or cont·rol ris k factors and hazards.
TI1e th in.! type - family r ha ractcdstic.,; o r fun ctioning - con s titutes th e client's ability
as a system m maintain its boundary integrity and achieve its purposes thro ugh a
dynamic intercha nge a mong its members whi le responding to the external m ul ti-
Tbe first type -
emoti()lrnl well-beii,i:; of each fom ily member .
62
environments along a li me continu um . Charnctc risti c.« of hca1H1y family fi inctioniog
are descri bed as flexible role patterns, responsiveness to needs of individual m e m bers,
dyo111nic proble m -snlvint, mech anisms, abi li ty tr, acc:c.pt help, npe n r ommunica tion
patte rns, cxpcric11ccof lrust and respe:c t in" w.irm :111d ca rin g at mosphere aJ1d capaci ty
lo maintain a nd crcalc cons tructive relal;onships with the broader neig hborhood and
commu nity (Cleme n -Sl one and others 199l, pp. :.t69 - 270).
In ord e r to achieve wellness among its m embe rs ;ind reduce or eliminate health
proble m s, th e s t1111dord o r norm o f the family as 11 funcLioning unit involves the ability
to perfo rm the followi ng h ealth tasks:
1.
Recogn ize the presence
or a wellness state or healt h condition or
problem ;
:?..
3.
4.
5.
Mukc decision:=; about t11king apprnprfate health actinn to mainta in
w ellness or manage the health prnblem;
Provide nursing c,11-e to lhc s ick, disnbled, depe ndent or al-risk membe rs;
Maintain a home envirnn m cnt co nducive to hea lth ma intenan ce and
personal <lcvclopmcnt; and,
Utilize community resou rces for h ealth Cbtre.
After rel ating family data to relevant cli·nical or research fi ndings and compa riso n of
pntterns w ith no rms or standards, Assessment data, as categorized o r reorganized,
a re interpreted and infere nces are drawn. The end result of th is an a lysis d uri_ng the
first-level assessment is a conclusion or a statement of a health condition or problem,
classified as a wellness po tential, health threat. h ealth dc fic.it or stress p oin t/foreseeable
crisis. T his definitio n constitutes any of the foll ov,ing:
Transition state from a speciiic level of wellness to a l1igher level;
Medical or nursing diagnos is indicating cun:cnt h ealth status of each
family m ember;
3 . Con dition of hom e a nd e nvironment conducive ·,o d isease/illness or
accidents; nnd,
4. Man1ration/dcveloprnentnl o.r s ituational cri sis situ ation.
i.
2.
T he second-level of analysis ends with a d efinition of family nt'lrsing problems. T o
dctinc family nursing problems, eoch well ness state or l1 e,1lth condition o r problem
must be nnaly,;ed in terms of how the famjly handles it. The process of data gathe ring
for this :malyi;is has bee n described ea rl ier (sec lnterview, Data-gathering Methods
and Tools). T he patterns and implications o f th ese data re □ect expbmations and
inferences about l11 e family as a flt nct-ion_ing unit u1 tenns of i ts problems rela ted to
performance of fa mily h ealth tasks. The causes of or the reasons for tl1e existence of
the condi tion or h ealth condition or problem reflect barriers to the fam ily's capabilities
to promote and m ain tain hea lth among its members as it maintains family system
integrity. Figure 2.1 sw11m.irizes the critical thinking process during tbe assessment
phase in family health nur.sing practice.
NURSING DIAGNOSES: FAM ILY NURSING PROBLEMS
171e end result of tJ,e second-l.cvel assessment is fl set of family mirsing problems for
each health condition or problem.
A well ness comlilion is a nursing judgment related with Lhe clienl's capability for
wellness. A l1ea1th condition or proble m is a situation which interferes witn tbe
promotion and /or maintenance of h ealth and recovery from illness or inj ury. A
6'3
~,•ellness state o r hc~l~1 co~dition /proble m becomes a fami ly nursing problem when it
1s stated_ as the fam1ly ~ fml ure to per form adequate ly specific h ea lth tasks to e nhance
o: sustu~n _the we_llness s ~::ite or m~ma11,e t h c- h~alth problem. This is called u,e nursing
d1agnos1s 111 family nu rsing practice. specifically d efined a $ a di11ical judgment ,1bout
the fami ly's response t o actual o r potential health problems o r life processes (1'onh
American Nursing Diagnosis Associat ion [NANDA] 200-1) .
O n e of the major barriers to the effective oper.1tiona]i7,.a tion ;ind appl ication of t he
nursin~ process in fami ly h ea lth c.ire is the absence of a class ifica ti on sysl t! m fu r
nurs ing problems th at refl ect the fam iJ., · !,"la tu:- and cap~bilitic-.s as a functioning unit.
To fncili t ate the p rocess of defining family nursin}\ prnble ni!>. a rla,;.sifieMinn .~ys1rm
o f family nursing problems was developed and field tcl-'tcu in 197R. TI1is tno l. ca ll Fci A
Tvpology of Nursing Problems in Family N urs ing Practice (;.ee Tnhle 2 . :-! ) . has
b;c n u sed by nursing :<tu dcnts. commu nity hea lth nurse pra<.:titio ncrs and c<l u ca tors.
Thi-o u g h the year.; red sio ns lu:l\·e been t k111 e to e nsure ;i ll-inclusive n ess a nd m11h1al
e.xclusive n e.,s of the list. Jn 2 003, pre.<;ence of wellness condition has been a dd e d in the
first - level assessment pa1-t of t he typology.
THE TYPOLOGY OF NURS I NG PROBLEMS IN FAMILY HEA LTH
CAR E
The orgam:rJng framework of the typc1logy is bnsed on the fo mily h e a lth tasks
(Frttmt1n t1nd l-l cinlich 198i, pp. 94 - 95). The rat ionnle for adopting these h ealth
tasks as 11,e frnmcwnrk <>f the typology is U1e fact that in con1111u11ir-y health nurs ing
p ractice. the n un;e dea l!.< mos tly wit h proble ms with in tbe domain of Jnm wn h ch,l\ior
or huma n response to !Ica lth a nd illn <?SS. It is no l v1:ffy o ft1;:n that 1l1e cpmmu n ity
health nurse d cnls wi lh Ila; physi<'nl, p,~yc·holog ic.11 nr c;li ni cal condition of t h e patient
requirin,:; he·r sus tai ned di reel scn·kes such 1l!< n11r:-i ng t:nre du rin g IJ1c .,cute phase of
an i.l.lncss in U1e bospi1:.1I sc ttiug. :vruch ot t h e nurse·s effort s are di rected a t effectin g
cha ng.:- in the behavior of clients to adtie,,e optimum healt h . 111e conunu nity heaJtJ1
nu:rsc "·arks with and thro ugh the family to improve its capabi lity lo achieve healtl111nd
wellness among its memlJers.
TI1e typoloro·contains si;,;; main categoric:~ of problem,:: in fa mily nursing care (see Table
2.2). The Jirst cate~OT)' refers to the p resence of wellness states, h ealth threats, health
deficits and foreseeable c,;sis situ:11 ions or stress points. The res ult of the analysis
of da w taken during the fi rsl - level a.s.sessmen t (utilizing tJ1 e tool Assessm ent
Data Base for Family Nursing) is re flected as statemen t of the he,~ lt h condition
or problem. a ,,·ellness st ate. h ealth threal, liealt·h deficit or foreseeable crisis/stress
point. .After ide nrif-vi n~ these bc:1lth conditions or problems. the nurse tletermines
the fornily·s ;ibi lity to perfom, the five hen Ith 1;1sks on each o n e . The remaining five
ma in catc-gorics of prolJlcms contain s late mea ts of the fami ly's inability to perform
the health t;isk.s. The results of the unalys is of Jata take u during IJ1e second - Jevel
assessment a rc reflected as statements of th e family nurs ing problems. There are five
main types. nam ely;
J.
Inability to recognize tJ1e p resen ce of the condition/problem due to...
2 . Jnnhi lity to make d ecisions wi th respect to ta.king appropriate h ealth action
due to...
3. Jnubility to provide n ursing ca re to the sick, disabled, dependent or at-risk
m ember of 1he fami ly due tv ...
4. Ioobility to p rovide a home environment wl1 ich is conducive to h ealtb
maintenance and personal deve lopment due to ...
5. Failure to uliJize community resources for health care due to ...
64
The c:a tegnriz.·1tim1 llf pn,blcm!- in th,· t~~iln!'0· r11n'<1 it111 L'5 "L',·rrul ln·l'I" :11:ct•rdin~ to the
dt')!.rec nf $!Ctwrnli{) "r :sp~-ci1ic·1t,·. ,\fipr c:1d 1 main l':llc'i,!c>r\" ,,i fan11l~· n11r-1nt problem.
;;e~--cnil mnn• spt'c·ift,· pr,1hl.-m--· ,tr,· i, kn11 ri,·d ro'lkc I 111i; ,·n11 r ril 1111, 11~ prnh l,•111,; to or
e~1'1:tna1ions f11r 1lw ,,,,,-1,•n,·,• nf tlw 111 nm pn,hl,·111 n,i-. i-. p.tr:ill,·1t111 h,· ,:, •ncq1ts of
immPdi:llC \'.111~·. int,:rnwd1.1t,· l :111,.,. ,lllt I ult lt11.tt1• l"JU..,· " lw11 crl, Ill ,r, 1111: th•• \ au!-e(~J
of morbidity "r m 11r1ah1-:,. "r :<-!rn1d111~ 1•r .u,,i .1 ...,n,11'-. 11111, ,•l' I 11f ,, 11111-.i11~ di:,,~111>::is
(:'> lundingt'r :md .J:1urc,n t',l--:;. pp. n<, - <.!-) • . \,·,·nnlin" 1,, 1lw latt,·r. ., n1 1r-111~: diai;nosis
com,ists of rwo pani:::
I.
2.
·n,~• :<lnlt'mcnt oi tlw llttlwalthflll n.•,sp~lt1Sl': :incl.
·n,t" '\latrm,·nt of t:io.:1nrs which -Ill' 1n;1inlninin" tin· 11111h-~lr.,hk respn n-<l'
:rn<l pn•,entin,z the do.:'iil'\?d d1.111~v
The more specilic thC' pmblC'm d,•1i11iti1>n (wlnl'h olqw11.I-., ,11 tltl' clrprh .md hrc,1dtli
of th e n:<St.!..''-:m1 e 11tl. th~ mnn• 11.-:t•f11I 1:- the• 1111r..,111;; .!1.,i-;111,-.1, 111 d,·1 ,• rm 111 rn1; nursin►:
in tervention. Th,·i-cfor,~. ,t:- rn ,m , ,1s lhn•,, ,,r f11t11· 1<·,·.-t-. ,,1 ,,,,,1,J1, 111 d,·lir 11 1 1, 111 ,·,11 , I,~·
st:itcd. T n illus lr:i l,•. in., f.L111il) "llh H pr,•11.11.,j 1'11t1,•11t ,,i,11 I'•
lhc , am, · ti1tu• tht·
hrcadwin nl!r of the f:trnih· ,111 d whn is 11111 r,·,·,·i,·i11~ ,111y car,· su,wr.·i-;a,n. llw 1111 .-.. 101;
.,t
problem mar be ,:;l,11.:<l n,.:
(Gencrn l)
(Sped fi c)
lnahi lir~ lo utilirt• , 111111111111it,· n·,-nurc,·:-: f, ,r lw.tlth c·:,rc
du~'''.' in 11 l: ·•1u;, i-, l;1111ih r,•,-0111·,·,,,., "P<'<'ih~·.illy.
11. 1·1mm("1:il n·M•ur,·,•-.
h . rno n I'<'" ,·r rci<1111 n•c •,;;
C. ti 1n ~•
I'-,, t •I tts..,~~ ... ,n,t..·nt. l ic fan11- y
.
.
.
.
•
nursing proble ms spcc,ficalh- rclntc cl ,,•111, s 11s1·1'111·,,1 ,. ,,,,.Jt, 1t , 1 1
•tt • Ih r ·11
•
•
•
•
•
•
~ "'l:.
~
ss"
.,
'-'$. " ' ' 1111 t c i 1n11 v
sys tem 1s :iddc d 1n the upd nt c<l typolo~,·.
·
With th e Lnclu si nn 01 we lln ess s tn re!: •'" r•11rt of th,· tir,; 1
TABLE 2.1 ASSESSMENT DATA BASE IN FAMILY NUR'ilNG PRACTICE•
A.
Famlly Struct ure, Characteri:.ti<:~ and Oyn1lmi• P/"' 1 b
I
' !>el!
~ "' ""on..~ Patt • rn'
1. Mem bers aft he hou,ohold. b1tthd.lt~•
c1v 1 .
'
and re lation ship to the head ol t h4: fa~ily ·
'
li!IUS. po~t·on •n the f.lm,ly
2.
3.
4.
5.
SocioderT1ogr.rphic da..-, of f'Tl".!mbers no: curr ' l• .
• h maior
· roe
I 1n
· rcsourct• e~nr•r.1o~n -'I'd us,
' "1 i IIVlnl'• 1n tht I ous.ehold but
wit
Type of famll•1 structur,. and Form- e II ma, 1 •
e)(te ndecl or blended
r arrh..,I or p:itr1Mcha1 , nuct";:,r,
Dominant family members in tc •nv of d~c
•
,- 1s1on rn lei
(
of h eal th care) and care tend,ng
" n~ <'<.pt•cl;ill•,· on matt, r<
Family dy11am1cs. c;ommunication p.ittern/s •
Interpersonal relationship~ (r 8 dyad
,; intcr.ict1on.:it Pr. o.:~.,~s .:ind
,c ilnu lrt.ld1c 1 t
innate or great potenti.il to mediate or potentt.:
" e r;, cnon,-J wh,ch pos~csr.
illness. growth, development .an·' th~ f
, ate factor·, rell•v;int to h,•.,..lth,
., ~ am,1'/ s. ab1I 1t
h
anticipated and unexpected event•,_
V to dn dl · confl,ct, ch.inse,
•Developed and published by SiilVllc,on G. Ballon-Reye~
.
(see Bailon SG and Maglaya AS: Fam,ty Hrolth Nurs/n _ ~~d Araceh S. Maglaya, 1978
Brain.c:hlld Managers and Consultants. 1990): revlew:d &. ~ Pro,:..:sj,. Pnnt1n1~ 4, Manila.
iiOd 2009 by A .S. Maglaya.
lJPdilt<?d •n 199•1. 1997, 2003
-
65
e.
s~io-economic and Cutt ural Characte ristics
• l ncom c a 1, d E,c~ nses
1
a. o ccupati o n . place o r work an d incorn e or ea ch w orking m em b e r
b . Ade q uac y to m e et b asic n c cc ssitf cs (food , c lo thh, g , sh e lte r)
c. Who m al<e~ de cision~ ;,bo u l m on ey ;in d ho w 1t Is sp ent
Ed u cati otii!I an alnment o l each m c m t,e r
Et h n •c: b ackgroun d and re ligious o1fflliation
fa m ily Traditions. event~ or p r actices affec;ting memb e r s' h e.a Ith or family
4.
rvnc ti on,ng
s ,gn ifiu nt Ot h er$ - role (sl t h ey play i n fa m i ly' s life
s. Re lati onsh ip of t he family to l arger co m mun ity - Natur e a nd extent of
6.
parti ci p.itton o f t h•• fam iiy i n comm~inlty a ctivi ties
c.
t{orne and Environment
1. Hcusing
a . /l dt!qu acy o f living s~ace
LI. Slee p •n!! arra•1.!;E•rn e nt
•
c. Pre !enc,; of brc e amg o r resting sites of vectors or diseases (e. g .
rno soul coes. r oaches, mes, rodents, etc.)
d . Pt e~ence of acCtccnt an d fire hazards
Food stor afie -a nd coo l,i ng racillties
W.J ter ~upply - ~our<;e, ownersh ip. potability
Toil e t ! ac,lol y - t,·pe. ownersh, p, sanitary conditi o n
Garbase/ re f,Jse dispo,al - t yp e, sanitary condi tion
Drainage sv~le m - typ e, san1 t a,r y rondltion
2
3.
4.
0
Kind o f ne1ghoo chood, e.g. congested, slum, etc.
s o o al and heal th faci lities avallable
communicacion and transport ano n facilities available
Health Statt.J $ of eac h Fam fly Member
1. Med,cal and nu rsing h,story indicating current or past slsn ifican l Hlne s ses or
2.
belief s and p raco ces condu civ e to healt h and illn ess
NLttr>t1c nal aH <:s~men t {speci all y for vu ln erabl e or at -risk members)
a. /.n throporne trlc d at a · M easures of nutriHonal sta t u s o f c hildren - we ig h t,
he1~ t m 111-upper arm ci rcumf erence: Risk as sess m en t m e as u res for
Ob e~1ty • bo dy ma~s index (8 1-.111: we l5ht in legs. d iv,d ecf by h e i g ht
,n /T\Ft e r sl ), wa1~ r circumference (\,VC; gr ea ter than 90 crn. i n m e n
and o reate r th;;" 80 cm 1n women ). wai st hip ratio (W H R = wa i st
ci1<.1.,n1forence 1n cm d 1v 1ded by hip circumference i n cm Ce ntra l O besity:
Wf1R Pquar !I) or gr e111er t han 1 .0 cm. in m e n and 0 .85 i n wom e n).
b, D'et a1 y n,sro ,y specify,ng q u al,ry and quanti ty of f oo d/nutrient intake per
day
c..
3.
•·
Ea ti ng/ fc~'1, ng hal:>its/pr ;ic n ce \
Developmt'r.tal dv,e i.sm ..nt o f infants, t oddle r~. and p r e schoolers - e.9., Met ro
M antia 0 e ,,elc p mem a l Sc reen ing i t"S t (MMDSn.
Ris k fano, as: essrne nt ind t.1 n n g p1'esen•c.c o f maj or and c ontri buting
modift.Jl::le risk fact o r s tor spe cific l,f~styJe diseases - e .g . hyperte nsion,
phy~i c.tl ,n.act1v1l y, se-d e11tary Jrfestyte, ci;ga rette/toba~c.o s moking. elcva l e d
bloo d lipids/cho!o1.ero t, obesil-y, dtabe~es mellirus, Inadeq u a t e Hber rnt .:ike,
Streu, a!cohol dr1n1'.ir-,a and ~Mer subst...mce ~buw
66
5.
6.
E.
Physical assessment Indicating presence of illnes5 r.tate/s (diagno:.-~ or
u ndiagnosed by m edical p rat:tltioners)
Results of labo ratory/diagnostic and other screening procedures supportive of
assessment findi ngs
Values, Habits, Practites on Health Promotion, Maintenance and Disease Preve ntion
Examples Include:
1. Immunization status of family members
2. Healthy lifest yl e practfcl!s. Specfry.
3. Adequacy of:
a. rest and sleep
b. exercise/activities
c. use or protective measures - e.a. adequate footwear ln p arasite-infested
areas; use of bednets and protective clothing ,n malaria and filariasii.
endemic areas
d. relaxation and other stress management activities
e. oportunltles w hich enhance feelings or self worth, self efficacy and
sense of connectedness lo sel f, others and a higher power, essence of
meaningfulness.
_ use of promotfve-prellentive h ealth services (such as maternal and chlild heal,h
4
supervision) and use of hc.il t hy life style-relate d services
• source: compendium of Ph lllpp ine Medicine. Guidelines for a Healthy and Safe Weight
en1 Program, PASOO Recommendation, 3rd Ed. (2000).
Mana flem
TABLE z.z A TYPOLOGY OF NURS ING P ROBLEMS IN FAMILY NURSING PRACTICE•
FIRST-LEVEL ASSESSM EIIIT
I.
sence of wellness Condition - sta t ed as Poten tia l or Readiness - a dlnical or
::r,dn g judgment about a clien t i n transltien from a specific level of we!lne~~
or c;apabi lllY to a higher level (NANDA, 2001). Wellness potential is a nursiAA
d ment on wellness state or condition based on chent'.s performance, current
ju mBpetencles or clinical data but ~ l!/'Xp lfcit expression of client dPsire.. Rea.diness
GO
. a n u rsing
. j u d gment on wellness state or condition
nhanced wellness sr.it e 1s
.
for e
client's current comp etencies or performance clinical data and e,cpliclt
bUC d Ofl
'
AnJon of desire t o achieve a h igher level of state or function in a specillc .;irea
expr...... ,
on health promotion and maint enance. E~arnples of these are the following·
Potential for Enhanced capability. for:
A. l. Healthy U f estyle - e.g. nutnfion/d iet, exercise/activity
. Health Malntenance/He al th M anagement
2
3. Parenting
f di
4 • Breastfeeding
s. Spiriti.ral Well-beIng - process o a dent's developing/ unfolding of mynerv
through harmonio u s 1n terconr,ecte ness that comes from Inner strength1
sacred source/God (NANDA 2001)
6.
O t hers, sp ecify: - - - · - - - - - - -
67
~
B.
II.
Readiness for Enhanced Capability for:
1. Healthy Lifestyle
2 . Health Maintenance/Health Management
3 . Paren ting
4. Breastfeeding
5. Spiri tual W ell-being
6. Others, specify: _ _ _ _ __
Presence of Health Threats - condit ions that are conducive to disease and
acci dent, or may r esult to fai lure to maintain wellness or realize health poten tial.
Exampl es of these are the following:
A.
B.
c.
68
Presence of risk factors of specific diseases (e.g. lifestyle diseases, metabolic
syndrome)
Threat of cross infection from a communicable disease case
Family size beyond what family resources can adequately provide
o.
Accident/ fi re hazar ds. Example:
1. broken stairs
2. point ed/sharp objects, poisons, and medicines improperly kept
3. fire hazards
4. fall hazards
s. others (specify):
E.
Faulty/unhealthful nutritional/eating habits or feeding techniques or
practices-spec if y:
1. inadequate food Intake both In quality and quantity
2. excessive intake of certain nutrients
3. faulty eating habits
4. ineffective breastfeeding
s. faulty feeding techniques
F,
Stress-provoking fact ors - specify:
1. strained marital relationship
2. strained parent-sibling r elationshi p
3. interpersonal conflicts b e tween fam i ly members
4 . ca re-giving burden
G.
Poor home/environmental condlition/sanitation - specify:
1. inadequate living. space
2. lack of food st o rage faciliti es
3 . polluted water supply
4. presence of breeding or resti ng sites of vectors of d iseases (e.g.
mosqui toes, mes, roaches, r odents, etc.)
5. improper garbage/refuse disposal
6. unsanitary waste disposal
7. Improper drainage, system
8. poor fighting and ventilation
9, noise pollution
10 . air pollution
d
H.
Unsanitary food handling and preparation
I.
Unhealthf ul lifestyle a nd personal habits/practices - specify:
1 . alcohol dri nking
2. cigarette/tobacco smoking
3 . w alking barefooted or inad1::quale footwear
4, eating raw meal or fish
5 . poor pe rsona l hygiene
6. self- medication/substa nce abuse
7. sexua l promiscui ty
8 . enga ging in dangerous sportts
9. inadequate rest or sleep
10. lack of/i na dequate exercise/physical activity
11. lack of/i nadequate relaxation activities
12. non- use of self-p rotection measures (e.g. non-use of bed ne ts in
malaria and fil ariasis cndemfc oreas)
J.
Inheren t persona l ch arac ter istics - e.g. poor impu lse con t rol
Health h istory which may par ticipate/induce the occurrence of a health
deficit, e.g. history of difficu lt labor
L Inappropria te rol.e assumption - e.g. child assuming moth er's role, father
not assuming his role
M. Lac k of immunization/inadequate immunization status specially o f
children
N. Family disunit y - e.g.
1 . sel f-o riented behavior of member(s)
2. u nreso lved confl icts of mem ber(s)
3. Intolerable disagreement
0. Others, specify: _ _ _ _ _ _ _ _ __
K.
Ill.
Presence of Health Deficits - Instances of failure In health maintenance.
Examples in clu d e:
A. Illness states, regardless of whether it i s d iagnosed or undiagnose d l;>y
m edi cal practitioner
B. Failure to thrive/develop according to normal rate
C. Disability - whether congenital or arising from illn ess; transient/
temporary (e.g. aph asia or temporary par.ilysis after a CVA) or
permanent {e.g. leg am putation secondary to di.ibetes, blindn ess from
measles, lameness from polio)
IV.
Presen ce of Stress Points/Foreseeable Crisis Situations - anticipated periods
o f unusu al demand on t he individual or fam i ly in terms of adjustment/family
res o u rces; t ransitions (Le. p assage from one life phase, condi tion or status
to another, causing a forced or cha.sen change that results in t he need to
constru ct a new reali t y) . Examples of these include:
A. M arriage
B. Pregnancy, labo r, puerperl um
C. Pare nthood
D. A dditional member - e.g. newborn, lodger
E. .Abortion
69
Entrance at school
Adolescence
H. Divorce or separation
I. Menopa use
.I. Chro nic Illness
K. Loss of Job
L. Hospitalization of a family member
M . Death of a membe-r
N. Resettlement In a new community
0 . Illegitimacy
P. Others, specify _ _ __ _ _ _ _ _ __
f!.
G.
SECOND-LEVEL ASSESSMENT
I.
Inabi lity to recognize the presence of the condition or problem due to1
A, Lack of o r inadequate knowledge
e. Denial about rts existence or severity as a ri!Sult of fear of consequences of
d iagnosis of problem, specifically:
1. soda I-stigma. loss of respect of peer/slgnfffcant others
2. .econom ic/cost lmpllcat1ons
3 . physical consequences
4. em o tlonel/psycho1ogicai Issues/concerns
c. Attlt ude/ph ilosopby In fife which hinders recognltion/aeceptance of a problem
o. Others, specify _ _ _ __ _ _ _ _ __
11. Inability to make declsrons w i th respect to taklngcapproprlate health action due to:
Failure to comprehend the nature/magnf-tude of the problem/condition
Low salience of the-problem/condition
Feeling of eonfu sion, he1pfessness and/or resignation brought about by
perctvved m.ignitude/severlty of the situation or problem, i.e., failure to break
down proble m s into manageable units of attack
o. Lack of/Inadequate knowledge/Insight as to alternative courses of a1::tion open
to them
E. Inability to decfde which action to take from among a list of altern atives
F. Conflicting opinions among family members/signlfk.int others regarding action
to-take
G
Lack of/ Inadequate knowledge of community resources for care
H. Fear of consequences of action, speciftcally:
1 . soda! consequences
2. ec;anomic consequences
3 . phys.leaf consequences
4 . emotional/psychological consequences
I. Negati\l.e .ittitude towards the health condition or pr-oblem -By negative attitude
ls meant one that interferes with rational decision making
J. Inaccessibility of appropriate resour ces for care, speciffcally:
1. physical Inaccessibility
2 . cost constraints or econom ic/financial lnaccessibllity
K. Lack of tru$t/confidence In the heaUh personnel/agency
l. Mrsconceptlons or erroneous Information about proposed course(sJ of action
M . Oth.ers,·specify _ _ _ _ _ _ _ _ __
A.
s.
c.
70
111. lnablllty to provide adequate nursing care to the sick: disa b led, dependent or
vulnerable/at- r isk member of the family due to:
A . Lack of/Inadequate knowledge about the disease/healt h condition (nature,
severity, complications, prognosis a nd management);
B. Lack of/Inadequate knowledge about child development and care
c. Lack.of/inadequate know.ledge of the nature and extent of nursing care
needed
o. Lack of the necessa~y facTlities, equipment and supplies for care
E. Lack of or Inadequate knowledge and skill in carryihg out the necessary
intenientions/treatment/procedure/care (e.g., complex therapeutic regimen or
healthy lif estyle program}
F. Inadequate family resources for care, specifically:
1. absence of responsible member
2. financial constraints
3. limitatiohs/lack of physical resources - e.g., Isolation room
G.
Signi ficant person's unexpressed feelings (e.g., hostiffty/anger, guilt, fear/
anxiety, despair, rejecti on) which affect his/her capacity to provide care.
H. Philosophy ln life which negates/hinder caring for the sl ck, dlsabled,
dependen~ vuln.erable/at-rlsk member
· 1. Member's preoccupation with own concerns/interests
J. Pro longed disease or disability progression which exhausts supportive capacity
off'.tmily members
K. AlteFed role performance• specify:
1. role denial or ambivalence
2. role strain
3. role dissatisfaction
4. role aonflfct
5. role confuston
6 . role overload
L. Others, specify _ _ _ _ _ _ _ _ __
IV. Inability to pl'ovide a home e nvironment conducive to health maintenance and
personal development due to:
A.
Inadequate family resoqrces, sp.edf!cqlly:
1. financial constraints/llmlted fin ancial resources
2. limited physical resources - e.g. lack of space to construct facflltY
B.
Failure to see benefits (specifically long-term ones) of investm ent in home
environment improvement.
Lack of/inadequate k nowledge of importance of hyg.i ene and sanitation
Lack of/Inadequate knowledge of ,preventive measures
Lack o f skill in carrying out measures to improve home
environment
Ineffective communlcatio,n patterns within the family
Lack of supp ortive rJ?lationshlp among family m embers
Negative attitude/philosophy In life which Is not conducive to health maintenance
and personal development
C.
0.
E.
F.
G.
H.
11
1.
J.
v.
Lack of/inadequate competencies. in relating to each other for mutual growth
and maturation (e.g. reduced ability to meet the physical and psychological
needs of other members as a result of family's preoccupation with current
problem or condition)
Others, specify _ _ _ __
Failure to utllhte community resources for health care due to:
A. Lack of/Inadequate knowledge of ~ommur,lty resources for health care
B. Failure to perceive the benefits of health care/servh;es
c. Lack of trust/confidence In the agency/personnel
o. Previous unpleasant experience with health worker
E. Fear of consequences of action (preventive, diagnostic, therapeutic
rehabllftatjvel, speclffcally:
1 physlcal/psychologlcal consequences
2. financial consequences
3 . social consequences -e.g., loss of esteem of peer/significant others
F. unavailability of required care/service
G. inaccessibility of required ca re/service due to:
1 . cost constraints
2 . physical Inaccessibility, I.e. focatlon of facillry
~- Lack of or Inadequate family resouirces, specifically:
1 . manpower resources -e.g., baby sitter
2. financial resources -e.g., cost of medicine presorlbed
I. feeling of allenatlon to/lack of support from the community, e.g., stigma due
to mental illness, AIDS, etc.
J.
Negative attitude/philosophy in life which hinders effective/maximum
utilization of community resources for health care
K. Others, specify _ ______ __
• Developed and pubtrshed by Salvacion G. Bailon-Reyes and Araceli S . Maglaya in
1978 (see Bailon SG and Maglaya AS: Family Health Nursing - The Process, Printing 4.
Manila. Braincillld Managers and Consultants, 1990); reviewed and updated in :1994,
1997, 2003 and 2009 by A.S.Maglaya.
CONCLUSIO N:
Guided by fou r m ajor t heoretical 1nodels presented earlie r i n this c hapter, family
n ursing assessment is a deliberate a nd systematic p rocess of gathering a nd a nalyzing
d ata to identify a nd con tinuo usly validate J1ealth and nursing p rohlems of famil ies.
TI1e operational framework for fa m ily nursing assessment described in this chapte.r
guides lbc n urse on how to understand a nd work with the family as a system and
client as it goes throug h growth, development, health and ilJness experie nces among
its members. By goi ng th roug h t h e process of data collection and a n alysis, the
nu rse learns that families as clients have varied views of life, that they b o ld different
nspirati.ons and that they respond to sjtuations or problems i n unique ways. Family
nursing assessment is an opportunity for learning about the families' ways of knowing.
The process challenges the n urse to evaluate her assumptions and premises in order
72
Lo a rrive al va licJ conclus ions. Accu racy in fam ily n 11 rsini; ,1i:sc.~!m1c nL is :ichicvcd ns
the nurse gets a~ close to th e fo mily's li, ·ctl c.x pcric ncc as n f11n,·1 inn in ~ 1mi1 1111d c:lien1,
us ing th e pa rticipatory a ppronch . Thr\lu~h p;,r1nership. lilt· 1111 r.<•· a nd lh c family ca n
enha nce each o ther' s ca p;ihili ty lo look at and a11:ily;:c 1hc family s it11;1tinn o r real ity
togeU1er in o rd e r to expl ore and pl;m for Ute m0-<.t cffer.::Livc, ,, fficien t ~tnd sustainable
o ptions fnr actio n .
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(
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Friedmru1. M .M. (1998). Family 111.a-sing: theory and practice.
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Conn: i\.ppleton a nd Lange.
21.
Hill R. and Hansen, D.A. (1960). The identification ofcon ceptual framewo1·ks
uLi lized in family study. Marriage Family Living, 22, pp.299 - 311 .
.
Hollnsteiner, 1\1.R. (1975). The Filipino Family Confronts the Modern World.
In M.R. Hollnsteiner a nd other s (Ed.), Socie ty, Culture, and the Filipino
(pp. 21 4 - 226). 9uezon City: Atene_o de Manila University.
Maglaya, A.S. (2004). Nursing Practice in the Commtinity. (4th e d .).
Marikina City: Argonauta Corporation.
Mauren, F.A. and Smith, C.:M. (2005). Commui1ity public h ealth nursing
practice: Health for.families and populations. (3rd e d .). St. Louis: Elsevier
Saunders.
25.
Meleis, A. I. (1985). Tlzeorehcal Nursing. Philadelphia: J.B. Lipp~cott
Company.
.Minuchen, S. (1974). Families andfamily therapy. Cambridge, M.A: Harvard
University P ress.
27.
McGoldrick, M. and Gerson, R. (1985). Genograms in Family Assessment.
New York: W.VV. Norton and Company.
28.
Mendez, P.P. and Landa Jocaoo, F. (1974). The Filipino family in Its Rural
and Urban Orientation: Tlvo Case Studies in C~ilture and Education.
Ma n ila: Cenlro Escolar University Resear ch and Developn1e11t Center.
29.
Mundinger, M.O. and ,Jauron, G.O. (1975). Developing a Nursing Diagnosis.
Nursing Outlook, 23 (2), 96 - 97.
30.
74
North American Nursing Diagnosis Association. (2ooi). · Philadelphia:
NANDA.
31.
Sntir, V. (1967). Conjoint family therapy: a guide to tf,eory and tcd111iq11e.
Palo Alto, California: Science and Behavior Books.
32.
Selder, F. (1989). Life Transition Theory: Lhe resolution o f uncertainly.
Nursing and Health Care, 10 (8), 437 - 4 57.
33.
Turner, M.N. (1974). Nursing Process: An Operalional f'ran1ework for
Nursing Practice. ln .I.E. Hall a nd D.R. Weaver (Eds.), Nursiny of Families
in Crisis (pp. 10 - 32). Philndelphir1: ,J.B. LippincoLL
34.
Wilkinson, J. (1996). Nursing process: A critical t/1i11ki11g app,·oach. (2nd
ed.). Menlo Park, Cn: Addison-Wesley.
75
CHAPTER 3:
DEVELOPING THE FAMILY
NURSING CARE PLAN
Araceli S . l\fag l aya
THE FAM ILY NURSING CARE P LAN
Fom111l:11'ion ofthf' n1trsi n ~ (';l ~ p lan is the n ex-t s te p in th e appl i~tio n o f t h e n u r s in g
pnx:c ~-: aflc>r .1, <;t>, ,mc:n t . " 'ht:n l hl' f.imiJy uursin~ p r oblem s of e ach h ea lth condit-ion
or h<!.illh pn1bli!'m h;i, ~ l;-c,en ,-.,x-cilic<l.
11u • fom il) n u rairu : l"31"C' pl.i n i,-. a h lt11.' prin l o i l h c nu rsin~ cure dc.<:ig nctl lo ~ •st c m nticn lly
en.b il n ("e tlw f;1 m ily'.; ,·.~p.1hilit)· t11 m;1it11:1in w c lln cs." n nd o r m:an:ig~• h c;1 l1h prohlcms
throuJ; h e ,pli nth lnrrn nl .11.-.;l ;:,,.1 )-< :ind <•h.1 1.•l·11n, s o l r-n n · :ind uclihc rn l ely c hn,;cn :;ct
of int,·n ~•nl h•n -. n.•,ou n ·.,._ .1nJ ~·, .1lual H~n l'ri to.:rfa . >= t,, nd .1 rd.~. 1nethod/ s ;1nd t ools. A s
a ~•Tit!f•n _cu HI,•. the r,un il:, 11 un,.i n~ ~·.1n: p la n is n tiwla rl~· upd n te tl for 111o u ifku tio11s o r
c h a n ,:c<: h ,'-l..-1 on fa milv n -...: r><>n ,-,.,,-. rcn li t i~•.::. hclrn,·io1·a l p rc>cessc..« ancl 011 tco 111 c·.s of
c..-ire.
Thc-n.· IJ~ .;,,,t>r:i l n':L!-'11L' for 11la ru1in!' nun.ini.: ~ trt.-'. lt i:- ;_1 1>')'l-tt.-"1n u tic way l <l gu ide
tl>c nu~ o n h u ,~ 10 c nh a 1wt• th t fami ly's cnp:thility (o r h e a lth ::ind h ealth c11rc n .•s ou rcc
,:.t n •· r .1t u•n. di<>• ;1110 n . •, • id n ti Ii 7.a t ir 111 Io rt ,. h i, ..,., • -.rwl'i fie d ,,., i n · d 1111 t,., 11111 .... 11f priori Ii1cd
h e:ilth ('1'>11<lit1 11n, prnhlt• m ,. P l.i n11111 ~ t"11h a rn ,, ._ th, · n u r,. .. ·,. fnr<'-< 1)?. h l fnr tr.1111work
:ind t'l>ordin ,:inn r,l ._. f'IC"•"' tu ••n_.:11rc :i dc4u .«· , and e ,m 1111uil ) o f . ~i r e. Sp,•cili1-.:1lly
111 wn t', n 1 ,rrn. th,• nur-in;r c:i rc plan r>nm1ntes s ~» tt•m:itl,· n,m 111111dn 11io 11 ;1111<>n g
tho--, ,n, "" r<l an th, ,wa h h .:,1 n t ff, ,n. mi n 1mi1 in~ ~-l P" ,md cJuplicnt i,m of ~•• rvk,·s in
S-c?tiut;.:, •~,h• H tht-rt.' t, 1 (r-L.,~U • n t t1 1rn,,,.L-- rrJf,1n((t\rh·h~n ~1·v,~n1 I h f...•i1lth v,torkC'"r<. <trc
providms:, an• 11, th, .__ un •· (., m ii~ Thi, i-; p,t rt in r b rl y t r1Jt: in v ill:-.'1,C<- , ,r :1 rt.-:1 -. IL"N.I a s
tkl.1 r rn, t1 ·um -<lit"" t nr tr.1 i n i 11~ in ,..,,mn111nit) lwa lt h \\ork.
Steps ;n Developing a Fami ly Nursing Care Pion
TI·e 1:"::,-<-, m,,n1 Jlh,1•<' o( t h < nu r..i ng pnx:c1-.., i.:t..· nl·ra t l' '> 1h, · 1,,-aJth 1.'Hlldit ion ,. a nd
:ml:• nur-1n1., prnblr m .., ,, ·hich h ..r , ,mt· th,· 1,;.i:-es (u r thl· d c ,.-lopme11 t
o ff ll' nur-,11~ r 11 , 1 L n l l,-~.-l•1p1ny. a fo rnr h r-;,r, • pb n invnh-c•s rn:iny , t,·J"'· C1·n1•rnlly
the pl.111 , ,m,,,,., ,, t h• f11 l! ..,-i11~ (, J Pri•,ri ti .,, -.1 h ••. rlth , -unditi,111 /.-. or problem,;; (:.!)
Go;i f-., :,pJ ol Jl ,·11,, .... 11{ nu r 111~ r.1n·; (3) r nt,· n ·1•n l i1Jn pl;i n ; :md. {4) E va h1;1 t ion pltt n .
('Orr, "]')'tn<hn., l
Th,. '\ .t n,1 a, , 1, f" 111 d , ·" 1, pin~ th•• f.,m, h n u r- ,nr, r:i rc- pl:1n cnrrt·,pnnd ..,;1ht lt c :1hovc
,'<.,rnJ""' n,·nt-. l- 1;:un· ~ 1 ..11,;,,-,,. ,; •~·h, rn:nre pn· ,• nta11,, n o f 1hc n u rsi n ~ rnrc• pl.in ni ng
I"'""·,..., It ,111'1:• ,,11h" h-1 , ,I h, .,lrh t-c,1.dt1ion, o r p n, hlt·m-. prioriti;,1-tl a<T1>rd i 11g
t n I l\.r, 111 .. t.· '" !,;, p,,., , :111\"<• r><•I • 1111,11 .,nd ·di,·rw,· T h,· p 1inri1l;,1·d lt,·ahh
Ct ndrt
,,, , 1 pr, ! '• 1 .,• ,! tlior , <irr~·• f>''ndrns: l a rn1h n ur.-111~ p r rihl, ·1n_-. h e ( 'C t1II L'
t h, !~'<- h ( Ill II •I ... , p "'"' h I' 1•1• 1, n1111wttfJII of s.:•u l 11 111J <>l, jl·l ti q•-. or 11 u r,i 11~
c-:ir. T1,, ,..,,.j, 111 ,! , ,t t 11\t ~ -p,-cl!) t~w, >. JH·rt ,-..1 h ,·., lt h/di nrc.il n ut t:nml· , , fom ily
r,.,....,...,r"" U "'- '- f..,. L.n, • T ,,rt.·• •n1pt: l<""-J!4) ou: t:on.t.-.,,.
76
T he next s te p is selection of appro pria te n ursi ng i ntcrycntfons. It focuses o n
nltern a ti vcs a11 cl decision o n app ropriate i nt crvcnl ilHl meas u res ln1s cd on the s pecific
ohjcctives formulated. T he intc rvc nt iuns s pecify the n urs ing actic,ns 1,, h e lp t he fam ily
eliminate the b~1rrie rs Lu the pe rform:in cc nf hen Ith 1asks o r th e und e rly ing ca use/ s of
no n-performance of ex pert ed hea llh I11sks . ·n1cse inlcl"\·l:lltions im:lude fomi ly fornsed
alte rnntivcs o r s lratc~i cs to help m c n, ht·rs rccr,g nize/dc t.ccl he ri llh prn hlc ms or
opport unities to enha nce wcll nc.~s ~t:,tc or co ndit ir:,n , m nnito r , e limi nate, r o nlrol ;ind
m anage h e n Ith probl e ms nr su:st:ii n wc llnc.~:, conditio n /,; , The method of nurse- fam ily
contact nnd th e resources needed rirc :,pe cilicd i1.1 this , tc p to e ns ure tha t necessary
prcp:.iratiou is d on(; lo ;ichievc the ,,hjectives o f ca re in llw moi,t. e fficient w,ty. 11)e last
step is th e d evc lopm r.:nt of the c v;d ll.,tio rL p la n . IL s pec ifi c~ the c ri teri:.i/ ou twml'. s and
eva luation sla nd.i r<ls .is e;: p lici t mc;;i,;urcs tha1 det erm ine ac hieveme nt of fo rmulated
objec tives based on a req uired or dcs irecl l evel of pe rfonna n<:c or accepted cha nge in
h e:1lth co11d it inn <J r fam ily reality. ·I11is close relatio n.ship between th e evalua ti on pla n
a n d Jhe form 11IAted goals a nd obj ec ti ves e.~plDins the broken liae between the two
boxes in Fig u re 3 . 1.
Prforitizing Health Conditions and Problems
Based 011 !ltnndnrds of com m un ity health nu rsing pract ice, the 111Jrse handles a
caselua c.1 r,f clie nts in a specifi c m unicipality or cluster of vill a~es. G iven a caseload
of families, thr n nr<;t> m :,y rea lize th:,t c vc n fo1· jus t one family, a number of health
cond ition!': and f.i m .i ly n urs ing problems ~a n nol he a dd ressed all :it 1hc s ame time
wil'hin n s pec ific pt.:rir,u. Co ns ic.l cring the s itu a tio n . s h e ca n rank th e ide nrified health
condilion!>/flrohlc m.<: into priori tie!>, Bail o n nnd ;\'1aglayn ( 1990) cl c, ;sed a tc,ol called
Scale fo r R:in king I fcnllh Cnnd irion ~ and Proble ms Accc,rdi ng to P rioritie s (See Table
3 . J) , Thi:< 1001 aims 1,, rnci lilnt e clecisio n-making in de te rm inin~ w hich p art icular
hea lt h ctm d il io ns a nd th e ir cnrrespo ndin.l( fam ily nursi ng proble ms can bE: add ressed
by the 1nmw with Lh e f:unil., a ,; clic11t -p,irtne r al appro priate po int.~ in time. The re are
fO\Jr c rit e ria for de te rmining prio ri ties among heal th cc>nd itfoa/s or p rob le m s . These
include:
1.
Nature of the co nclit ion or problem prese nted - categorized into wellness
sl:llc/po tc ntinl, health threal, h eulth defici t and foreseeable c ris is;
:?.
t'louifinbil il:'Of the rondition e1rprobk rn - re fers to the probnbililyofsuccess
in e nh a ncing th e well ness s tat.:, impro, ; ng lh e co nditi on. minimizing.
all evi:l ting o r totally c raui ..:aliug the problem through inte rve ntio n :
3.
Prt'vc ntivc Po w nliCl l - refers to the nnlu reand magnitude of future pro blems
thn1 rnn h r m inimized o r totally preve nted if io l.irven ti o n is done on the
coucHti <m nr pro hlem unde r considera tio n ;
4,
Salie nt·,· · re fe r:s to the famity·s pe rception a nd evaluatio n of the condition
o r p roble m in lcrms o f seriousness a nd u rge ncy of attention needed or
fami ly rca clillliss.
The c xpcricn,;e<l nurse prn ctitio ne r c;rn tlcte rm in e prio ri ties a m o ng hea 1th conditions
o r prnblcms utilbr.i11g her jutlsn ll'11t uu all these. four c riteria without necessarily
g oing th ru11,-:h Lh c process o f scllrini . 111l' nrithm e tir coru puta tions u til ized in th e
~cnlc ca n. howe,·cr , ~11idc the slmll' nts o r n ew practitione rs who still need to gain th e
skll l i11 <.h:l'itl i11g wh k lt foct11rs have m o r..: weight over others. The <'nm pnratio ns help
:,-ystc rnafru: p riority :-cllinll, hy de te rmining_ a s pecific sco re for each p roble m o n the
list. The nurst.> co nsidt:r:. se ve ral fac tors in o rde r to be objecti ve in lh e d ecisio n-making
process whe n selling prinriLie~.
77
Prloritite the Heal th
Co n ditions a n d
Probl ems based on:
• Nature of
Condition or
Problem
• Modif1ablll t y
• Preventive
Pot enti;ll
• Salience
Define Goals and
Deve lop the Evaluation Plan
Specify:
• Criteria, St and ards,
Outcomes Based on
Objective~ o f Car e
• M ethods/Tools
Devel op t he Intervention Plan
Ob)ectfves of Care
Formulate·
• Expected Outcomes:
Cond,rions which
sustain wellness
~tate
•
•
Conditions to
be observed to
show problem
Is prevented,
contr olled,
re:.olved or
eliminated.
a ent response/s
• Spec,'lc, Ml'asurab le
O•ent-centered
Stat ements/
Competenc,es
78
• Decide on:
• M easure s t o h elp family
elimina te:
• ba rrler s to
pe rform;,nce o f
heal th tasks
• underlying cause/s
o f non -performance
o r health UHkS
• Family-cen t ered
altern,mves to recognize/
detec t, moni t or, contro l o r
manage healt h condition
o r p roble m s
• Determine M ethod s o f NurseFamily Cont act
• SpecJfy Resources Needed
•
Factors Affecting Priority-Setting
Consiucri11g Liu.: fi rs t c ritcrim1 - n ature of th e condi tio n or rrnbl c:m prcscn wd the bigges t weight i !i i.:ivc n tn well ness s t~1tc ur polc nti:il b(:t:i11se of th e prnm ium o n
client's cffort!l or cJc,;irc lo s us tain/rnaint:iin h ii.;h lc,v1JI welln ess. The sa1m: wci1{hl is
a ssigned ton lu.:a lth d eficit IJccaust• of ii.<: se nse of clinical urgc11cy w h ich rn::iy rt:qu ire
immeuiu lc in tcrvc11 1in11. Forcsc1:;1hlc; c·ri sis is given t he least wcigbt because cullureJinkcd vi1riahles / f:1 c t.o rs us ua lly provide our fami lies w i th ,ideq11 nlc s upr,o rl Lo cope
w ith c.levcl o pmcnta l or s il.11 ali o11,1l crisis.
The 1111r!le co nsiders fh c nva ilability o f the foll owin g factcJrs in det ermin ing th e
modifiability of a ltcnlth condition o r problem:
Curre nt knowledge, technology and in terve ntions to e nh ance th e w ell ness
state or mnn ngc the problem
:2. Resou rces o f th e fam ily - physical, fina ncial an d m anpowe r
3. Resou rce~ or Lh e nurse - knowledge, skills and ti m e
4 . Resources of th e co mmun ity - facilities nn d co mmuni ty organi :r.ation or
s 11 p po r1
1.
TQ d ecide on an appropria te score for the preventive pote ntial of a health condi t io n or
proble m , the foll owing fa ctors arc cons idered:
1.
Gr.i viLy o r sE--vc ri ty of the problem - refers 10 th e prog.rcss or tl1c disease/
pro blem indica tin g exte nt o f ,da mage on th e pat ient/family; ols o indic;1tes
prognosis, reve rs ibility or modifiability of th e pro blem. fngencral, th e m o re
severe o r adv.incctl the problem is, the lo w e r is the preve ntive potc nli al of
tl1e p ro blem.
2.
Du ralio n of tl1 e problem - refers to the length of ti m e the problem has
b een exis ting. Generally speaking, duration o f th e pr oblem h as a d irect
relntionship t o gravity ; th e nature of th e problem is a variable tbat m ay,
h owever, a lte r U1is relations hip. Because of this r elation ship to gravity
o r the problem, duration has also a di rect rela tio nshtp to preventive
poten tial.
3.
Curre nt Man agem ent - r efe rs to the presence a nd appropriateness o f
interven t io n meas uTcs instit11 ted to enhan ce the wellness state or r emedy
the proble m. The i nstitution of appropriate interventi o n incr eases the
co ndition's pr eventi ve pa ten.ti.ti.
4.
Expos ure of any vu lnera ble or high-risk
preventivepotenlial of :i condition or problem.
gToup - incr e ases the
79
, - - - ~ - - - - -=--=-::N~K:1:N:G~H
=E
~A=l~T:H~C~O
~ NDITIONS ANO PROBLEMS
TABLE ~-1 SC.ALE RAACCORDING TO PRIORITIES
Criteria
1.
W eight
Nature of t he conc!Jt:,on or
problf!m presenrea
Scale•"': wellness state
health deficit
healt h threat
forseeable crisis
2 _ Modiftobi/lty of the condition or
problem
·scale 0 : easily modifiable
partially modifiable
not rnodlfi'able
Preventive potential
Scale,,.,.: high
3.
moderat e
low
4.
I
Sa/fence
Scale ••: a condition or probl em,
needing im mediate
attention
a condition or problem
not needing immediate
attention
1
3
3
2
1
I
2
2
1
0
1
3
2
1
1
2
.
1
0
not perceived as a
problem or condition
needing ehange
Scorin g:
1) Decide on a sc::ore for each o f th e cr iteria.
2) Divide the SC"ore by the h lgtiest p.o ssible score and multiply by
the weight: (Score/ H igh est Score) x Weight
3) Sum up the seores for all th e criteria. The highest score is 5,
equivalentt0 the total weight.
•
•
~
Developed by Si1lvac1on G, Ballo111.an d Ar acelis. Maglaya, For details,
see article: "Tools and Guidelines for Nursing at the Family Level " . -rne
Anp hi Papers, 2.2(1):1 3,1977. Updated b y A.S. M aglaya in 200 3
Figures (0,1,2,3) for the weights and scale values are a rbitrary, dictated
more by conveni ence ln computation.
Effective heal th m anagement/health m ainte n ance pattern and d esire for or engage
or
roent
condition.
in healthy lifestyle activities in crease th e preventiv~ potentia l of a wellness state
80
To d etermine th e sco re for s alience, the n urs e evaluates th e fanuly's perception of
the con d ition o r problem. As a general rule th e fam ily 's conce rns . fell n eeds :md/or
readin ess increase the score on salience.
Scoring
After thl:! score for each criterion has been decided on, the number is di vhlcd hy the
high est p ossible score in th e scale. The q uotient is multiplied by the weighl ind ica ted
for the criterion being cons idered . Then th e s u m of the sco res for all the criteri.i is
taken. The highest score is five (s), eq uivalent of the to tal weigh t. The nun,;e considers
as priority those condi tions and p rnblems w ith t otaJ scores nea rer fi\·~ (5 ). Th u~. tJ, c
higher th e score o f a given cond.i tion or prob lem th e more likely ii is tn kc n a~ n pd ority.
W ith th e a vailable scores , the mrrse the n rru,ks h ealth con ditions rLnc.l pr oblem s
accordingly .
Formulation of Goals and Objectives of Care
A goa l is a broad des ired outcome towa rd wh ich behavior is directed . An exam p le of
state ment of goal in family health n ursing p ractice is :
After nurslnn lnteTventlon the f amllywlll be able to take care o f the
disabled Ghlld c,empetently
A card inal p rin ci ple in goal setting s tat es that goals must b e set jointly with the fam ily.
This ensu res the fam ily"s commi tm ent to their Teali zation . ]3;"1sic to the establishment of
mutually accept.i ble goals is the fa mily"s recognition an d acceptance of existing lwallh
needs and problems. The nu rse must ascerta in tJ1e family's kn owledge an d accc p tnnce
o f the problem as well as the d esire lo take actions to resolve th em . This is d one du ring
th e assess ment phase.
Barriers to joint goal settfog b et wee n the nurse and th e family inclu de the follo wi ng:
1.
Failure on t he part of the family to p e rceive the ex.istence of th e problem.
In m a ny instan ces the problem is seen only hy th e nurse while the fo mily
is perfectly satis Aed with the existing situation . An examp)I;! of th is is the
thre at posed by in tp roper was t e disposal. Many fa m ilies esp ecially in the
rural a reas, have no sani tary toilet faciliti es. But to i:;om e fo mil ies th is is ao
proble m at all s ince th er e is the wide open fi eld , th e b ush o r Ll w river whi ch
can serve tJ1e same pu rpose.
2.
Th e fam ily m ay r ealize th e existence o f a health condition o r probl em
but is too b usy a l t he m oment wi th other co ncern s and pr eoccupations.
For example, a m other may perceive the need for imm unizati on for the
children but her h ousehold chores take p recede nce over oth er con cerns.
3. Somet imes the fam ily perceives the existence of a problem but does
n ot see it ns serious e no ugh to wa rrant atten tion . T b e common cold is a
condition that is all too often taken for gra nted. T he same is tn1e wi th
intesti n al parasitism wh ich is comm only regar d ed as a no rmal conditio n
in ch ildhood .
4. T he family may perceive the p resence of the p roblem a nd the n eed to
81
lake action. lt m ny, however, refuse lo face a ad do something abou t the
situntion. Freeman (1957, pp. 126--128) offe rs t h e followin g reasons for this
kind of behavio r.
foea r of conscquence(s) o f Laki.ng action - For example , diagnosis
o f a d isease condi tion may m ean expense o r social stigma for the
family.
b. Respect for trad ition/cultural beliefs, v.ilues - In P h ili p pine c ultu re,
elders piny a pa rt in d ecis io n m.iking. Be havior which al'e n o t
s an ct ion c<l hy the old fo.l ks in the fam ily arc n o t likely lo be adopted.
A couple, for ins tnnce, muy uot ncecpt the gonl o flim iting family s ize
to just t h ree children iftl1cir parenls d o not npprove of contraceptive
pmcticc.
c. Pnilurc to perceive th e bene fits o f action p roposed -Th is could b e a
functi on of a client's p1·evions ex p ed e n ce with heal th w o rkers a n d
t heir services. Going lo a h ealth cente1·, for example, is un advice
frequ c11t ly g iven by n uTses. When th is doe:; n o l yield b e n e ficial
results fro m the poin t of view of the family, it will be ig no r e d the
next time it is o ffe red.
cl. Fa ilure to rela te tbc proposed action to the family's goals - FamjJies
differ in their prioritizing of goals. Econmnic and social goa ls
gene ra lly occu py a higher position tha n health goals in fanli lies'
rn nking o f their con ce rns and preoccupations. W1~en p r oposed
actions tu improve health are n o t related Lo frunily's goals (e.g.
economic stability), they arc not likely to be accept e d.
a.
5 . A big b:irrier to collabora tive goal setting between t h e nurse and the family
is fai lure to develop a worki ng relationship. Noth ing will be accomplished,
as a m::ittcr o f fact, in a nurse',s wor k wi t h fam ilies u n less the fam ily s ees
the nurse as someon e who is genuinely concerned with its welfare. The
elements o f mu tua l respect, trust and confidence a1·e c rucial to t he success
ofU1e nurse-family partnersh ip towa rds bett er ]1ealth.
Goals set by the nurse and the family shou ld be realistic o r attainable. They should be
set at reasonable levels. Too high goals and their eon sequent frul ure frustrate bo U1 the
fami ly and t he nurse.
'
A clear defin ition of rhe problem s ituation and a n accurate assessment of availa ble
resources facilill.lte the set1ing ofrealistic goals. Both of these are functions of the d epth
and breath of the assessment process.
Goals, like obj ectives, are bes t stated in terms of client outcomes, whethe r at t he
ind ividual, family 0 1· comm unity levels. Objectives, in contrast to goals , r efer to more
specific s tatements of the des ired results or outcomes o f care. T hey specify the crit eria
by which the degree of effectiveness of care is t o be meas ured. Goals tell where the
family is going; objectives ar e th e miles tones to reach the destination. ·
Objectives stat ed as outcomes o f car e in fam.:ily h ealth n urs ing practice specify physical,
psychosocial states o r family behavior (or competencies). Examples are given below:
1.
After n ursing interven tion, the m alnourished p r eschool m embers of the
family w:ill increase thei r wejghts by at least o n e pound per month.
2. After nursing intervention, the family will be'ab le to:
82
►
a.
Feed Lhc rncntol ly rc t.n r d cd child a ccording to prescribed qu a ntity
and quality of food.
b. Teach the nfontally rctanJecl chili] si m p le s kills related to the
activit ies of daily living.
c. Apply m easures taugh t lo prevent infedion in the mentally ret arded
member.
'11ie 111ore specific the ohjective1,, the easier is the eval u ation of their attainment.
specifically staled o bject ives de fin e th e criteria for evaluation .
Objectives vary nccording lo Lhc lime s pn n required for tJ1cir realization. Shortterm or imme di.itc ohjccl ivc.-; ,1re formulated for problem s ituations which re q ui re
immedintc nll'c n tion, and resu lts cn n he observed in a rnlntivt:ly s ho rt period of time.
They arc ,wcom plishcd with few 1111rsc-family contacts ,rnd wi th th e use of re latively
less resources. l.0 11~- lcrm o r ultimate ohjecLives, on th <.! othe r hantl, re quire several
nurse-family c-11cc>1111t,e rs and a n invest men Lo f more resources. ·111c n:iture of outcomes
so ught require time Lo demons trate. Suc.:h is the: natun~ of behavior chan ge which is
often th e object of 11urs i11g intl;!rvcntion. Mctl.iu m- tcrm o r inte1-mediate obj ectives are
those wh ic h are not immed iutely achieved an d are re.q uired lo attain the loog-t e nn
ones.
As wilh goals, objectives s hould be realislk and attainable conside ring t he resources
of the nurse, the family .iml the community. 1n .i<lcliti<Jn, they should be measurable.
Speciiic statements of objectives foci! itate t h e evaluation of their attainmen t. Objectives
and evaluat ion are directly related. Wl1en objectives are stated in terms of observable
fact nnd/or behavior, the criteria for evaluation become inherent and evident.
,axample:
Nursing goal •The family will manage malaria as a disease and th reat In an endemic
area.
Short-term/Immediate objecttve - The sick member/s wlll take the drugs
accurately as to dose, frequency, duration and drus
combination. All members will use self-protection
measures at night tilt early morning when bltfng time
of the mosquito vector is expected.
Medium-term/Intermediate obJectt-ve - All members will have regular medical
check-up -an d laboratory confirmation (i.e., blood
smear) to monitor presence of malarTa•
. Long-term objective- All members will car ry out mosquito vector control
measures.
DEVELOPING THE INTERVENTION PLAN
The next s tep in develop ing the family nursing care plan is formulating the
intervention plan. This involves selection of appropria te nursing interventions based
on the formul ated goals and objectives. In selecting the nursing interventions, the nurse
decides on appr opriote nursing actions among a set of alternatives , specifying the most
effective or efficient method of nurse-family contact and the resources needed. Some
examples of methods of nurse-family conta ct include the home visit, clinic conference,
visit in the work place, sc;l]ool visit, telephone can, group approach (like health classes),
83
1
a n d use of the m oil (e.g. letter /s, elect ronic m ail). The resources whi ch include n1alerial
(e.g., supplies, equipm ent, teaching aids/kits. visual lr\aterials, h a ndouts, charts, etc.)
or bunwn (e.g .. other health te::im members. de"elopm ent workers, community lead ers)
must be !.pecifi ccl in t h e plan to e ns ure thnt n cccssucy preparation, coordina tio n and
collaboration are done before t h e implement.ttion phase to maximize efficiency.
The following general directions for nursing interventions ca n guide selection of
appropriate n u.rsing inte.r,entiom;:
1.
2.
.'\ .nalyze \,;th tb e Family th e Curr ent Situation and Determine Choices and
P ossibi.Hties basecl on a Lived Experience o f Mean jngs and Con ce1·ns.
Develop/Enhance Family'i; Competencies as Thin ke r , Doer a nd Fee ler
3.
F ocus on Interventions to H elp Perform the H ealth Tasks
4.
Catal~-1,e Beha"ior Change through Motivati on a nd Support.
Analyze Realities and Possibilities based on Fam ily's Lived Experien ce
of Meaning and Concerns
Family life and aursing p_ractic_e are bo~ phen?m ei:iolo~ical unified rea lities o f
rienci ng the self interacting \\'1th others m specrfic s1tu abons that are affected b v
expe
.
.
d
- .
d m eanings. concerns . em ot1_0J1S. past experieJ1~es _an anti~tpa~e fnture (Benner and
Wrubel 19 s9 ). Theappro~r1nteness ?fthe nursm~ mterveotton 1~, therefore, dependent
the Jived meaning OI t.he experie nces of fan1.1 ly members vv,t h each o ther and with
00
~i-;e nurse, gi\·en the current _situation _and_ possibilities in h ea)th and illness realities.
Because family health nursl.tlg practice 1s a phenomeuolog1cal a-._-perience for the
fan,ih" and the nurse. t he family becomes an active participant in the ap pl ication of
the n~rsing process. Th e fam ily a ud the nurse a re participants in an active, mutual,
dynamic in terchan ge of realiti~s, con c:~rns _and r esour ces_. Both n ~ed to _analyze and
understand th e current health/ illness s ituation as the fam ily expene nces 1l. To ensure
appropriateness of oursi!1g inter,ention, tbe nu rse n ee~s to . expl<;>re with the fa_mily
the p0ssibilities and ch oices presented by the current situation given the mearungs,
con;ems, sociaJ relations, and resources.
Through the participatory approach the nurse can select experiential learn ing strategies
to help the family understand its behavior in terrns o f dynam ics, realities, vulnerabilities
and po.;;sibilities. T h rough the ULook-TI1i nk-Acl~ cycliC<ll process, the family can be
encouraged to analy7.e antecedents o r factors contributin g to o r producing specific
health problems. Based on the ana lysis, the nurse can cataJy,:e learning processes such
that tl1e family caa learn to deconstrucl m.indsets or current beliefs and be guided on
h ow to re-order patterns and r elationships for fresh insights and w orkable options to
modify and im pro,·e family dynamics a od r ealities.
Develo p/ Enha nce Cog nitio n, Vo lition a nd Emotion
To determine the appropri ate ness o f nursing intervention , the nu rse is g iven a choice
of possibflitics t hat he lps he r and the fam ily gain a clea rer unde rsta nd ing of the self as
a thinker , a doer and a feeler. The choice contributes to a process of self-unders tanding
of th e fam ily as a system and of each individual member (Allanach 1.-988, p p. 78-79).
Nu rsin1; in terve nti o ns tlui t c nh nncc ,w ma.ximi:,,c the comp ete ncies c,f th e fnmily as
t h ink e r includ e m nki ng inform;-i Lion / d ata o r knnwlt'dp,c· rl'mlily nv.i ilnuk· 1111d m·ccssiblc
for ease nf and <'on fidc n..-c 111 t111dt'rs t ,111d111i n 1rrc nt s 1rur1 t io11-. 1n hea lth and illness.
Oecisio11 -mak mg 0 11 approrri:it e :H·t i1111-, t " t. ti-a• :1 rt '. IIkC'wisl·. 1·nit .111e·,•1 I. Ilt•\'l' lop ing :ind
m aximi zing th <' skills :111(1 cnmmu11k,11iu11 <'•> n1petc11 d ,·, o f thr 1':im1l~ as tl nc r c 11ha ncc
co nfidence in carry111~ nu t thl' 1\l'ed 1•<l i111 cr.,•111 i1111..: tn lni t iat v .,nd s 11-:1;1i11 1'1 11111gc for
health pro moti,111 ~md 111oi11 t1•1u1 m ·<·. nnd acn,rnte di ,L':i,-,·/ pn>l, lc 111 nrnni1J!1·1111·n t. As
feel er. the fa m ily need~ l•• di.!, dop t•r ,-tr~ t11llh cn it s ., rr..,,-1"''-' 1·<>111pd1·1wie'- i II onli!I' l<J
a p propriately acknn\\' lcdgc aml undc r:,tand c111uli11m, gcrwrall·d b~ fa m ily lifr n r h en lth
;ind illness s itu atio ns (e.~ .. fe,1r, nn),(cr, an:dct y. j c:1l rmJ<y. guilt).
B y doing so $l1 Ch e m otio ns r:m he l rn nsro rnwd into growth- promo ti ng C'hoh•rt-, n nd
action s. \ 'i11c n the family renli:,es that acknowll:tlJ?,iniz fcd in)!..-: a 11d a ll <n,; n~ l hc m lo
gu id e understanding of lh c s ituation and th tJ sci f. l lw cx pcricm.:c <.:.111 a l la in llw grea tes t
freedom in m ovi n g into new pt1ssihili1ie:<. Bc nnl'r nm l Wruhel ( 1989) succi111·1ly
expl ::;
a.:.;
ir:.:.
1:...
: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ---.._
By acknowl~dgin~ t hl! J1.v~II ng in •It o<.1. •om; ,1111I 111c11," " W• ,,1 our f,., !m g!. v,f.! c rn
gain the skill lo rehe.:tr~r :ind ret urn to po 1•111, f ~clrn•" ~\I' h , ~ 10v. pr d •. c;om!o rt ,1nd
con tent ment. .. Sy rem embering .ind rf! llP"" ,,1:111 • pc, 11111c t,•elins•, o n r1 w o cCJJs,or\$,
w e are som etimPs ""~bled to ch~n&e our co t ·xt Qi' ,;hr..t1m ,t;,,n , , •, to on~s th t fc ~tc,
th ose Feelings, see new poss1t:tilities for , ti on 11th• um:h.w ·cd cu cum • t mce~. or -.,mply
experien ce pleasure and see th ln&s 1•1 .i ro._l r li"l11 ih,s pn~H•\'e .1b11ttv m'-1 pr< ,,,cit• n
respi te and offer perspecbve d 1r1ri11 a mn of n1; t,,, It,; l1n: ~u<:11 ii lu 1r or an , Je ~y.
Thls respite m ay b e what one 112cd 5, 10 fo,c
nd und •t!.t ancl t l:n •ourre o f the ncg;nive
feelln.gs (p p, 170-1711.
Focus on Interventions t o Help the Family Perform the Health Tasks
The n urse needs to focus he r cho ice of i alc rvc ntion.s on he lping th e fam ily minim ize
or elim inate the p ossible reasons for or t:a uscs o f Lhc family's inabi lity to do the h ealth
tasks:
1.
2.
Help th e Family R ecogn iz e U1 e Proh l em. Examples of nurs ing
interventions to enhance th e fom ily'i. ability t c, rccugniz.c its heal th needs
a n d problt:ms i,u.:lu tl!:!: (a) in c: rc.1.sing I he fnmily's k n owledge on the
n ature, magnitude a nd c.1 u sP o f th e prnhlem; (h ) helping the fami ly see
the implications nf th e :-in.1iition, or t he etJn.sequcncel, of the condition;
(c) relati n;,; hc..lth n eed:. to the !/,\Jali-: of the fa mil~ (both he al th ;111cl nonhea lt h relatcu :;ual<;); (ti) c n couragin )!, posil h ·e o r ,,·hole.some e m otional
a ttitude toward the pro h lc m b y affirmin )'!, th e fam ily's c-~1pa b ilities/
qual iti es/ reso urces a nd p roviding information on a ,·ailable options .
Guide the Family on H o·w to Decide o n Appropri a t e H ealth
Acti ons t o T ake. Tbii;: can he don e throug h : {a) illcal ifyi 11g ur cx p l()ri ng
with the family Lhe courses of actio n ,1\'ailable a11d Lhc r~ou rces n eeded for
each; (b) discussing the ccH1sc4 u1mces of each co urse of nc ti o n nva ifoblc;
and, (c) an aly-1.i ng w ith the fom il_\' the 1:011;,cq11cmccs n f innction .
•'3-
Develop th e Fam i.ly's AbiJjty and Commi b'ne n l t o Provide
N urs ing Care to its Men1bers. The n u rse ca n increase the family's
co nfid e nce in providing nurs ing care to its sick, disab led nnd depende nt
8.5
..
member llu·oul!,h demonstration and practic.e St!ssions on p rocedures ,
treatments or techniques u t-ifo:ing readily available, low-cost mate rials
a n d e quipment and ot h e r 1·esources.
Contracting is c reative interventjo n that can maximize opportunities to
d evelop the ability a nd commitment of t he family to p rovid e nurs ing care
t o its mem b ers by focusing on assisting t h e membe r::- to act effectively
on th e ir own behalf (Cle m en-Sto n e and ot h e rs 2002, p.281). It is an
intervention whereby the nursC' l;reutes n s itualiou in onler Lhu t the c lien t
learns to achieve a specific h e al th-rel ated b ehavior thro11gh a s equentially
arran ged e.xpHcit s teps and c.:o m.lil io11s or elements jointly identified b y
both parties. T his inte rvention uses re inforceme nt con t rac ts on a va riety
ofhfilllth -re lated he havior requi ring compl ex b ehavioral ch a nges such as
adherence to die t, medication and othe 1· trea tm en t re gime n s to mninta in
d esirable laboratory val ues. lose weight, and control bl ood pressur.e
(Steckel 1980, p . 1597). Such com plex bchnvioral changes n::q u ire t he
performa nce of e/1.--plicil step s (interm ed iate behaviors) a nd e ncl, step
reqwre.s re inforcemen t if the terminal n ew b e h avior is to be l ea rne d a n d
maintained. Con tracting provides a systemat ic method of inc reasing
desirable client beh a,;or th rough th e u :,,:e nf th e principle o f posi tive
reinforcement. Usin g- this 1>rinciple the n ui:se a nd the clien t m ul:l.1ally
agree on favo rable re inforcing exp eriences or consequ ences a s 1·e w ards
when the client perform s t h e desired behavior.
In order to m nke this intervention e ffec:Live, the nec:essai:-y e lements o f
the desired be h a,;or must he made explicit a nd must b e ,Hitten in the
form of a.n agreement. To m ake tJJ e b ehavior co n sciou s ly re inforced
it mm,"t be observabl e a 11d m t:asurable. The contract spe c ifies th e
terminal, intermed iate h e ha viors and the rei n forcers as rewards for the
clie nt in return foi: perform i ng t h e beh aviors. The client and th e nurse
jointly ide nti fy the terminal beha\ior and ll1e cumponent in termediate
behaviors. Steckel used contr.1c ting a::; intervention in h er researchei; o n
patienr ad h e rence to h ealth care p r escri ption s. She r ecommen ds t h a t th e
contract be writte n , d ated, sign e d by aJI parties concerned and a copy is
given to each one. F urthe rmore, she s p ecifies in h e r contract Lh e method
for monitoring the behavior UtrQugh recordi n g. See Box 3.1 for a sample
fam ily- nurse con t ract.
4-
86
E nha.n c e the Capability of the Family t o Provide a Home
Environment Condu cive to Health Maintena nce and Per sonal
D evel opment. l11e family can b e taug ht specific compe t encies t o
ensure such a horne en vironment t h rough e nvironmenta l modificu ti o n,
man ipulation or ma n ngcmcnt I n minimize or clim.inate h ealth th r eats
or risks or Lu instaJI fa cili ties for nursing care. The fam ily c·an lea rn LO
constn1c1 or mod if,,- needed facilities in the h o me s uch as a com m ode for
a disabled or agc<l ~ember who ca r, not u se th e fam ily·s toil et b ecause o f
distance. Em iron m e m~ I c·ond it io n s con<l uc.:i ve t o hrecd i ng and b ab itatio n
of vect o rs of disease.,:; (suc h as mosqu itoes} can , likewise, be imp roved
by the family if it has th e n ecc.-=;snry competencies to cn rry o ut vector
cont rol measurt>s. For example. the nurse ca n teach !.7:>ecific tec hniques
o r procedures like clearin g Slrf'ilm h::inks of overh anging veget.ut ion and
deb ris l.O expose them to sunlight a nd s p eed up wat er How to e liminate
breeding sites o f Anopheles flaviros tris , the primary mosq uito vector uf
Malaria. Another exa mple is U1e need to c h a nge water in flower va s es
....
at least every two days or n ot to allow water to rema in stagnan t .i n
artificial containers (like old t ires or discarded cans) in order lo eli mi n ate
breeding p laces of AerJes egypti, m osquito vector of Dengue and D engu e
Hemo1·rhagic Fever.
To minimize or elim inate psycho-social threats or r isks in the home
environment, the nurse can work closely with t h e fam ily to improve its
communication patterns, role assum ptions, relatio nships and in teraction
p atterns.
5-
Facilitate the Family's Capability to Utilize Co1n 1nunlly
Resources for Health Care . Ano ther m ajor inte rve n tion involves
maxi mum use of available resources through coordination, collabornt ion
an d team work provided by an effective r eferral syslem. Ea:,--y access to
available health a nd socio-economic r esources starts with maintaining
an updated file that lists such resources, their ad dresses or telephon e
numb ers a nd specific services offered.
A sample format of the file o r index of communi ty resources is shown
below:
Name of Agency
and Person to
Contact
Officil cand
E-mail Address/
Telephone
Number
l\'pe of Client
and Specific
S-ervices/
Schedule
Requirements/
Procedures for
Referr;il
A two-way referral system can facilitate mobiliza tion of resources for
families. The n urse or the agency establishing such a system can ha ve
previous arrangements or agreements on the referral procedures a nd
services with the agencies or r esou r.ces involved.
A sample two-way referral form is shown in Figure 3.2, The nurse of
the referring agency accomp]jshes the first half of the form providing
the necessacy information or case s ummary a nd specif);ng the reason s
for referral or the services re quested. She can let the family bring the
form to the agency wh ere referral is made. She can advice t he fam1ly that
after the necessary consultation is done v, ith the agency where referral
is made, the family can brin g back th e second half of the form with
information on services non e, fincl ings and recommendations. Other
alternatives are possible, such as a messengerial service that brings the
fonns from one age ncy to the other. The nurse can also do the necessary
comm unicat ion \~ith ll1e personnel of the agency where referral is made
for fol low-up an d coordination.
An effective two-way referral. zystem ern;ures monitoring of the case,
problem or situation, follow-up ofreq uired intervent ions, case or services
and evaluation of the clients· status or family's problem/si.tuation.
87
(letterhead of Referrlng Agency specifying
Name, Address and Telephone Number)
Name of Agency to Which Referral is Made:-_· _ _ __ _ _ _ _____ _ _
Address:_ _ __ __ __ _ __ _ _ _ Date:
-
Name of Pati ent/Famll y Head: - - - -- - - - - - - - -·- - -- -- -Age :_
__
Sex:_ _ _ _ Civll St atus: _ _ _
Occupation: _ __ _ _ _ _ _____ _ _
Address: _ __ _
Case Summary:
Reason f or ,teferfal/Servlces Requested:
Signature of Referring Personnel
and Designation
."
Name of Referring Age11cy:_--'--"---
Addre.ss: _ __ ___ _ --,- ~ - - - - - - - - -
--- -
Date:_ ___ _ _ _ _ _
Name of Patient/Family-Head:_::::.;.--".:..;.;~:!.:-- - - - , - - - - Age:_ _ _
sex:._ ...--- -----,,-
$AfYlces Oonm/Flodfr,s.$/Reoomm~end~ons: ·
'"
'
'I
, ., ·signatur~ and DesJgnallon
(fit!e back-pageJor lnstrl)G#,t>nj)
Fie- 3,2. Sampla Two-Wa~ Refw i Form
88
(back page)
Two-Way Referral Form
Objective:
Set-up a r'e ferral system that facilitates ~ccess to services and i nformation by client/
family and agencies.
Instructions:
1.
The personnel of the r eferring agency (e.g.• barangay station; R.H.U.) fills
up the first half of the form providing pertinent data as indicated (i.e.• case
summary and reason for referral or services requested.
2.
The client/family brings the referral form to the agency where referral Is
made to avall of the services needed.
3.
The personnel ofthe agency to which referrallsmadefills up the second halfof
the form, specifying the services renderetf/findfngs and recommendations,
and sends back the form to the referring agency thmugh the cllent/family.
4.
The client/family brings back to the referring agency (e.g., barangay station;
R,.H.U.) the duly accomplished second half of the form for decision, action
or Information. The form Is flied with the client's record.
89
,
Cat a lyze Behavior Change Through Motivation and Support.
To bring about self-directed cb ange, p eople must learn to learn from their experiences.
According to Ch.in and Benner (1976, p.3.7), frequently people have learned to defend
against the pote ntial lessons of experience when these threaten existing equilibria,
whe ther iu the person or in the social system. I11 order to help people lower their
defenses a nd a llow themselves to experience the needed change, it is necessary to have
a l earning emrironrnent that nurtures the change. The change agen t can help the client
pul to maximum use valid knowl.edge t hrough concern for: (1) human needs or the
"use-value~ of a given piece of knowledge; (2) security, trust, self-esteem, self-identity,
group esteem and group identity; (3) accurate and appropriate preparation and
transmissiuo of messages. To catRly.tc the change process, support is needed so that
an otbenvise insecure, threatened or anxious client who is facetl with t h e stresses of a n
u nfami liar reality can e.,1>erience s tability or feel some sense of self-trust or confidence
to sustain actions and complete the behavior change.
lo family health nursing practice, the family as a system needs to a chieve optimum
reality-orientation in its adaptation to changing internal and el\.1:ernal e nvironment.
This is done by developing and institutionalizi ng its own problem- solving structures
a nd processes tJ1rough performance of the family health tasks. To catalyze the
beh:wior ci1ange towards problem-solving competencies, a theory of family healtb
nursing intervention was developed by Maglaya (1988). Motivation and s upport are
components of this in tervention. Motivation as conceptualized in the intervention
theory is :rny ei,: perience or infomiation that leads the fam ily to desire and agree to
undergo the beh avior change or proposed measure and take the initial action to bring
about the cha nge (p. t8). Support as an intervention is any experience or information
that ma intains, restores orenbances tbe capabilities or resources of the family to s ustain
these actions a nd l'Omplete the change process. The intervention leads the family to feel
"secured~ or "in control of the situation~ in the face of uncertainties, stresses, blocks
or ba.rriers to t he solu lion of the heallh condition or problem or threats to self-esteem
and affection or danger to life (p.19) . To ilJustrate, a young mother with a severely
malnourished nine-month o ld baby s uffering from dia1·rhea can be s o overwhelmed
with her child's condition that she rejects a ny advice to do oral reliydration and
continue feeding the child. Experience tau g ht the mother that such action s lead to
vomiting and more frequent bouts of dia rrhea. Through m~tivation and s upport, the
nurse c:m help the young motlie r understand the cyclical relat ionship of d iarr hea and
malnulrition and the causes of diarrhea when giving oral feed ing. She can develop the
mother's competencies to administer oral r ehydration sl owly through the cu p, spoon
or dropper. She Clln demonstrate to the rnotJ1er how to prepare and give easily digested
rice gruel mixed wiLh protein concentrates. made from powdered beans, sun-dried or
toasted-dry small .fish o r shrimps (see Chapter 14). During t he ini tial ex-periences of
the mother in carrying out s uch meas ures to manage diarrl1ea, t he nurse's physical
and psychological availability or accessibiJjfy are sources of s upport especially during
experiences of fear, doubt and hcJplcssncss. When the nurse can not be physically
presenL, the young motlier can be made to feel that the nurse's help is readily available
through t he clinic visit, telephone or written note.
·
ln an evidence-based inten1e ntion research on family empowerment for malaria
prevention and control in a rural barangay (village) in Abra Province, motivationsupport intervention consisted of four major components (Maglaya e l al, 1999). The
first component included visioning or goal-setting activities which helped fa milies
clarifr or spec.:ifr the reasons for th e needed behavior cha nge. The second component
consfared of plann lng sessions which focus.ed on developing family competencies to
specify the objectives and strategies to achieve expected goals (i.e., what can be done
90
►
to achieve the specific behavior changes and how t11ese can be carried out). The third
compon en t consisting of impleme ntation or practice sessions centered on providing the
families guided experiences or opportunities to carry out or practice the competencies/
skills lean1ed. The last component focused on evaluatio-n activities which developed
the faro.Hies' capabilities to specify "What happen cdr, "What were missing?" and,
"'What to do ne"'t?" Research findings showed that these four components of ilie
motivation-support intervention significantly improved the fam}lies' competencies
on early casefinding, prom pl/appropriate treatment, use of self-protection measures
and environmental manipulation to eliminate the breeding and resting sites of t he
mosquito-vector of malaria.
Fleury's model of wellness motivation was adapted u sing the motivation-support
intervention. Families were guided thru the behavior change process: from constructing
the intention to initiate/sust ain the change to translating the intention into actions,
and lastly to integrate the actions/change int o exjsting lifestyle. Appendix E s pecifies
the nursing interventions to facilitate the families' movement through each stage.
Chapter 18 describes in detail the family empowerment process and outcomes based
on an intervention research on malatia contTol done in Danglas, Abra Pi:ovince from
1997 to 1999.
Criteria for Selecting the Type of Nurse-Family Contact
Effectivity, efficiency, and appropriateness are major criteria for selecting the type
o f family-nurse contact . While the home visit is expensive in terms of time, effort, and
logistics for the nurse, il is an effective and appropriate type of family-nurse contact if
t h e objectives and outcomes of care require accurate appraisal of family relationships,
hom e and environment, and family competencies (i.e. ilie best opportunity to obse.r ve
actual care given by family members).
The clinic or office conference is less expensive for the nurse and provides the
opportuuity to use equipment that cannot be taken to the home. In s ome cases, the
other team members in the clinic may be cons ulted or called upon to provide additional
service. The clinic or office conference also emphasizes to the family the importance of
empowerment and asswning responsibility for self-help.
The telephone conference may be effective, efncient a nd appropriate if the objectives
and outcomes of care require immediate access to data, given problems on distance or
travel time. Sttch data include monitoring of health status or progress during the acute
phase of an illness state, change i.n schedule of visitor family decision, and updates on
outcomes or responses to care or treatment.
The written communication is another less ti.me-consuming option for the nurse in
instances when there are many priority families needing follow-up on top of problems
of distance and travel time. If the family is motivated and independent enough such
that the nurse can use the advantage of placing responsibility for action on the family,
sending a letter, note (as reminder, follow -up on medica.tion/treatment or update on
progress or referral) and learning materials are appropriate, effective and efficient
options. A school visit or confe rence provides an opportunity to work with the family
and school authorities on how to determine the degree of vu lnerability of a nd work
out interventions to help children and adolescents on specific health risks, hawr<ls or
adjustment p roblems. An industrial plant or job site visit is done when the nurse a nd
the family n eed to make an accurate assess ment of health risks or hazards, and work
with employer or supervisor on what can be done to improve on provisions for health
and s afety of workers.
91
l
DEVELOPING THE EVALUATION PLAN
The evaluation plan specines h ow the nurse will determine changes in health
status, condition or s ituation and achievem e nt of the outcomes of care specifjed in
the objectives of t he family nursing care plan. The pla n includes evalua.tion criteria/
indicat o r s, s tand ards, met h ods and tools/evaluation data sources. As the nurses•
systematic guide to facil itate improvement in client's health st atus, home and
e n vironment condition or situation, behavior or role/task performance, the evaluation
p lan specifies the criteria as objective, measu rable and Oexible indicat ors to determi n e
achievement of expected perlonnance, behavior, ci rcumstances or clirucal s tatus (ICN
1989). An evaluation ~tandard refers to t11e desired or accep table condition, clinical
status or level of p e rformance corresp ond .i ng to an evaluation criterion or indicator
against which actual condition, clinical status or performance is compared.
The evaluation plan also includes evaluation methods and tools and/or evaluation
data sources. Examples of evaluatio n methods include di rect observation, interview,
oral or writte n tests, record revie\,v, health/physical examination (e.g. _vi~aJ signs a nd
anthropometric measurement-taking, IPIPA, etc.), Note that t hese a re s1 m1 lar methods
u sed d uring the assessment phase. It_must be re~e mbered t hat because the cyclical
n ature of the nursing process, e~al uation ush ers m the assessm~nt phase a t the next
level of appHcalion of th e nursm~ proc_ess. ~valuation tools mclude performance
evaluation checklist, ratmg scale, inteIV1ew guide, food recall form, food frequency
and food record form as examples. Instruments s uch as weighing scale, thermometer,
blood pressure apparatus, t ape measure and glucometer are e..xamples of evaluation
tools too. Evaluation data sou rces are records and reports which document the
data results generated from specific m ethods and tools to determine achievement of
expected outcomes based on the goals/obj ectives specified in the family health nursing
care plan. See Table 3.2 for a sample evaluation plan
·
DOCUMENTATION
The family ca r e p lan isa written guide of the n u rse and fam ily to ensure a systematic
approach to plann ed behavior change. Appendices C2 and C3 include The F amily
Service and Progress Record (FSPR) and the instructions o n the Use of the Fa m ily
Service and Progress Record. Together with Appendix C1 (Charting N ursing Care,
P rogress Notes and Client Responses/Outcomes), these tools a r e examples o f how to
set up a record keeping system which proyjdes direction for planning, implen1entation
and evaluation of client care. Accurate record keeping is an important r esponsibility
of the community health nurse. It provides evidence for profession al accountability
and quality care.
92
.
TABLE 3.2 SAMPI.E EVALUATION PLAN
EVALUATION CRITERIA/I NOICATORS
OUTCOMES
Goal: Improve the nutritional status- of the twoyear old family .member
Objectives1
The family will be able to:
1. Provide adequate
care to the two-year
old member
.
it
.
g_
S°·
Weight (as nutrltfonal status crlterlon)
EVALUATION
STANDARDS
Increase or at least 1
kilogram In six weeks.
EVAWATION
Method
. Weight MonitorIng
Performance Criteria/Indicators:
La identify inadequacies Jn specific Correct identification of Dietary history
inadequacies in intake of taking
nutrlE!fllS generated from the
sperrlfic macronutrients,
baseline dietary intake of th@
vitamins and mlnerals
child.
critical to growth, bonedevelopment and strong
immune system.
Prepare meals based on
cycle menu plan •
Lb.
Mcurate application of
Dally Nutrition Guide
Pyramid for Filipino
children 1-6 years.
Record Review
Tool/Data Source
weighing scale, Early Chilonood Care
and Development Card for 0-6 years
food recall form or food frequency
record
I
I
'
!
l
menu plan
I
;
l
&>
ij,
~
"~
I
-
j
...,
1.0
___...
\
f
TABLE 3.2 SAMPLE EVALUATION PLAN (Continued)
:~ .·,.~;·iJ6iaMis
f.'1': ' ·'>-'·
. . . . ,,
<
-~ :_;_:.i..._~
' · . . _,.,...,.._JIIIN
..
· '
IYAWA1IDII
f1'MIDANII
miparau1>n QT
MWAl10II
.....
.,-,.....,n...a
_• _
_
Method
o6iei ·-···n
penormance i=v111uamn
meats aulded by
prtnclples such as
nutrient preservation,
Increased variety and
appeaUng to taste.
1.c. Feed the child based on
aareed upon quality and
quantity of food.
1.d. Carry out strategles/
• measures to address child's
it
•
g_
S°·
&>
ij,
~
"~
2. Utilize community
resources for care
1
eating Idiosyncrasies and
problems
Child's dally food
Recor,d Review estfmated food record
Intake based on
Observation performance e,,a\uatlon checklist
recommended energy and Interview
and nutrient Intake
for age group
Appropriate and
Interview and
effective measures
Observation
performance evaluation checklist
based on child's age
and nature/magnftude
of eating/feeding
PJ'Clblems
2.a. Bring the child to the health Clinic follow-up at
center/clinic for regular
least once during the
early childhood growth
month
monitoring and care.
Record Review Early Childhood Care and
Development Card for 0-6 years old
,
p
REFERENCES
1.
Alfaro-LeFevre, R. (1999). Critical Thinking in Nw·sing. Philadelphia:
W.B. Saunders Company.
Allanach, E.J. ( 1988). Perceived supportive behaviors and nursing
occupational stress: An evol ution of consciousness. Advances in N11rsing
Science ( 1), 73 -81.
3.
Bailon, S.G. and M aglaya. A.S. (1990). Family Health N ursing-71,e
Process. Manila: Brainchild Managers and Consultant<,;.
4.
Benner, P. and Wrubel, J. (1989). 71te Primacy of Caring: Str-e.~s and
Coping in J-le_alth and Illness. Menlo Park, Ca : Addison-Wesley.
5.
Chin, R. and Benner , K. (1976). General Strategies for Effecting Change in
Human Systems. In WG Bennis and others ( Eds.). The Planning ofChange
(p. 37). New Yock: Holt, Rinehart and Winston.
6.
Clemen-Stone, S., McGuire, S.L. and Eigsti, D.G. (200 2). Comprehensive
Com munittJ HealthNw·sing: Family.Aggregate and Community Practice.
St. Louis: Mosby.
7-
Denham, S. (200 3). Fwnily Health: A Framework for Nursing.
P hiladelphia: P.A. Davis Publishers.
8.
Fleury, J . (1991). Empowerin g Potential: A Theory of Well ness Motivation.
Nursing Research, 40 (5), 2:86 -291
9·
F reema n, R.B. (1957). Public Health Nursing Practice. Philadelphia: W. B.
Saunders.
Little, E. and Carnevali, D.L. (1969). Nursing CarePla,ming. Philadelphia:
J.B. Lippincott.
ll-
Logan. B.B. and Dawkins, C.E. (1986). Family-Centered Nursing in the
Community. Menlo Park, Ca: Addison -Wesley.
Maglaya, A.S. (2008)- Delivering Quality Sen,ice Serving Communities:
Nurses leading Primary Health Care. Philippine Journal of Nursi11g, Vol.
,78 (2), 10 - 13.
:Maglaya, A.S. ( 2 004). Nur sing Practice m the Community. (4tl1 ed.).
:M arikina City: Argo.nauta Corpor ation.
14·
15·
Maglaya, A.S. and others . (1999). A family health empowerment and
interve ntion model towards prevention and control of malaria in th e
Philippines: The local government unit/ nn-al health llnit perspective.
Manila: DOH -ENHR.
Maglaya, A.S. (19~8). Beh avioral Catalysis: A Theory of Nursing
Intervention i.n Family HeaJth Care. The Anphi Papers, 23 (2), 14 -2 0 .
95
1
16.
l\tnurer, F./\. and Smith, C.!\--1. ( 2 oos), Comm1111ity/P11blic H eal~l1 Nursing
Practice. Hcaltlrfor Fam flies a nd l'op11latia11. (3 rd ed.). St. Loms: Elsevier
Saunders.
Steckel. S .B. (ig8o). Contracting with Patient-Selected Reinforcers.
American J ournal of Nursing, Bo (10), 1596-1599·
1
96
CHAPTER 4:
IMPLEM ENTATION AND
EVALUATION IN FAMILY
NURSING PRACTICE
Araceli S. Maglaya
Meeting the chall e nges of the impleme nta tion a nd evalua tion phases is cn1ciol in
family nursing practice. The nurse experiences with tl1 e family, a lived m eaningful w o rld
of mutua l. dy1mmic inte rchange of mea nin gs, concerns, pe rceptions, biases, emotions
and skills. ,Jus t as the self nims to achieve body-mind integrati o n to nchieve wholeness
in the experience of "'being" and " becom tng", lhc mn·se mus t e ngage in foll awareness
of being in this •1ived experience of ca ring with Lh e family", if she aspires to achieve
"being'' a nd "becoming·• in csp erl cm·ing. The nurse can achi eve cxperl caring w ithin a
d ynamic and e mpowering family-nurse relatio nshi p directed at making choices in this
meaningfu l world of coping, aspi1·ations, em otion;, nnd skills.
EXPERT CARING: METHODS AND POSSIBILITIE·s
Expert caring during the im plementation phase is demonstrat ed when the nurse
ca rries out interventions bused on the family's understanding of the lived experience of
coping and being in the world. Expert ca ring is developinl!, t h e cap ability of the family
for "engaged care•·. Thro ugh the m1rse·s skilled practice, the family learns to choose and
carry out tl1e best possibi lities of caring given t he mean ings, concerns, emotion~ and
resources (skills and equipment) as experienced in the situation. W11ile the challenge
for eirpert caring is a reali ty, the nurse _is e nriched els a result of s uch an e:iq)erience
(Benner and Wrubel 1989):
..•ay belhg expen:s in ca.ring. nurses must
takeO-\iJ::r and transform the notions of experttse.
Exp~t c:,ring has nothlhg to do with possessi ng
priVlleged Information that ihcrea'ses one's c-ont;t-QI
a ,cl donilnatfon of another. Rather, expert carlng
unleasnes t he possrbllities inherent in the self and
~ sltu:,tion, Expert caring liberates .:1nd facilitates
in such a way that the one caring 1s enriched In the
process (page 398).
While expert caring does not happen overnig ht to the novice nurse, th e r e are methods
and possibilities tha t can e nhance learning towards e >..-pe rt curing. Such met h ods
and possibilities need to b e carried out a n d experienced in real contexts a11d real
relationships to achieve s killful comportment nnd excellence in the curre nt situ ation.
97
111ree s uch major m e L11ods and po;;sibilities a re discussed in this chapte r for ill ustrnt iot1
purpOS<'.S:
11"41teatnfi
Telichl'h&
I Oevelopment
~ng ~ ~:,P.ali!iift
racttce
COMPETENCY- BASED TEACHING
A su bstantive part o f the implementation phase is di rected towards d evelo ping the
famuy·s co mpete ncies to perfor m the health tasks. This is ca lled co1n pctency- based
teaching.
Comp ete ncies include lhe cogn,itiv~ (knowledge), psychomot o r , (skills), and attitudi n a l
or affective (emotions, feeli ngs, ,·alu es). The following are farn.ily ,11ealth competeucies
deri,·e<l from their corresp onding heal th tasks as exnmples:
Health Task: The family recognizes the possibility of cross-infection of
scabies to other family members.
Compr•er.c:lu:
'!ltlaln$d'ltcaaseof-sca~
e n ~ •avs I>), w~ ~
l)f-
es tan occ.ur a mo ng
:Ii 111'-"s.
Health Task: The fami ly provides a home environment conducive to health
maintenance and personal development of its members.
Hea lth Task: The family decides to take appropriate health action .
111 nrdC'r le> ,,,..ste m nti = llv wor k tn,,.·a rds dcvclopmc11 t of ti ,e fomily"s c" m pl.!lc n c ics, such
c-, omp<"t c nci~~ n<>Nl ln h~ explieith- d e fi n ed. Cog n il ivc ~ind psyc-h o m oLO r eom pcLcncics
n re n·Ocnecl e ,Tllidily 1,s ohj,'<"1h ·,• -; in th<.: n ur:,;i n~ L:.'1r t· plan. The .i ll ;1w.li na l or affecl i v e
<'Ompet t! n<·ie~ , na) ;; I!.<) be I ran>'l.1tcd in t o o hj (·<"t i vcs o f en n: :i i- fouli 11gs. e motions o r
philo,ophy i11 lif.;- th.it en h anee the fo mil~··s de,- ir'-' <Jr commitment t11 behavior c hange
n nd sust;,i n the n e ..Jed actio ns. The following ,,i re examr,lcs of learn ing p rin cipl es a nd
tea ching- lefl rn ing met h o ds nnd t echniques that th e n un;c c;ui use in compete n cy-based
98
teachh1g (AbhrHt 1980, pp. 35-73): (1.) Learning is both nn intcllccr,wl and emotional
proces!:i. H elp Lhe family hancllc the affective components of learning for s us tain ed
behavior; (2) Leaming is facilitated when experience hns meaning. Focus learning
on the family's mean in gs, concerns and situalecl p<Jssibilities; and (3) Leaming is :m
indiv idual matter. Ensure m astery by woddng 011 t he fa mi ly's current capabilities ~u1d
potentials.
Learning is an Intellectual and Emotional Process
Bci.tig ;iware LhaL fa mily members as pcTsons are integra ted beings, a change io hm,,,
th ey think about something or in their und erstanding of the situation will affect how
they fee l a bout that situation and t he need to ch;in1,;e iL A ch ange in beliefs or p e1·sonal
meanings wi ll affect emotions. Li kewise, a shift in e motional oullook opens new ways
of tJ1i11king_ abou t siluali011s (Bmrncr a ncl Wrubel, p. J83). To illustrate, the nurse
C.'ln motivate Lbe fami ly to desire change by incrci:ising the salic 11cc of th i;: proble m
through chi1J1J!,C in Lhe fam i ly's cognition (e.g. broadening ils knowledge base to
m()dify pcrc:cplicm of the problem) and vo li tion (e.g. developing the necessa ry s kills).
17. xperientially, s 11ppc,r-t as an intervention need to focus on fccUngs or e m otions that
i11tcrfcre with I lie fomily's feeli ng of" bcing in con trol" orl11esit ualion du1·i11g the change
process ( Mngl ay:i 1988). The family needs to be aware of, acknowledge and analyze th e
source o f i;ucb fee.lings of insecu1ity, anxiety, fe;i r. guilt, resentment or apathy in o rder
to lrnnsform lh <ii r e n e rgies into possibili ties for clrnnge. Support makes Lht: family feel
thnt the n urse is ava ilable a nd accessib le (_physically, psyc holo~icaUy o r e motionally)
to pro vidP the necessa ry affirm a tio n , reassurance, feedback and rc.;source to rega in
s 1rcJ1g1h nnd refine n ewly developed skills to handle the ba rriers o r blocks to sustai ned
acti om;. Illness experi e111:cs uf long duratiun (e.g., i:ar<li ai: problem, men ta l illness all(]
rel~trdation) arc exam ples of s uch s itua tions that c1t n d ep lete the family's emotional
reserves if suppor1in! interventio ns are not ca rried out.
Five ge neral methods and t echniques a re discussed here as examples of bow t o t each
attih1des oi: h e lp th e f,u11ily hand le the affective i;omponen ts of teadting-lea rning
situations (Abbott, pp. 50-55; Benner a nd WrulJcl, pp. 165- 168):
1.
P rovide luforn1ati.on to Shape Attitudes . Formal he liefs abou t
health. choosinp,henlth and planning for health are shaped and changed by
infom1 atio n wli ich ure 11ot 11ecessarily restrict ed Lo o rnl tin,-ritl e a la ngunge.
Prom u phe nomenolog ic.:a 1 pci:speclivc.;, sensorimotor information through
nctn,11 perc.:cplun l experience of Lhe sensation gi ves the b~sl information
abou t th c s ituat ion. What a pernon/ family actually secs. h<'nrs, ,c;m e]ls,
to uches or feels influences his/her/ its perc.:eplion a nd altitudes towar<ls a
particul;rrobjccl, person orevenl. Experiendng health as hodilysens,1tions
o f " fcclin g good and strong" c.n n be a powe rful first s te p in m a king healthy
cho icc5 of proper rest·. good nutrition, regulnr cxen:i:-;e a nd recreation.
Rc framinl!, n :-.itua tion by keeping the family me mbers think about its
understand ing o f the cu.n·c nl situat ion can open up new a11ernalives. rt
req uire:; gelling in touch with th e mcani.Jig:, a n<l conc;crns thiH 11re s t::ike in
the s ituatio n . Foi· example . a fo mily can be mo liv::itccl to help t he p regnant
mo ther recog ui ze the n eed for re~ular prenalal c:heck-up by providing
tJ1 c n c<.:e.s:mry information l'egardfog the implication of the signs a nd
symplDms as ..:xpc:rienc.;cd by the pregna11t men1bc 1· and the conseq uence
of failure lo lake t he approprialc actions. Relaling :;rn::h cC)ns;cquences
lo the prcgna 11t m othe r's m eanings and co ncerns about being ;1 healthy,
happy person , a produclive, caring mothe r im a n responsihle, lrwing wife.
ca n liel p the fami ly reframc the sihiation for her.
99
Through an,,th c.:r vnrin lio n or th e rol c-playinJ!;. th e cl ie n t s ils o n lhc "hnt:,;c;i t'' fr,c.:i ng au empty chair o nto which he pmjcct.<: hi,; m n ny selves. 11Jis
tcchni q111.: rrnvid<; ~ ;111 1,r,pnrt1111i ty fnr Lheopposi ng for e~ wit hin a person
i-o rnlk ¼1 th eac h t>thc r. have it ou t with each o lh e r. forg ive each other.
comprom ise o r gc:t to k n ow each othe r. Th is ca n help the fam ily m e m ber
11 11clc rs tan d hirni;clr, his r.lrcams, fant a sy a nd renlity (Ki n g a nd Ge rwig
1981. p. 4 S).
Throug h role-pl;i};ng, f;,mil}" membe rs c:an e..,-press. acknowledge and
itl c ntify lc dings a nd emotio ns generated by the d ay to day adj ust ments to
cnch <Jlhcr':, n:a li Ly nnd c,,pi n g ,,itl1 health am.I illness si tuat ions. TI1rough
s uch fl wm·, •nr~s, c:11ch fami ly m r·mbc.r c:an di~c.over additin na l rJspcct,s o f
the self. This ope ns n ew experiences a nd a ltcm,Jtives to transform feelings
a nti e m otions lo better opportuni ties fo r ach 1e,;ng a positive self-conce pt
th at c n ahlcs one t<> lea rn to ca re for othe r m e mbers.
(,.
E:,plo re th e Benefits of Power of S ilen ce. E ncourage family
mernlwrs It> use tl1 f: p<Jwt:r <>f s ile nce a~ a.11 interven tion to Lransfvnn
t he e m otion.~ or feelings th,H in fluence th e a tt itude into less painful . less
nhstina le and mnrc nbjcctivc e..,pcricnce of Ion king into the .';elf for rrt'ative
11pp111·t1111ities tu lt1.:::1I. n urlu rt: nr care. This is particularly useful du ring
e m ntinn- lndc n f,1111ily encoun ter o r recurrent psycho\ogi,;al irritations
of daily ct, ..nppnintmcnts or c n ntlicts. F,,mily rncmhcrs can lcnrn to use
:.1l,·n,·o.: (wi th «l nw d,•ep b rcalhrng) n.s an :-ic:tive PxpPrif'nce r)f ht>ing aware
or nm··-. sens..:,-. acccptini :-ind being tolerant of th e self and others despite
th e fn1 1< trn1im1.~. d isappointm e:m s orstrcsses. Slow. deep breathing relaxes
the body ,md pro,ide.s for better o:..-ygcrn1tion of brain cclb. Thi i; allows a
mm,· obj,·ctive and Jes$ emotional e.,,-icrience of being ,,;th the self wbile
a n al~, inp, the problem o r th e issue for better problem-soh;ng.
Learning is facilitated when experiences have meaning to the
learner
F11cu.~ nnd rdMe lcarni11i:t e.'i pcric.nccs to the clienfs/family's. m eanings, a,;pirntion.s
nnd lwst dn,in• n111C1ng options ;n·ailable in the family s itua tion_ To e mphasize th e
imp<>rt:mt·,• " ' ··11w:ininp... in learn in~. the follm,;ng exercise is used as a n adaptation of
a si 111 ilar 1•;,,i•rris1· ill us t r.it cd by Ai>h;11t (p.4 1)
Look for nl>ou t two seco n ds nt th e two di:igrarns below.
•
I
101
1,
M :1k1• tltt! lr:nrnin;~ ;,clivc by pmvid in g opport u ni ties for t h e (:1mily to
do SJJ<!c-i fir· :ll'livili1:s, 11n1;v1Pr q w-:sl i11ns n r apply learni ng in , ,, lv in g
prnf>l,:ms . l'r,ivid c 1• nn11gh o rport u niti cs to pni c;ticc p e rfo rm i ng th e s k ill ,;
such ;11, menu p btnn in g, rrcp:irat i,,n of me.ii,; :ind feedin g :i m a in n u r ish ed
m e mlwr.
2.
Ernrnrt· r:larit y in t1•nd1ing. I isc• wmds, r:x;i m plPs, vls11nl m ate rials p nd
ha11un111s I h:11 I hr: fr, m ily c•a n 1md,m, t,, nd. J n t,iach ing skill,;, Ih e:: n urse
mwa firs t d esnilw 1111' Gki ll : (11 ) 1:xpl riin ing why ii is impnrt:rn r: (h) wh en
j l ,; l11,11lcl he 11<;1•tl, :111d; ( t: ) I h e SI; , ~(,.,S Ill' <.lt!fl'i in pe r formin g t h e ,;kj II. A n er
des cribing 11,c sk ill. til e nurse m ust d e rnrm sln ,lc it. correctly, explr1ining
c:wh st1• 11 as s hl'.! is dem<in'it rating ;rnd emphas izing im portant po ints
(Aliha ll , pp. ~7-60).
:i.
Ensu re ad eq ua te eva lua t io n, feedback, rn r,nito ring an d 1,uppo rl for
s us t:, i nc d action hy: (a ) l:!XJllaini ng well how th e fa mily is d o ing; ( h) gi ving
lh e n('(·1·~s;1 1-y n fli rrna1irins l)r r1::1<;su l'an t r:<i; {c:) e.>:pl:Jin ing ho w t he -:ki ll
can be impmvcd; ;ind, {d) exp lori ng wi l h l hc fa mily how m o dificatio ns
,·:in lw c:arricll CH II 111 ma xim il.r' s i111;t1e<1 p os,;ihililic-,; or h c,; t o ptio n,;
a v:i il ,1hlc 1,, the fam ily.
MAXIM I ZI NG CAR I NG POSS IBI LITI ES
Effcct iv1• nurs ing o f famil ie.-; c a n put n g rc;i l d c m:1n d nn thP. r e.<;nurces o f tlw nurse
10 11 poin t wh en c:h c rn ,,y feel c:o n1p l!.!tC r hysica l, m en ta l and e 1110 U<1 nal deplet io n . T h is
is :, r1•ality i11 f:,mily nu rs ing pra clicc whi<.: h m:ikc\c: rrm tin c a nd pror·cd u rt••u r ic, nt cd
acti v11 i1•s 1ik1· r1·1·n rdi 11g, g iving i11j<·ction;,, l:ikin g h lood pressures. an d h1,11;,ekeering
t usk s nmn: ; i ll ract iv,· nnd crm vc11ic; nl t o m a ke 111.: r:-cl( b u.-;y wi th . I lowever. l he esse nce:
ur n11 rs i11 g is (•a ri ng. 111 tin, fat·1· of a fomil y's co11fli c.:1, cnn f11s i0 n 11r hl"iple ~1-nes", th e
r111n<t' s h :n·es lwr ,·.\Jll' rt is 1• a nd cm01 icm:il/ psyd1nlr,gi ca l sl nmgth ns la m i ly rrwm bc rs
lea rn w tl1 •\'cl11p i:11111pt,l£.!11cic.~ l•J ma nage hctillh L~>ndition s o r prtihlt"!ms. 11nlc·«s thr.:
n11rsl' hus an p,ir,•d ~u<'h 11 1,hilt,snphy n( ca ring, commi tm ent lo cxccllem·e i n nursing
pr;1cl in• will """"Y~ r(•ma in an dui:i vc ic.lc,1I. Philosophy a n d co mm itment arc, the re fore,
i11 gn·di e111s o f' effecth·c 1111r1,ing pr:11:tic£.!.
,\notltcr l'lia lk- n~e i11 lamil y 11111-s ing pract ice is the difficul ty in o pe ni tionali7.ing
fnn1ily -1·,•11i.•re d c a re'. Nu rsing c:ir·e or indi1.;d11:1l family m e mhcrs in t h e h o m e se ttin g
is , u fll 11tinw~. lhl· nurse 's id ea abou l fa mi ly 111m ,inl! pra ctit.:c. It is q u ilt' com m o n 1ha 1
nu r/;CS offer rml~· lip s ervice to the con ce pt th;11 the whole fa mi lv is affectecl hy ;incl is
n ffec·1i ni.: ib ind ivid , ,a l memhc rs. It req uire~ a b rnacl k 11, ,w h.:dgt:! ha!-'e on I he h ch:1vinral
~a-i{:11ccs f'r11· the 1111 rs e lo t11Hfors ta11cl a nd co n crc1 i1.C" t lw con ce p t of d ynamic in l<'l'(:ha ngc
lw1wr•r•11 fami ly n,,.mht•ri; in 1hr ~,: hi c\'ern cn l nf h en It h :rnd f: 1111ily d evelripn w n t goa ls .
Anolhcr sourr.:c 111 llw diffin 1lty in op1.:r:1lio 11.1 lizini: fn rn ily-ccni e r cd cn rc is th e na ture
:111d mag ni111d l' nf fa mil y t·orwc:-rn ~ 1111d h l'n li h p rc,blcm,-,. U fh:11ti,nes he a lt h prnhl1,,m s
c11,·111111tt•rcd by fon ,il ic,: a n.' l111gc, cn mpli1:;i tud by a numbe r o f v;1ria hl es s u ch :rn
s ocin- c11h11 rnl aud <•1·0111 1111 il' fnrto ri;. 111 1hc fnct' o f s u ch complic:at ion s the n u rse feds
h t>lpl cs1- l o ti n: Jloi111 of wi thdrawi ng frn m tlw 11pportunil ics L,, wor k with fam ili l!l> ns
d i1.:11ls . C11n,, id<' rini; s 111:h a tllffirnlt:, of idcnlifyin11 t h e scop e o f he lp t ha t lh c nu rse
c:in provide, )!,Ui<ldincs a nd l o<>b can d evelo p h e r s kill in b re ak ing down h c:'l llh and
1111rs i11i.: prnbl1:1rn; into rn a nag,eable uni l s of a ttack
0
-
Probl em s in working wi th families .i re som etimes due Lo wron g d efi ni tio n of health
nr nu rsi n)!, pro b le m . T h is mny be u conscqu c m·c of impro per co ll ec tion o r e rroneou -.
i nt.:rprclat ion o f cu l:!s, dat;J or fads. T he nurse n my lack the l rai ning or skill i n (lb,er.;ni.
103
3.
Hea lth- rela ted m otives m ay not a lways g ive r ise to h ealth- related h e havior
and conversely, h calth-rela tea behavio r may not aJways be dete rm ined
by h eal th -rela ted motives.
These prin ciples on motivaticJn have ddinile impl ications l o n ursing intervent ions.
Util izing Lh e li rs t 11ri 11ciple. tile n u rse can h e lp Lhe fami ly n,eogn izc Lhc ex isten ce of
he,illh p robl e ms a nd motivate the fam ily to tukc nc1inns on th e m by help ing individ ua l
menibers see the prob lems ;is having serious consc.quences and high proha b ility of
occ urrence with in th e family's reality. T h e second priuci ple ,Hn gu ide the nu ri-e to u tilize
social nnd cconomi<: moti\·cs in maki ng rh e fa m ily renlize the 1:1J11scq ue nccs of health
prob le ms ,rnd heal th ncti<ms. Co usid e rini:; the Lhi rd principle. th e n11rse can c ncournge
heal th b c haviu1· by u lil b.in g 1wo-hca l ll1 11101 i ' ' CS wb ich have mo l'e weigh t in influ enc ing
action. T h e need for ,1 ffi rma lion. the need to belong, socia l pressu res of re la tives a nd
s ig n ific,1111 othe rs -rill th ese ca n genera te enou1,;h m o tiv:itio n for appropriate health
behavior.
Effoctb, e n ursin g of families mny not be to o cn,;y n tns k in i-hc face ofliruited resources.
b ot h materia l an cl m:111pm,·e r. Considering the problem on limi lC' d ma tcrin l resource s,
the n urse can exp lo re I he pm<sibility of ut ilizing indige no us supr,Jies to s ubstitute for
e.,,,e n si vc . commercial ones. In the face of mnnpowcr rn ns tra in ls. th e nurse ·s a bility
nt developing th ,• cn pn b ilitit:s o f cl i1: 111,-; lo s uppo r t th e h c,l lth cn1·c system can he p u t
to use. Fc1r examp le, slw can leach incl i,~du a ls o r w-oups on the s ii!,.m, :-mcl ,;ymptoms
or common h ea lt h pnJblems so l ha l the_,, can serve as m o ni lod n j:\ ne twork in th e
com nmnity lo in fv rrn Lit e n urse of pnJhlcms th al n eed h e r immi:Jiatc alien lion. The
n urse cll n a lso tr::i in a11x iliary :rnd village h ci1h h w1wkcrs tn 1mm:ige simp l e h ealth
p roblems 1>r do roul i n,iry work a nd pn:iecclUJ·e •()den tcd acth·itics. Hy doi ng U1is, s be ca n
u tilize h e r t ime dt>i11g the f u m:Lio 11 lhal requ ires ltcr cxpertise - ht:lpinl!, f;1 mi lic;; deve lop
co1111wtc11de_:; fo r h ealth dc,·clo p mc11t. Th e n urse a im s to a t l.iin s elf-rcl i:111cc amo ng
fam ili es hy ckvclnp i11i:; thc ir skills to r<'cogniz~ and m n nage s impl e II N1lth 11rohle ms.
Ni 1lt is is achieved. there i,; no need to heaYi ly d epen d on the overburde ned limited
healt h resources fo r problems Ih a t farn ilie~ 1:an adequa tely man age by the m i;elvcs. IL
is, likewise. i.111port:mt th:11 the nurse lie well -in for med alJout the availabl e comm u nity
resources so t ha t !\h e c::in u tilize thcn1 app rr,priatcly.
EX PERT I SE T H RO UGH REF LECTI VE PRACT ICE
T h r<> 11~ h mfleet ivc prnclice. Lhc imp lc111cn ln l ion p lrns(' 11ro,;c1e.~the best o p portunities
to wick n cxpl'rl i:;;I.' in fom ily !wa ll h c·n rl'. S,!vcn,I authors de~cribe two sels of reflective
l)rnct ice: Relki:Lion -in -adinn and Rc tlcclion-n n - :iction (Gl'l;'Cnwuod . 1998).
Rc lle<·tin11 - i11-:1L·lio11 means to th in k wh a l one is clning whi k nn e is doi ng ii. lt a ll ows 1h e
n urse lo rc-dcsii.:.n wha1she is doin ~ whi ll' slw is d o ing il (S<.:hon. 198::i. L987). Re flec tion on .. actiou i 1n"c,l vf•s rcvic,,..lnJ!i 01· re-cvalunti n ~ o nC"·s :.H.: tiu n s to: (L) re la te what unc has
lc.1rne d frnm th is c:,,.-peri<incc lo he r 1•x.is ti11g knowledge' ~tr 11c111 rns; (:!) me ntally test
her n ew 1111dcrstantli ngs in ne w con tc:-:;ts; mid ,(~~) 111nkc th e k nowledge gained J1er own
too ls for cril k,11 thi n k in~ untl ,·xpcrl c;i rinp, Relh:t:tivc pn,cl icc e 111.:011ni;1es llw nurse
lo immerse i1110 tin· c li<•nt"s rc,il ity :os h nl h lcarn tul-\cthc1· lo trnnsfonn l hc ex p.,rionc:e
in tn n ew w:iy~ of h e ini.:. anct hccnm in)!.. Us ing l'a r:;o's T h eory of Tlum 1111 Flecnmi n g
as;, ~uide, the 1111 rse learns to u ndcrntund full~- th e cl icnl·s responses. fee li n:;s, nn d
pt!rccp l irnrn. This expcricnec 011 eliL•11l -n 11n,<' imme rsion in the d ic11 1's rea lit y guides
both 1ow:1 r tls trnn~i:cn d in~ till! ,·111-r1•nt st~11u s r·•u eing.") to th e h<.!sl pus~ihh; h ii.;hcr
level o f stale o r fum:t inn in~( .. Bc<:om in i:(). Sa m p le process quest io ns for each type of
reflective prnctice arc s h ow n in Bo~ 4 . L.
105
can ma:dniiw tcmchir1~- li.:.inli n g 11rprJ rtu n itics for th e f:1mdy t n s e le c.:t
:1nrl 11,.'il 01 11 in l1·rvc 11ti1m r,µr iw1 -r t,1 d1 •t<· rm in r th r ir AJ')r, ropria rcnf"qS
it1 h rl p i11g tl1t• f.imi ly tow;1rd nt:1:c..l rc:mlu tio1 1.
T H E EVALUAT ION PHASE
,,r
Eval11;ilinn is lh c crrn tirrn r,u s r:r iriq11i ng of P:1d1 asp er!
tl1c nursin14 pruccss
(Cle m e n -S tone and others :.!l> IJ:l , p. 2 8:3). Al t hrm~h t•v;d11;1tion is dis 1·u ss<?d as ;i
sc p ,1ralc phase, il Ill us l t akc p l;u:e crn1nr rri•nt I~· with all r lw 11I lw r i,h:iscs ,if th e riurs i ng
process. ;i:, ill11s t ral1:d i11 f'iA, 1.1 (i n Ch:i p re r 1) . us ing an ad ;1pt.iti o n of the di agra m o f
/\ lf:t1·n- l.t: Ft•vn• (:.!1 111:.! , p . 19 1). Within 1his fnimewo r k. two types o f e valw,tion includ e
form at ive and !,,ll ll111l at i\'C!.
Formative cv;ilualinn oi:cun; during t he co urse o f th e nurs e- fam ily re lati<J ns hi p.
O ngnin~ fccd h:1!' k is done and c lic i t ccl J n i ntJy wi t h Lhe fa mi ly 1,, d Ptrrm ine if ~oa fs,
pl::ms :md i11t e.-·c 1di 1m str.,t t:gic.- s ;1n: apprl)J)ri atcl~ f<Jcusecl. lbsed u1 th e ev;ilu;ition
plan w hi c h speci fi cs th,· c ritc ri:1/ i11d icalo1-s , evaluatinn s tan d;ircl ~. m f'lh ods a nd tools.
rt1m111t ivc· 1•v,1l ua1inn is dcme ill pc rira1<.lk poinL, during th e implcmen l ation ph:,sc lo
d<·l c-rmirw c h 1111~Ps in t lw 1:liC'111·.s lw11lth cond it irrn or hqmc :incl environ me nt n:;ilities.
Us in g t·val11atio 11 <'i-iter l:, I n h e lp hoth nu1"s1: 1111d fo mil~- tr, rl e t,: r m i ne ;r the o bjective s
ure :1l ta i111•, I. tlw nu r.-e ncetl to r<•\·ie w ;in d de te rm ine h em · llw criteria rclale IQ eac h
s ta~C' n f t h r nnr;;in i. prrwr-ss . \•Vh c: n both th e 1111 rse and the fn rnily re.i lizt.: 1h a1 the
objec tives an· n o t 11r-l1 iev c cl, th e,· ca 11 a n a h·zc pnssihle r~;<r-,ns . S o m e examp les include:
( 1) in acl<'q1rn13 of ;i:-.sr,;s m c n t d :1tn; (2) s.;nals m id o bj e c ti ve:- :1 n · to o hro:1cl n r unrealis tic,
or lh at 1hey ,m· 1\<'Jt mu t uall y es tn h li s lH,d: (:-\} family reso urces or en ergiec: are not
foi:1 1H·d 011 prio ri1 y f.i m ily n ccds or Jrc r.lC!pl c tcd ns n rc,;u lt of c rises -.itu a l in n:-: o r (4)
th r f:1111 il.v lad;s l hf" inl r mnl o r l' Xf e rnal '<t~rpo rl it need s to hnn d k· th e cha nge process
(Clc m t•n -Sto n L' :in cl ,,tfwr;: ::WO:!, p .286 ). Form.iti,·e e valu;1t.io n µ;ui d~ bo lh l h c n u n,e
antl tlw fami ly !Il l d e l"isi n n :, nh01 11 m n diti c M irm s o f g n als. ohjrct i,·es a nd inre n •f'ntio n
st.rn t c1;ics / m e a s 11 res , d q .1c-11clinv. upo n th e curr ent s itua tion. emerg ing or addit1onaJ
hca IL h nc,·ds / p rnlil,•n 1s n n d prio rities o f t h e family.
Su mm ativ l• cvn hmtio11 occurs at t.he e ncl of the fnmily-n11ri;,e relatio n s hip. It determines
if l h i: g,mls as s p L·t: itil-<l in th e fam.ily nursi ng r~'l r<~pl11n nre 11c-hir\'e d a s n1e;is 11re d by the
n11 tr n11w r ri ll•ri n and l.'\'ll lual 1o n stnndards. Ba !;Cd on the famitv·s c ur re nt s itua ti o n
a n <l/ , ,r n·111:,i11i1 1!!, lwa l lf1 11cct.b or pr1>hlc111s. th e n 11 r:;e cnn guide th r family o n m a ki n g
cJrnicc:-. ahi tlll l t•nn i11utio11 o r referr a l.
CHA LLENGES AN D DIRECTIONS
Falllil_\ health n11rsi11~ prai:lkc is n pl1cnomenolop.ical l'S '[lf'rienr.e of r:irin g and
(·opi ng with c:11·,,g i\'il1 );. F.xccllc·n rr in suc h nn c n)?H).\L-<l ca r in~ is re flecte d m skillful
c o1 11port1 11<•11L , ~in.: 11 Lh e 1111n;c's p c r:-onal antl pn1fessi11 nul m e a n i ngs . cu nct1 rns,
e.xp1•,·t:11i n 11,-.. s t~·lv. hahils ond rcsonr rcs. 11:Lrtinilarly c:-.-perie nced durin )!; the
im plL·1111: 11ta l io11 phas,:. Cn111111ilmcnt lo cxeellc::.n cc' or p rai:tit:e i:,; :i li,·t-d 1;::xpt? rience o f
b e i11" cffc1.:t i"<: in I1arn.l l i11~ t h ~: ch,\l len!;CS c•f wo rk i11g wit Ii fa 111 iii es. Th,· i rnplt' nwnt.it io n
:1nrl 1·v:il uat i•> n rhn"'<'S provi de c,·e1;-· avai lnblc o pp1,rt unity tor th e nt1rsc and th i:: fa m tly
t r, ,·a lidatc a:-!-.e,-.:,;mt·rtl d:11a a n d 111<1tlif) ah,• 11ur"ing can• plan h :ised o n th e fa mily's
p cn·, ·pt i1111 o f a111 I n·~ r11 11 "<'S 111 l'\'e ry nur;,1:- family d f ort ,It explorini; the b e s t choices
in the fami ly·:- :-ilu,tll·d pv:;.-;il,tlit1e~.
Thro u~I , in1111ep,io11 in l<1 th,· clien t":- re ality. th e n urse gels a fu ll tmc..l erstanding
of th u d t•p1 h of tlw m e aning o f Lh e client"s experic11ce as both e nhan ce cn c.h other's
11pport uniti e s Ir>fodJ ilatc the joun1e y Crom apa Lby tocourage. vacillation lo decisiveness,
107
Greenwood, J. ( 1998). The role o f re!l cc-Lion in s i.ngl e a nd d ouble loop
learn1ng. J o 1wnal ofAdua11ccd N 11rsi11 g . 27, 104 8 -105~.
9.
10. J o hns , C. and Fres hwa ter , D . (Eds.) . ( 2 005). Tram:;_fm·ming Nursing
Thro11gh Reflectiv e Practice. (2nd ed .). Oxford : 131.ack,vcll Publishing Ltd.
11.
l(jm, H .S. (20 00). An I ntegT:1th.:e Framework fvr Co rn;cptu ulizi11g Clien ts :
A Pro posa l fo r a Nu rsing Perspective in th e N ew Century. Nurs ing Scie11ce
Quart erly . 1:; ( 1) . ;37-44 .
12.
l(jng, V.G. and Ge rwi g. N .i\. (19 81) . H11111c111i;,:i11g N 11rs i11g l~cl11 co t ion: A
Co nfluent Appruoc/1 1Jwougf1 G roup P1·occ,s:;. \Vakdk ld . Mass.ichLtsclls:
Nurs ing Resour ces .
13. Kock. T. and Kraffk, D. (:wo6). Pn r l'icipolory Actiu11 Research 111 H,.wlth
cm·e . Oxford: Bl.tckwcll l'ublishin g Lld.
14 . M nglayn , l \ ..S. (:wo8) . Deli vering Q 11111i1y Servi ce Serving Communities:
Nurses le ad ing Primary Hea lth Cr,rn. Phi/i7Jpin e .lounial of N11rsing . Vo l.78
(2) , 10 - 13.
15.
Maglaya, A.S. (2004). Nrll's;11g Practice i11 the Cn111111unity. (4th ed.).
Marild n a City: Argonauta Corpoi:-:1Lion.
16. M aglaya ,A.S. a nd others. (1999) .Af c1milyhealth empo1uer·me11tinterl}(mfion
model Inwards prevention m rcl co11trol of 111ctloric1 in tlw Philippines:
The local gcwen1 m e nt 1mit/ 1·w·ol hen/th 1111it pe ,·speclivc. Ma rula: DOH
-EN I-IR.
17. Maurer, F.A. a nd S m ith, C .M. (2005). Conmwnity / l'uhlic ffeC1lth 1Vu,-s ing
Practice. Health fo r Families ancl l'op11latio11. (3 rd ed.). SL Louis: E lsevier
Saunders.
18 . Parse, R.R. (1998). The Human Becoming S chool ofThought: A Perspective
for Nurses a n d Other Health Professionals . Thousan d Oaks, CA: Sage.
19. Parse, R.R. (1995). llluminadons: The Human Becoming Theo ry in Practice
and Research. New York: National League of Nursing.
20. Rosenstock, M . (1960). What Research in 1Vlotiva tio n Su~gests for P ub lic
:E-ieaJt h . Amcrica11 Jountal of Public Heall fz, 50 (3), 295-302.
21.
Sch on, D.A. (1987). Educating t he R ef/ectiue Pra c titio11er. San Fran cis co,
CA: Jossey-Bass .
.
22. Schon, D.A. (1983). The Reflective Practitioner. New York: Basic Books
23. Vlilkinson, J . (2001) . Nur s ing Process and Critical Thi11/.:ing . (3 rd ed.).
Upper Saddle River, New Jersey : Prentice Hall, Inc.
109
Providing E.'-cperiential Learning Activities to Sha pe Attitudes.
Specific s im ula ti on e.."Xercises can p rovide direct experience:'i to unde rstand
a nd handle iucli,;dual and fa.m ily psychologi<:<11/ attit uclin al issues. For
e." ample, " lettin g go·· and ··aggression- assertion·· exe rcises can p r o,ide
sensorimo tor inform a tio n ~L1 e.,1>eriences for fa.mily members to gain full
awareness of and manage effectively issues like powei- play or family
contlicts.
2.
Oppo rtunities to s ee , observe. i.nte niew other p atients or h aving a dir ect
e.' -J)erience o( feeling the advantages of ch oosing n heaJtl1y life s tyle
(such as engaging in regul a r exercise) can b 1i ng aboL1t att it ude chaugc.
To illus trate, a mother can b e g iven lcnrning opportunity t o obser..-c and
intenie" · oth er families w i th malno ud s b e d chjJdren to h e lp h er re ali ze
the nature a nd m agnitude _of m a lnutrition as a problem so tha t she can
motiv ate her family to address the problem.
.
P roviding E,xamples or Models to Shape Attitudes. This is don e
b v a llowing the family t o experience ideal s itua tions or inte rview case_-=; or
p~rsons d e mons trating the attitudes or attribu tes to be deve lope d. As a n
example, a fam ily (sp ecii.icall y, the coup le ) cau inte r-view othe r co uples
using differen t m ethods of family p lanning. If the couple has m ajor
-concerns aboul t h e s ide effects of family plannin g rnetbods, the couple
can be expose d to scientifica1ly-basecl natural family p lanning n1ethods
(NFP) s uch as t11e ovul ation metho d , bas al body tempe.r ature 111ethod or
syrn p to-thermal m e t11od. Coupl es wh o are successful auton on1o u s u s e rs of
~FP can h elp expla in U,eprocedu re and how intimacy issues are h a ndled
d ur:ing t he ferti le phase. These autonomou s u s ers can a lso act as models
of how couple relations hip and family life ca n b e e nhan ced thro u gh
b etter alterna tives of relating. expressing affection , communicating a nd
a chievi.ug w h oleness of self a11d of other family members.
4•
Providing Opportunities f"or Small Group Discussion to Shape
Attitudes. Discussion in small g roup (among family members or among
members of otl1er fam ilies s h n ring th e s ame problem or s ituation) will
b elp make U1e p revio us three met hods more effective. For e xample,
when member s de:;cr ibe a.ad d iscuss thefr e.,l)etieuces o n specific h ealth
proble ms (e.g. addi ctions, coping with.chronic illnesses o r dis abilities) the
sha ri ng may influence the p e rcep t ions of o t her m en1bers in tJ1e g r oup.
Attitudes may ch a n ge when g L-oup members talk a bout t heir feelings,
concerns and exp erie nces on how hard they try t o cope. The process of
putting tJ1eir ideas in to w ords ,rnd experie ncing t h e caring, rnn·turin g
attitud e of others in the gro LIP can be an effective way of b1inging about
attitude change. For this technique to b e effective a group of 8 i s ideal w:ith
a maximum o f 15.
5.
Role-playing Exe1·cises. I n thls techniqu e a family member e it h e r: (a)
acts t he part of auother to exper ience and understand the other person·s
phe nomenological reality; 0 1· (b) imagi11es and acts out a ll the parts in the
sih1ation. The nurse con centrates on how t h e m e mbe r i s acting nov,•, not
o n why he is actinA th.at way . This tec1rnique ca n h e 'lp clarify r efotionsb .ips
behvee n fam ily member:; or h e lp a fam ily member become f ully awar e
ofthc e motions being experie nced and tJ1ei r e ffects on one's b e h avior o r
perception of a p r oblem situation.
3
100
TI1rough anoth er variation of the role-playing. the client sits on the ~hotsenl~ facing an empty chair (>nt•o which he proj ec ts his many sel ves. This
techt1iq11c provide.,; nn npporlu n ity for th e o ppniaing forces within a person
to talk with ench oth er. haw il out with end, other. forgive t:Hcl1 other.
com promi.~c or get to know each other. This cnn help the family member
tu1de rsl and himself. his dreams. fantasy ,md reali ty (King and Gerwig
1981, p. 45).
Thrnugh ro lc-p la~;ng, family 111c111bers c:111 express, :icknowlcdgc und
identify feelings and emotions gencratC'd by t he clay to day :1djm:1menu: to
e:ich other's reali ty and copin~ 1,·ith hc•,1lth ;111d ill ness si tunt io ns . Thro uf!_h
such a"·aren ess. each fa mi ly m~ml>er can discover additiv11 a l aspects of
th e self. This opens new cxp c•dc1n:cF and nltt•nwtives lo tra11sform fcdings
a nd emotions to better opportu nities for a chi c\'ing a pos itive sctr-c;cHwept
thn t enables one to learn to ram for othe r 1111m1bcrs.
6 . Explore the Benclits of Power of Silence. Encoura~c family
members lo use th e power uf silence us 1111 inlc1·vcntio11 to t r;msforrn
the emotions or fcel.in)l.s that in:flue 11C'e the nll illldc into less painful, less
obsti nate a nd more objective cxpcric1Ke oflooki ni; into th e self for crt!ali\'e
opportuni ties to heal. nurture or care. This is particulal'ly use ful during
emotion-laden fa mi ly encounter or recurre nt ps~'chologicnl irritations
of dai ly disappoi ntme nts or co11llkts. Family mem bers can karn lo use
sile nce (";111 slow deep brea thi ng) a;; an acli\'c cxpcdcm:c ofbdng aware
of one's senses. acc;e pti ng and hl!ing tolerun l o f till' self nncl others d espite
the frustrations, <lb:appoin tmcnts or stresses. Slow. deep bi-eathing relaxes
the body nnd provides for belier oxygc1rntion of lll'a in cells. This allows n
more objective ;ind less emot ional expc,;cnc,~ of b e ing with the self while
analyzing the prob lem or the iss ue for better problem-solving.
Learning is facilitated when experiences have meaning to the
learner
Focus and relate leamin~ expe riences to th e clicnt's/fan1ily's, mea nings, aspirations
and bes1 choice among options avajJ.tble in t11e family situation. To emphasize the
importance of"meaning" in learnLng, th e following exercise i1, usetl as an adaptation of
a similar exercise i\lu1,trated by Abbatt (p-41)
Look for about two i;econds nt th e two diagrams below.
A.
B.
101
Now 111r11 over lilt! h ook a n t i tl raw dia~ ran,s /\ a nd ll. /\l'l c r you lw vc «J r.m e.: I h is r end
nn .
/\ I 1110 .sl l·crl a inl y yo,1 c:t ,11 lcJ d rn w di .iv.ram 13. The p al 11, r n o ft h rec .S~f11 :t res p i r1c <l 10141.:1h,, ,.
mn kc.s st; llSf!. Dia g r ;, 1n /\ w;1 s proln, bly Ju ,nk: r lo rc m cmbcr h r:c;i mw Lh <:r·c is n n shn p c _
no 11 1c,11, i ng 111 i i. Bui lh c 1t umbc 1• o f lin e.-. fo ,· ea c h diagram w;,s cxucl ly t he .s111ne.
J .ik c D ia14n11 11 H w hi c h is c11.sy 10 remembe r hcc:,usc it is .similar lo a pallc n1 yo u h 11vc
scc 11 h c fr, n ·. tca ch in14 111us t h ave mcan in14 so t hn l fo mi li cs lc:arn a n d rc m c rnbc r more
e a s ily . Sped lie ,:x Hm p lcs or lww to do this arc 1.uggcstc d :
1•
Analyze and process with familymemhers all leacbin~- l c arning
ln1sc tl on LJ~cir g rw;p of ·t he l ived experi e nce of the situation in
tcrn1 s of iLc; mean in,:; fo r· t h e .scJf. T his h m; b e en p r e viou s ly c.l iscu i-st! d
as t h e r>hcn omc 11olo~ic.i l n ,:i lily Ihe fomily expe ri e nces. S u c h II re a li ty
is ( l, c 1n1 ll t•r11 l h ,11 h ;is mc:.111i1114 IJccau sc lhc m crn be1·s a,·e f:1m ili;,1· w ith
it.. Th uy Jive i t. Withi n the fom ily 's 1·e:ili ty, the nurse ca n s 1~1rl wit h t he
proble m wh i ch h ;).s l h ,e, J11().';I ,;alie n cc to th e f:1111ily. 'fh c c:nu ple cnn be
h e lp1·cl t/J rct:rJgni;r.c an d an.ilyzc t he s itu,1 t io n in ,·c lat io n I n f:orn Hy g,w ls
;ind ;is pirminns . The critica l iss u c for th e fa mily is, n o t knowing what to <lo
gi ve n 1he 1h1·c1.1ts/fcun; r c la t r~ cJ with :,rvaiJ:.,hl !! alt c rn;it,ive.-.. Thc issLJe c:..i n be
used by the n urse ..,-. .in c nl ry p o int in esi..iblish irt ~ u working r<.:laLiuns h ip
w ilh t h e.: fumily lha t c:onlinu cs on lo incl ud e th e o th e r h c r c-iinc.1 - n ow
problem s s uch a;:; hig h risk preg nan cy an d m .ilnu t·rition .
2.
Tnvolve the fa mily activ-c ly in determinjn.g area s for teachinglearning hase d on the health t asks that members n eed to
perform. The fam il y mus t kn ow in adva n ce w hat compe te n c ies or
objec:Livl!S arc to be le a rn e d_ These mus t Ix: re lated to th e h ealt h t...-is ks that
t h r· fam ily pcn;civc.,, must be done and 1·h e f:imily's situated possjbi litics
or bes t options based o n exi s ting a n d potentia l r eso urces, mea n i n gs a nd
concerns .
3.
U se examples or illus tration s tha t the family is familiar with .
Analogies t ha t are s imila r o r congrne nl w'ith t h e fomily's way o f o r ga n i,:i n g
its experien ces a nd perceivin g th e wo rld (e .g., t h e fa mily's wor ld v iew)
a re effeclive exa mples. T o i!lus tr.:ite, in ex plaining to ru ral fa milies th e
concept bth incl fam ily plan n jng m et ho clo;, 1bc nu rse c an u se tJ1 c ana logy of
~1n :.gri L"llltur& I pr:; <.:tice o f farmers w h e11 t hey prune or c u t- o ff a lte rn a t in g
lrnd.s r,r fl r;"·e r \ (that n.r e tor) c:l()se to cnch o th e r in a vi ne) lo e!lsu re h eal thy
fni i1..s. /\ n•1lher example is LJ1c use <Jf lh e l in ea r d rawing o f t h e fert ili ty cycle
(rather t/rnn the circular one) in expla inin g NFP concepts to m ost co u ples
in th1, rurn l itn:;,s. The linear d rawin g i s s imilar to the fam ilies' d ay to d ay
or ,;.;i le ndar way o f exp eriencing the wo rld.
Learning is an Individual Matter: Ensure Mastery of Competencie5
for Sustained A c tions
J\ llr, w for individ ual diffe l'enccs by le ttin g families lea rn at tJ1ei r own s p eed , providing
e n 1 >ug.h t ime 1,, pn,c:ticc the behavior and us ing a varie ty r,f teaching m e th ods. T hese
an, c:ri l'ical in en~ urin g t hat th e families arc confident and foci compete n t in p e rforming
th e nec:.t__:ssa ry cngniU ve a nd p syc:homot or s kiJJ.s . Some tcclmiqu cs to deve lop mastery
a re I he: following:
]02
1.
Make th e learning 11C:tivc by providing opportunities fo r 1he fam ily I<>
do sp1:cifi1: ad ivitics, ;111swe1· que..:li ons or 11pply leilrning in solving
prohl1:ms. Provide cnn ur;h nppnrLUnil'ics to practice p,: rformin g the skills
s uch :-1s menu pln nn in g, prcpa rnlion of men ls a nd fecdi ng a mal no11rished
member.
2.
Ensure c:larity in 11:aching. IJ!1C words . cx;1m ples, vis ua l 111ale rials and
lrnnd()uls Iha! th e family c:111 u11de rstand. In t,;;1ching skills, 1·li e nurse
must first d 1:sc:rihe lhc s kill: (n) explaining why it is impor1:111 t; (I>) whon
it $hnu ld h<> 11so,d, :ind; (c) the sl,1gcs or stqis in performing th1; Hkill. Aft(,lr
dcs1:.-ihi11g the 1,ki ll , the 11ursc: m ust demo nslnolc it cnn-ectly, explr1ining
ench stc•p ns ,;he i~ demonstniting and cmphas bdng im portant poin ts
(Ahlw tt, pp. fi7•6o) .
3.
Ensure ad equate eval uation, feedback, moni toring and s uppurt for
sustain ed action hy: (a) explain in g well how the fam il y is doing; ( 11) ~iving
th e n<:cr~.s,;;1ry nffir111:i\ir111s or n,;,ss ur:m,·e..~; (c:) ex plaining how the i;kill
can l>c irnprnved; :,nrl. {d) ex plori ng with the family how mo di ficali o ns
cnn he c:1rricd nut w max imi ze s it unt.ed possibili ti es or bes t o ptio ns
avaik1blc lo the family.
MAXIMIZING CARING POSSIBILITIES
Effective nurs ing of fomilic.c; can put a great de m:md on the resources uf the nurse
to a point when she m ay feel complete physic,d, m e ntal and cmC>tional d e pletio n. 111is
is n reality in family n ursi ng pruc:tice which makes routine and prncedure -o.-iented
activit ies like record ing, giving injections, taking blood press ures, a nd housekeeping
tasks more attracti ve and convenic:nl lo make herself busy with. However, th e essence
of nu rsing is caring. In the foce of a family 's t:annict, confus io n or hclpl c.,;.sness, the
nurse shares hr,r cxpcrti.c;c a nd cmoti nni,J/psychnl()gic:,I SlTrmgth 11s fa m ily membe rs
learn to develop compete ncies t<> manage health condi tions or problems. Un less the
nurse has acquired s ucb a phil,Jsc,phy of ca r ing, commitment to excelle nce in nursing
practice will always remain an el us ive ideal. P hilosophy and commitment are, therefore,
ingredients of effei:tive nursing practice.
Another challenge in family nursing practice is the difficu lty in operationalizing
family-centered care. Nursing care of individ ual family members in the home se ttiJ1g
is, oftentim es, the nurse's idea about family nursi ng practice. It is quite common t hat
nurses offer o nly lip service to the concept that th e whole family is affected by and is
affecting its individual memhe rs. Il requires a broad knowledge hase o n the behavioral
science-, forrhe n urse to un de rst and and concrctizc 1·h e c<>ncc_,pt of dynam ic: interchan ge
between fami ly members in th e achie ve ment of health and family clevelupmen t goals.
An<Jlher source of the di ffie11lty in operationali:>:i ng fam ily-centered care is the naru re
ancl m agnitud e of fam ily concerns a nd hea Ith problems. Often ti mes health problems
encountered hy families a rt: huge:, complicated by a number of variables s uch as
socio-cultural nnd cc.onornic factors. In lh e fllce nf such complications th e nurse feels
helpless to th e p(>int of w ithdrawing from the opportunities to work ,vith families as
clien ts. Considering s ueh a u iJficulty of ide ntifyi11g th e scope ()f help tha t the 1.Lurse
can provide, guidelines a nd tools can develop he r skill in breaking down health and
nursing problems into m a nageable units of attack.
Problems in working with families are sometime.~ du e to wrong definit ion of health
or nursing problem. This may be a consequence of improper collection o r erroneous
in terpretation of cues, data c)r fact!; . The nurse may lack the training or s kill in observing,
--
103
\
eliciting data or analyzi n g the informution gnthered .
Wor k in g with Ute family C11 n al so be difficu lt if its coopcn1ti~ n in ca rryi ng our
h e:ilt h m eas~re cannot be elicited. This m :iy he a conseq uence of the family"s fa ulty
compreh e nsmn or non-ncccptnncc of th e n eed to take m:tiom, o n its heal U1 p roble ms.
The fo llowing facto rs or co nd itio ns (F1-ccman 19(,;{, pp. l34- 135) m ay b 1·ini; th is
a b o u t': (1) The family's info rm a tio n 111:iy be inadeq11:1lc o r inaccurate; conscq11c ntly
it may not ,,:ee the problem or :;ee only :1 part o f the problem; ( 2) T he family h as U1e
necessary informa tion b u t fails to relate t hem to the problem s ituation ; (3) T he fa m ily
is not willi n g or rea dy to face lhe re:-ility of tJ1 e s itu:it ion or alter its behavior; (4) The
m e mbe rs m ay no t b e willing lo oppose family, peer or soc.in I pressu res; (5) There may
b e c1dhc re ncc lo p atter ned hchnvior; (6) Thcrc is foi h1re to re lntc the needed nclion to
family go;:ils; ;md, (7) The re is lack o f con lidence in th e ;icLiou p ro1>osed .
Problems durin~ the im plementation phase may be d u e to in appro p riate choice of
nurs iug in terventio ns . Th is m a y b e brought about by the following causes:
1.
2.
3.
T he ten dency of the n urse to usc pnttcrned or "conned"' approaches in
workiJ1gwi th fn milieswi thout recognit ion o f the possi bility o r rea lity that
s he affects and is nffectc<l by cad, nurse- family illtcr aclion , in the s ame
manner th;tt the family is affected and reacts to ll1e nurse's b e havior as
she carries out n un,ing inte rven t ions.
w adequate app reciation of social and cultural factors or realities which
can be maximized or utilized e .g., mobilizing family support system s
s uch as in-lnws, or use of b t:rbal medicine o r othe r olternativc h ealing
techn iques based on culture/tradition .
In adeq uate or limited repertoire of interve ntion techniques and s kiJls in
the foceofcomplicatcdbelrnviora l proble m s in family life like management
of marital dishar m ony. Th is can c halle nge the nu rse to enhnnce her
clinical comp ete nce and be updated wilh current literature on n ursing
practice, such as research findings for evidence-h osed p1·actice.
There are several th eo ries o n motivation which the aurse ca n us e a s ~ases for
interventions U1at she can implemept. Rosenstock's Uiree principles of motiva tion a re
used h ere as illustration (1960, p. 299):
]04
1.
PrC\•cntive o r therapeutic b e h avior relative to a given health p roblem in
th e individu nl is determined by lhe extent to which h e sees the problem
as ha ving both se rio us consequences and a high prob ability of occu r rence
in his case, and th e e11.1:en t to w hich h e believes th a t some course o f action
open to him wi ll be effective jn reducing the threa t .
2.
Be havior emerges ou t of frequent conflict among motives and a mong
course:; of action. \\there motives themselves conflict and compe te for
atte n tion those wh ich h ave Lhc h igh e~t va lue or salience for the individu al
will actu ally be aro used. H ealll1 m a tters - at least in th e individual who
believes himse lf healt hy- a r c pro bably not as p otent as a r e certain o ther
m o tives, s p ecially economic n n<l social ones. Whe re lhe conJJicl is based
on lhe ind h •idual's bclieflhal no ava ila ble cou rse of action wi ll be e ffective
o r wh er e a prescribed cou r se o f action is believed to creat e e quaJly or
more serious pro ble m s of othe r kinds, the conflict may be r esolve d i n a
variety uf m a lad11pt ive ways.
3.
Health-related motives m aynotalwaysgiverise to health -related behavior
and conversely, heal th-relate d b ehavior m ay n ot always be determined
by health-related motives.
These principles on motivation have de finite implica tions to nurs ing interve ntions.
Utilizing the firs t principle, Lhe nurse can hel p the fomily recognize the existe nce of
health proble ms a nd m o tivate the f,~mily t~ take actions on them by l~elping ind(v_idual
membe rs sec t h e problems as haVJng s enous conseque nces and high probab ility of
occurre nce with in the fam ily"s n!ali ty . The second p rinciple c:i n g uide t he nurse to utilize
social and econo mi<.: m ot ives in ma king the family realize the com;eq11cnccs of health
problem s a nd h e.alth act ions . Co nsider ing t he Lhird principle, t he n urse can en courage
beallh behavior by utilizi 11g 11<Jn-h ea 1th mo li ves which h ave more weight in infl ue ncing
•tction . The need for affirmatio n, t he n eed to belong, socia! pressures of relatives and
~ignificant others - all thes e ca n generate enough motivatio n for app ropria te health
behavior.
Effective nursing offammes m ay not be too easy a task in the fa ce oflimited resources,
both m a terial and manpower. Conside1;ng the problem on limited material resources,
the nurse can e.,,.plon~ th e p ossibility of utilizing indige nous s upp lies to sub stitute for
e.xpensive, co m mercial ones . l n the face of manpower cons traints, the nurse's ability
at developing the capab ilities of c lie nts to support the healt h care syste m can be put
to use. For example, she can tea ch indiviouals or groups on the s igns an d symptoms
of common h ealth p rnblerns so t hat they ca11 serve as m onitoring n e twork in the
community to inform the nurse of proble m s that need be.r immediate atte ntio n . The
nurse can also t rain auxiliary and village health worke rs to manage simple health
proble ms or do rnutina zywork and procedure-oriented activities . By doing this, she ca n
utilize h e r t ime d o ing the fonction that requires h er expertise-helping famili es develop
competencies for h ealth develop me nt. The nurse aims to at tain self-reliance a mong
families b y d evelop ing the ir skills to recognfae and m an age simple h ealth problems.
As this is achieved, there is no need to heavily depend on the overburdened limit ed
h ealth resour ces for problems that families can adequately manage by themselves. It
is, likewise , importa nt tl1at t h e n urse be wel1-infor m ed about the available community
Tesouroes so th at she can utili7,e them appropriately.
EXPERTISE THROUGH REFLECTIVE PRACTICE
Through reflective practice, the implementation phase provides the b est opportunities
to widen expertise in fainily health care. S everal authors describe two sets of reflective
practice : Reflection-in-action an d Refle.c tion-on- action (Gree nwood, 1998).
Reflection- in-action means to think what one is doing while one is doing it. It allows the
nurse to re-des ign what she is doing while she is d oing it (Schon, 1983, 1987). Re 1lectionon-action involves reviewir1g or re-evaluating one ·s actions to: (1) relate wh at one has
learned from t h is expe rie nce Lo her existing knowledge structu res; {2) m entally test
her new unde rstm1dings in n ew contexts; and, (3) make the knowledge gained her own
tools for critical thinking and expert caring. RefJ ective practice enco urages the nurse
lo immerse into th e client's n:alit-y as b o th learn together to t r:) nsform th e exp erience
into n ew ways of b eing and beco m ing. Using P ai:se's Thco1y of Human 8ecoming
as a guide, the n m·se learns to underst a nd folly Lhe client's responses, feelings, and
perceptions . TJ1is experience on client-nurse imme rsion in t h e client's reality guides
both towan:ls t ranscend ing the current status ("Being") to the best possible higher
level of state or functioning (''Becoming'"). Sample process questions for each type of
reflective pra ctice are shown in Box 4 .1.
105
----~
lmlil
,-..
-Acti"~"
t
l fe~I abl'llll whilt hilppt?nt"di'
lty uoders:to od th~ 1.; 1,e nt's
or respbh-s~s to tht> h<-.ilth-lllooss
aee
~ ac;lioni mAtch nw bellofs/
ot~rpoS$lble o ptlcu,s c;i n
J.1$1• to Improve on h ow I can
cNr.stand the cUent's conc.?rns.
~lnp and potentials? How
f~'these options to impr ove my
ltyto ht-lp the cllen t t ranscend
a hlaher level of state or functioning?
t would be the consequences
hematiw action s for t he family?
dllfeumW
,:aided aatco
liii,i,.~-~~
f1
ha~~ Uf)!llrience changed mv
&f kdOWt"'-abo ut; (al t his ~uent;
~
f es a persbn ~nd as a nurse/
1
As sbown in Box 4.1 , reflective practice offers a guided expeiience on bow to make
excelJeuce in nursing practice a 1,•ay of lifo. By focusjng 011 th e family·s respon ses
and umlerst~oding the depth of the family's reality in the "here-fu1d- now•·, reflective
practice can offer a systematic appro.a ch to:
106
1.
Deter mine the accuracy and completeness of assessment data and
analysis;
2.
Validate responses to and perceptions of ,.vhat is happening dUI·ing
each interaction , or what the family and the nurse a re expecting from
each other to achieve Uie goals aod objectives of family h ealth care;
and,
3- Utilize the feedback mechm1ism to understand h ow each one is
e>.l)eriencing the reality and challenges of behavior change. Through
the ~Look-Th.i nk-Act" cyclical process of the participatory approach,
the family and the n urse can analyze together the fam ily"s issues and
at:nbiva1ences regard ing internal pressures for a nd aga inst spontaneous
or planned ch;mge or fear of getting o ut of tJ1e comfort zone of status
quo. Through the feedback mechanism of reflective practice, the nurse
..
t•,rn maximize tcach in j.\-l<'m·11 i11g o p p cn-tuni tics for th e family to :,clccl
ll ll Ll test lHII int e rvent ion option:; to tlctcn 11ilu.• th eir appm1>rintc ncss
in hclpi11 g the fomily tow.ud need rcsol11 t lon.
THE EVALUATION PHASE
E"nlua l inn is tlw con li1111011:- c ril iq11ing o f cnch as pPl'l (Jr t ile 1111rsi11g p rocess
{Cl,:nw11-S1011c• and ,>1 h crs :2002. p.:28;~). i\llhc111).th c \·al1111Lin1 1 is discnsscd ns u
,;cpant IL' p h ast•. it mus t t ak,• plu,·c <'• llll'1tlTL·111ly with nil t lw ot lwr ph.1:-l'S o f Ihe nurs ing
111·m·,•:,;s. :ts illns trnl,•d i11 Fig . 1. 1 tin Ch apte r 1), 11s1 11i; :111 m lap tation of lhc.' diagn11n of
Al fn ro- 1.,•F,•vr,· ( :.!tH 1:2. p.1~1t) . vViLh in this frmm:wm·k. two Wpc:; of eva l\1111 iun incl ud e
fr,rmati vc u nd s 11111mali\'c.
F t)n11a li\'(~ C\':1'11:1 tim1 occnrs d11ri11g t he course o f th e 1111rsc-fn111il)• 1·cl111ionship.
Ongoing feedba c k is dClnt,• ,md elidt ud ,ininlJ~• w ith the family to clclcr111inc if gt1a ls,
p l.m s a nd i111l'r\'c1ttit111 s tra l,:gics ;11·,· :1 pp r<1 prialcly foc:11sc•1.l. llns,·d in lhl: eval11a tic:m
p la n wh il-h s1wci li cs \he n itl·ria/ i11dit-,11ors. c valualitlll s la nd:mls, meth o d s a nd too ls,
for111:1 I i\' c' ('\',1111 :11 io n L-: don,· n t p L•1·ioclk poin ts d11 ri 11A the i 111plt:111~·111111 ion phas~ lo
dclc r111i1w c: h ;m A<'S in llw eli(•111 ·s hL·11Hh i.:011di l iu11 or h um c a nd e 11viro m11c 11l H::1litics.
L1::i11g ('\'al11at inn c-ril!•ria tu hdp lmt h nurs,· :111<1 family IP d drr111i1H' ii' t lw 1,hj1•ctivcs
are n ttn in,•d , t·lt<:' n urse n..:cd lo n.:,·ic-w it 11d t,lclt:n n ine hnw th,• cri te ria rc la l.t• lo each
s inge o f till' 1rn rs i11µ. pn1niss. \V h en bNh. th e 11111·s~• anti th e family n:alizc thal t he
objcc ti\'CS an: n n t .icilicn:d . th l'Y can analy·, ..... possiblt: r(·asn ns. So inc 0x.1 111plcs include:
(1) i11adc q11 a c·y of assessn1c111 d 11t11: {2) ~oal:,; and ()bjcel i\'CS arc tnll J)l'ocJ d or 111Hcalistic,
or that th ey a re 11e11 mt1l \la llr es tablished ; (;3) fami lr rcso11 rce-S o r c n t• rgicn nre n o t
focu sed o n pric1rity fami lr needs or arc depl ctccl as a result of n isei- s i1.11;1tio 11s ; o r (,I)
t h e family laC' ks t he i11L,•rnal or external s upport ii n eeds In ha ntll c th e cha n).tc process
(Cle m en-S tone and o lhcn; :.!\l l):.!, p.:.!86). Fo rnw ti vc c valuatio11 g u i1.h:i; both Lhc nurse
a nd the fa mil:,• on <lc•cis iom; ah<l 11I m odilic.atio ns o f goal s, object i\l e:S und intervention
s t rategi es/ m easu res, de pending u plln the c11ne11l s ilualio 11, emergi ng or .tll<lilional
hea lt h n eeds/ problems a nd prior itie:- o f the fa mi ly.
S mumative evulu a Lion occurs at the e nd of t h e family-nurse r elationsh ip. It d eter mines
iftbe goals as specified in the family m.u·si r.ig cnrc pla n a re ilChieved as m easu re d by Ute
o utcome c riteria a ncl evalualion s ta ndards. T3asell on t h e family's c11rrcnt s ittrnrion
and/Dr re maining h ealth needs or pl'oblc m s, t h e nurse can guide tho family o n ma.king
choices about tern1innlio n o r 1·cfer1·al.
CHALLENGES AND DIRECTIONS
Family h ealth nu rsing practice is a phenomenological e11.-perience of caring and
coping ,viU1 cart:givi ng. E xcelleL1ce in such nn enga ged caring is reflected in skillful
comportJnent, given the nurse's pe rson a l and profession.il meanings, concerns,
expectations, style, habits and resources, p articu ln rly experien ced durin g the
im plementation phase. Commi b11ent to excellen ce of practice is a lived experience of
being effective in ltau dlingtbe cha llenges of working with fam ilies. The impleme ntation
and evaluation p h ases provide every avaifable opportun ity for the nurse and the family
to validat e assessment da ta a nd modify Lbe nursing care p lu.n based on th e fam ily's
perceptio n of ru1d responses to every nurse-family effort at e:-.."J)loring the b est choices.
in the family's s it1.1ated possibilities.
Through immers ion into lhe client's 1·eality, the nurse gets a full understanding
of th e d ept h of the ·m eani ng of L11e client's exp erience ns both e nh an ce each o the r 's
opportu nitiestofacilitate th ejow·uey from a pathy lo courage, vacillation t o decisiveness,
107
hopelessn ess to cmpow1::rmcnt. The rhythmicity in the polnritles and parudoxes of
the journ ey to human b ecoming ( Parse, 1995) brini:;s clients to the thresh o ld of thei r
own le arn ing in o r der lo maximize t hei r e mpowering poten tial to make a c hoice abou t
rcfcrr.,1 or termination of t h e n u rse-fa m ily rela t io nship and movi ng on. Nurses and
fam_ilies e:qJcri cnce per:;o ni'II feelings about separation or Mletting-go" during the
termination p h :,se. Cllrt:ful plan ning (on w hen 1111d how to seek health care agai n),
advance not icu (fo r lTa m:;fers) and nllowi ng opportunities to d iscu ss issues ab01.1t
separation ~111ci e:1.-pressing reactions or e motions help families perceive themselves as
being able to Jrn nd le upcoming situations independen tJy. 'I11is e:1.-perien ce p r ovides
the n ecessary support for tlitJ family lo make t he truns ition to i ndepe ndenc e and
termination. (Clemen-Ston e and otliers 200.2 , pp. 3 12 -313).
Family h ealth nursing practice challenges the ~o,~mun ity ~1eaJ!h nu~se to syslemaLically
est ablish a n d supervise a caseload of pnonty fam1J1es 1dcnt1ficd a nd classified
geographically by health ~are need or h_calth progrn_m or service, using methods a nd
tools like the eriidemiolog ,cal map or clie nt case registry by health problem or health
p r ogram. lJs[ng the c~se munagc~1cnt ap'?roach, the nurse works with p riority
famili es guided by a frumly health n ~rsm g practice mt:thodology such as what h as been
described in Chapters 2 , 3 am! 4 (this chapter).
Guided by nu rs ing cru·c stand a rds/protoco)s, recording and reportin g
systems a nd referra l procedures, u_ll c~icnr r eAlities, responses, p rogt·~s and
outcomes arc documen ted. Rcrords.u·e ma, ntam ed to en bance tcamw0t·k, coordinat ion,
a nd heal tli program and pe1fonnancc evaluation to support qua lity assura nce and
en hance excellence in comm uni ty health nursing practice.
REFERENCES
1.
Abbatt, F.R. ( 1980). Teaching for /Jetter Learning: A Guidefo r Teachers of
Primary Health Ca re Sta.ff Gc.n cva: Wor ld Health Organization.
2.
Alforo-LeFevre, R. ( 200 2). Applying N u rsing P1·ocess: P T"omoting
Collaboratiuc Care (5th ed .). Philadel phia: Lippincott, Williams &
Yl'ilkens.
3.
Andrews, M. (1996). Using reflection to gain clin ical e"-pertise. British
Journnl of Nursing, !i (8 ),508 -513.
4.
Balfou r, M. and Clarke, C. (200 1) . Searching for sustainable change. ,lou1nal
ofClinical Nursing, IO (1), 44 -50.
5.
Be nner , P. and Wrnbel, ,J. ( 1989). The Prima ry of Caring: Stress and Coping
in Health a nd IUness. Menlo Park, Ca: Addison-Wes ley.
6.
Baud, D., Keogh , R. und Walker, D . (1985). Pr omoting reflection in l earning:
a model. Ia D Daud and others (Eds.), Reflection: Turning Experience into
Le.anting (pp. 38 -40). London: Kogan Page .
7.
Clemen-Stone, S., McGui re, S.L. and Eigsti, D .G. (2002). Comprehensive
Community Health Nursing: Family, .4-ggregale and Comm u nity Practice.
St. Louis: Mosby.
8.
108
Freeman, R.B. (1963). Public H ealth Nursing Practice. Philadelphia: w. B.
Saunders.
....
9.
Greenwood, J. ( 1998). The role of reflection ia single and double loop
learning. Journal ofAdvanced Nursing, 27; L048 -1053.
10. Johns, C. and Freshwater, D. (Eds.). (2005). Transforming Nursing
Through Reflective P,·actice. (211d ed .). Oxford: Blackwell P ublishing Ltd.
11.
Kim, H.S. (2000). An Integrative Framework for Com:eptualizing Clien ts:
A Propo~al for a Ntu-sing Perspective in tl1e New Century. N11,-si11g Science
Quarterly, 13 (1), 37-44.
12.
King, V.G. and Gcnvig, N.A. (1981). Humanizing Nursing Education: A
Corifluent· Approach 111r-ouglt Gmiip Process. Wakefield, Massachusetts:
Nursing Resources.
13. Kock, T . and Kralik, D. (2006). Participatory Action Research in Healt!,
ca,·e. Oxford: Blackwell Publishing Ltd.
14. Maglaya, A.S. (2008). DeUvedng Quality Service Serving Communities:
N urses lea ding Primary Health Care. Philippine ,Journal ofNursing, Vol.78
( 2), 10 - 13.
15 . Maglaya, A .S. (2004). Nur·sing Practice in the Community . (4th ed.).
Marikina City: Argonauta Corporation.
16. Maglaya, A.S. and others. (1999).Afamily /wall!, empowerment intervention
model towards prevention a n d control of m,,lal"ia in the Philippines:
The local government unit/rural health u.nil per-spectiue. Manila: DOH
- ENHR.
17. Maurer, F.A. an d Smith, C.M. (2005). ComnnmitrJ/Puhlic Health Nursing
P,-actice. flealthfor Fam ilies and Population. (3rd eci). St. Louis: Elsevier
Saunders.
18. Parse, R.R. (1998). The Human Becoming School ofThought: A Perspective
for Nw·ses and Other Health Professionals. Thousand Oaks, CA: S:ige.
19. Parse, R.R. (1995). Illuminations: The Human Becoming TheonJ in Practice
and Research. New York: National League of N ursing.
20. Rosenstock, M. (1960). What Researcl1 i.n Motivation Suggests for Public
Health. American Journal of Public Health, 50 (3), 295-302.
21.
Schon, ti.A. (1987). Educating the Reflective Practitioner. San Fran cisco,
CA: Jossey-Bass.
22. Schon, D.A. (1983). The R~flective Practitioner. New York: Basic Books
23. Wilkinson, J. (2001). Nu,-sing P,-ocess and Critical Thinking. (3rd ed.).
Upper Saddle River, New Jersey : Prentice Hall, Inc.
109
Chapters
THE PARTNERSHIP
APPROACH and the
PARTICIPATORY ACTION
METHODOLOGY: THE
NURSING PERSPECTIVE
A1·aceli S. Jvlag laya
HUMAN CARE AND NURSING PRACTICE
Globally, t bc crilical ro le of the nurse has been e nlrnnced by knnwledge d evelopm ent
in nurs ing science nncl utilized by nu rse practitione rs in various h ealt h cnre settings.
Humna response :md human-universe health process as pivotaJ concepts in n:ursing
prac tice promote and s ust:1i11 better o ptions for health care or h uman en1·e, defined
as recogn iza ble a nd structured i11teraetion in human sodeties tln o ngh wh ich persons
g ive and receive assis tance with basic human needs, in. wellness a nd illness, across the
life ::.l)nn before b irth, t hrougho ut life and beyond dea th (Cody, 2006). W ith human
response ns the focus of n ursing practice, the nurse's main concern is the person's
p erspective of health. with e;;1ch human reality as the m eaning of t h e situation . To
elucidate. Parse (199;;) explaiJlS tba t qua[ity of life cannot be detennined by t hose not
living the life: tJrns tJ1e person is the only Oile who can describe his or h er q u ality of
lifo. Tile person's perspective becomes the critical working arena for motivation to
p ro111ote, sustain or cbiinge any hnman reality, willJ th e 11w·se acting as transition
pm:tner-calalyst to provide technical, affective o r instrumental support to facilitate
creation of t he h u man rea lity desired by t]1e person as client-partne r (Maglaya, 1988).
The n un;i ng perspective emphasizes partne rshi p and the partici p atory approach in its
practice met hodology.
In
The participatory pe,-spective is not a new concept esp ecially in community healtll.
19781 it was specified by vVorl d Health Organization as the critical elem e nt in primary
health care (PHC) as n global call to achieve l1eaJth for all by t h e year 2ooo_P rimacy
health care is defined as essential benlth c.irebased on practical, scientifically sound a nd
socia11y acceptable methods a nd techno logy made unive rsally accessible lo individ uals
and families in the communjty th rough th eir f ull participation and at a cost tJ,at the
conunuuity and coun trv can afford to ma inta in a l every s tage of their development in
t he spirit self r:eliance ~d self-determination (WHO 1978).
Three decades late r, m nny developin g co untries are still ex--perie ncing a limited
capacity of Lhc health care system to deli ver o utcom es with inadequate resources for
the health s ector nnrl geographical and !iOcio-e conomic inequities. Social, cultural
and political d ifferences are sources of inequalities nmong g rou ps, ci-eating biases
and mies in institutions that favo r more powerful and privileged groups. 111e s triking
110
differences in health s tatus among s ocio-economic groups reflect ineq ualities in access
to information, facil ities that provide decent s tandards of living an d means to pay
for ~ood c11 re . Specific harrie rs lo quality care include: ( t} lack of voice o r sense of
em powe rment which delay d ecision -making 10 address health n eeds/ problems; (2)
unrespons ive s et"\;ce pro,; ders who n ealc a social tl.islance which discriminate ag:ii nst
the p0<) 1· ,m d th e m al'gina li,.ed: (3) inaccessi ble or poor q u ality se rvice!; a nd p rohibitive
cost o f he a lth care especially for treatment or major ill nesses a nd injuries (Ashford,
2006; 'Norld Bank Report, 2006).
OPTIONS FOR CHANGE
Wlrnt ar e possible areas for analyses Lt) understa n d t he curren t scenario? Based o n
outcomes a nd barrie rs explica ted in the Ashfon.l and \Nodd 13ank repor ts, it seems
that the fnll participatio n or Lhe key p layers of primary hca ltl1 care, Lhc imlivid uals and
families in the community. nrc not q uite in tJ1c wor king .irc11a 10 achieve the go.ii of
health for all. \-Vhy have we missed the full parl icipntion of the key p layers'? O n review,
o f doc um ent:,; a n d c.,perknccs o r t~u·ct• d cc.idt'S, there ar e nt least three areas lo analyze.
Firs t , t h e report of a \>V l-lO Expert Committee 0 11 education a nd tr.i ining of nurse
teachers and mauagcrl.' \,;tJ1 special rcgnrcl to PHC ( 1984), em phas ized manageri al
and supcrviso1-y ro les wi th com petencies o f 11un<ill'1, person nel ;11 th e per ip hcrnl level
geared towards direct care to th e community. training of community healt h workers
and impro ving 01· cxtcnding the knowledge a nd sldlls t1f lraditiurml hcnlth prm:titioners.
The rule uf nursing personnel on cnm m uni ty p a rlicipa t ion inclndcs :u·o usi u g the inte rest
o f the cc;mmrnn:ity in the be nefi ts of a posith·e h ealth approach and collaboraling in
identifying health nncl relat ed prnhlc!1ls and priorities for action. In nursing practice,
nurses often realize th at ccillahnrati()n wil h lhc comnnmit)' in ide ntjfying problems
and p ri orlti e:; for action is not quite a rea lity in many villages hl!cm1sc ide nt ified locnl
leade rs and volunteers Lack p rnblem s olving l'lnd leader ship skills and co mpeten cies for
collective action. Local and international e valuative s tudi es ( Constantino- David, 199s;
Laverack, 2001) provide evidence that this compcte11ey limita ti on among leaders and
volun teers is a barrier to i11ili,1l a ttempts at involving the commun ity in developme nt
effo1·ts. Within this con texi:, unrespo nsiveness of ser,..icc providers can be analyzed as
a consequence of inad equacy in ed ucatio nal preparation to address th e challe nges of
installing the participatory fra m ework as r cqt1isite o f community self-r cliunce andselfdetermination. Second , autborit:V-drive1i practice as a consequence of socialization
into 0 11.e ·s profession, c,1 11. control a nd predict client-pai·tners· perspective of h ealth and
hu man reality . Combined with inadequate Im ini ng o n tl1e particip::ilory approa ch, the
a r rogancl.! of "knowing it all'" sus tains an au toc ratic behavior which can create social
distance between ser vice p roviders and clients. This nurtures lack of voice ilmong
clients causing frustra tion, pessimism , a.pathy or th eir derivatives. l n any ca se, tl1e
cycle caus es delay in decision-making to add ress health needs and problems and the
economicnlly disadvantaged groups stru ggle \,ith dysfunctiona l health services. A
third area for analysis is the possibility t hat nurses do n ot qui te under stand how to
address h u m an response lo inequi ties in resource allocation an d barriers to "health
for all", s uch as poverty and related bu.man resp onses Uke hopelessness, hardi ness and
ap athy.
The cur rent scenario will be perp eh1ated by both nurses and client partners if t hey
d o n ot realize that there is a 11eed t o c:t·eate a i:e;ility where both perform the best
orchestratio n , rhythm and p attern wl1ich p1·oducethe harmony required for u nleashing
the e m powering potential fo r h ealth and healing. The participatory approach creates
t he working a r e na for client-partne rs and nurses to change the cu rrent reality as a n ew
one is envisioned an d u nfolds. It gnide·s the par tn ers to move i n t he same rhythm,
creatin.g a pattern together and being invisibl y nou1ished by it. Both _partner-clients
111
and nuJ·se-catalyst go t hrough the prot:ess of looking al the cu1..-en t s ituation, analyze
wby il is happen.in~ anti acl to co-create a re nlity which provides aa expciience of
being s trength en e d thrnug!J relie f and e:ise; enhances quality of life; ensures healthy
life:;tyle or e ncourages pOs!-libili tics and options to address h11m n n ancl e nvironme ntal
challe nge:.. Pnrlicipating with pe ople (clients a.nd ct,mmunity) is t h e way tn move
forward towards sustain;iblc buurn n c;u-c .and se1·viccs LJ1al evoke human flourishi ng
(Koch ,md Kralik, 2tm6, p1) . The cydic,Ll., iterative pruce~s of look, think a n d act is
faci lit.1ted by t.h e nur.;e thro ugh molivnlion-support interventio ns lo c r e a te Lhe desire
to go through eat:h phase n f look-think-act and provide the necessary technical help to
access speedy flow of infonnation or s e rvi ce anti tru e presence as sour ce of courage,
offirmalion, hope 01· comfort (Maglaya, -1988).
This chapter focuses on partne,·ship concept s and the pr,1ctice methodology of
participatory action with emphasi:; on reqi 1is ite cognit ive, psychomotor and :1ffcclive
compelencics to enhance th e nursc·s option s to address issues o n u nresponsiveness.
social clistar\ce, apathy o r h opele~sncss.Nurturing the cnpabilityofinclividuals . families,
population groups a nd th e communit~,r t o ut ilize participatory action t o e nhan ce th e ir
em p owering puLe nlial is the key to co-cre,1ting order through ehaos, affirmntion
t h rough s tTuggle a nd contentment throug h discontentmenl, ;ill ine v ita ble realities of
learni ng ;ibout collective action for social cha nge and transformation . Partne1·sh:ip aud
the participntory approach enhance com petencies for interdisciplinary an.d io teragency
collabora tion.
PAR:f.JCI
'TOGE
Partid
unde
1n
ners 1
emotfonal
man car~
-partners
roblems,
th these
s an~ In
of the
raphs
orn a
OM
tune
,;s
has
Is.
true
ent,
as
112
..
'
Thinking refers to exploring, analyZlng inte
.
and lnterpretations. It Involves info ' . rpreting and explaining events, story llnes
sJtuation. Partners Interpret, explar::~8~ ~econ 5ttuctins ~nd or confrontfng t he
success (nwhatmade ltwork")ord fi
" lyze th e situation In terms of areas of
1
here?· Why are thihgs·as the'•
., eWhc encles, lssu~and optfons: What Is happening
•
• 8 re,
at Is missing? 1-iow dad
Do we need to challenge certal t ke f,
we come to be llke this?
evident In our"thfnklng/ practic.e~ ,: ., 7;.,~r-gt ranted assumptions/ realilies that are
? Th
e.
a can we do to address the sltuatton and
move on.
e nurse as facllltator encourag~s ell n•
/
•
~
e ,-partners Rarticlpants to engage
In discussion and dialogue to de,v elop mutu--11y a~ pt bl
. .
.,
..ce a e accounts d escrtbtng their
experlenceJ,. Participants
learn from each othe• t th
•
h
.
.
,, a
e same nme, e.ac person
has an opportu_nrty to t>e heard. Facilitators and parttclpants share perspectives
to create meanings through convers••.,,
•
.
.
.....ons. -r,Qgeth er they compare and contrast
their various l,~terp1"£ltati01:"1s. Stories and analysis occur conturreritly; wh1ch help
id_entl~~ ~merg1.ng ·under.standing from early data to gulde "the ~bsequent group
, d1seuss1_'.'ns. Ongoing feedback support validation ofth8'data.generatfon process.
The,rnam:them.es or construetfons fr-0m•the prevrous group session .or meeting are
rtesented and ,co"fll'me~ at each gathering or conver-sation.
•
'
ActiRg atte_n,pts, to ·addres,s the Issue ·or elrmlnate ttie problem. The participants
questi0n wnat is important in their lfves, consider the options that ar~·availabla to
,•· th1rm, 1sarcry:the rn o.~_tan_djotn!lydet-erm;{ne the-worth, eff~ctlvent:.ss, apprQpnaten~s
, ard outc0mes oftne-;ict1~1'\S1a~en.. .l:\cfing rnv.olves reconstructing (e.g., "How might
,;, Wf# do things differently?':), and evaluating (e.g,, "Hpw wlll we know~if thlngs have
cn~ng~d7".,). · wheh workil)g.Wlth multiple ,groups of people focused on the same
, top re, it: is imp0rtant tq', retain .both Ifie dlst1nct111e,f~<ltUres orthetnes of each group
while detei:mining recu rring constructs or themes across,g roµps,
"
(
Throughaut t he took-think-act .cy-cle anq wlthiA the context of sharing multj"~le.
, p.erspettives, tti.e 11urse0 fitcillta\or can help :1:.JientYesommunity-partners address
• qu'est!cios oriss,u es rel/ited with posslbl~sourees,ohhepfoblern·or gaps rn solutions
') where,.f:t>'r .example ,epidemiolo-gicaf, medfcaJ and othel' ac:ad~J111c-pased models are
need,~d to·answe:r-guestions like " Why dkl 1t happen?'' or "Why did it-net work?"
.
'i
.
'
.
Koch an"d. Kralik (2006; p. 30)..explain that in practice, the conceptual differences
be~ween· the •'look, think anq•act' elern~rits begin to dissolve and merge. The
' particfpants e ngage in -many, cycles of reflection on action, leam1ng about actl.o n
conslderlhg p os~Jbilltli!s i!l'ld '. theA dmloP,ing new Informed action which in t~rn
1
becomes · ther-toplc
·or theme of further r~ection (Wadsworth, 1998). During
,dlal.ogues; p~pie l(l~rn1new ways o.fs.e'elng,or th1nklng In the ltghtof.tt;ei~ experience,
feading,to hew abtioQsi'With pMctlc.e, these beoam.e,the focus~f dlscus;;lon, further
rerecti6n •,a nd gt,<>UR se,lf underst.ndlng, €he nge as a ,re.sult·Of the 'action' ~art
· ofn!t he_e'xpe~leric~ does not·1:15ually happen at ~tt:ie end ofa partfdpatory action,
'lnq ulrry. ' lt,h"a·~_pe(ls,througho"1t (W~dswotth11998). Duol'lg the l)B~cipatory ac:tipn
p'roc~ss, lt,oft;~n 1,app\an"S'that the focus of what 11eeds to change will shfft over time
as partners a!ter•,thefr; i,mcfercStar:fdlrig ofWhat·ts reaUy lmpc0rtent to them .
•,..
,,:. ,.,...
,,I
..
'
•
,.
113
PART I CIPATORY ACTION AND EMPOW ER I NG EXPERIENCES
OF FAMILIES IN DANGLAS: ABRA
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o f t b ,• '- l 11 11kip.d11, 111 P ,1111:l., , 111 \h r,1 1'1cl\1m·,• ,;i t11.11,•d 011 tlw 1•ast 1•1·11 :-id, • o f the
Ct>l'l lill,•r,1 \ 1111>111111 ,.,,,, K, 1-:11 >11 ( l ' \R l. Hn,.111)!11~ n .,111~l.1s i,: hi~111rit·:dly II c u 11111111nity
<>f i11tlii:,·1h•n" ,,.,.. ,,,1, • .,11,-.1 I 111.:.1:u1,111, or 1111..:~. But .1, n ,·011s ,•q11c111·c c,f 111 igr:1t ion.
,t
11rn·u1h :1 ,, 1111 lll·t,·r,, :•·11 ...•11" rt1m1u1111i1y " ;t h .,fliliat ion h~· h und,: of n,a r ringc
wit h 11,.,. in,". llu,il ., ·11 ,..: .11ul \ " ·" ·""· \\ "hik tlw n r igi 11al di:iltTl i!o l';tllcd l 11':111d. nil
U,, , 1-.,11 11111m11,· r, ,i,k11t, ,.111 unJ,·r-o1.111d a nti :-:pcnk l'ilipino. th1: 11111inn al l:111g 1111gc.
At th, um,• ,.( 1lw n,,::ird1 , tll , i,,y- 111111' h o u i:..- h,1ld:-: wl.'rc· n·pn•s1•11 t (•d in H•,·c rnl
c:ip•1 lo, 11 -,, -h11dd11i... c•om nm III t,. t,.,,,·d 1•,p,·ril't1 t i.1 I It-a r n ini: :-cs,i<111s I h r o 11J,! ho11 t Lhc
fir-.1 , 1 tr,,/ · h· pn•f•, I ll1t n·....·.1n·h 11•;1m 11tih1t·tl lh t• partic-ip:.i toi:· nc-tinn prc•c<'S.'- n:t,,a,u 111 1, r, • .,,,.,11 111, th,,.J .. J•~~, tn d,·,·, lt>p 11pt 1011!- ,111d ,ch cmt•:- tu 11111kr-.1:111d field
re:\.IJIH'' "' " ' " m.d 1rt 1 ; ...• 111. , 111 ,t.1,· m m .111y rur.il ,;lta,.:es nnd lwlp thl• c-Pmlll tt nity ns
clil'rll . 1,.,rt 11• r 1,i ,,Id r, •,:- I h , · 1"If<"' ;ind f:1cto,-.. r c• Ia I ,·d " i th I h ,· prt ,h h•nL Th1' n •:<cn rch
prnj,'\'! u,,.. J ",, ral pr,,,:\.'1.lun·- t,"<"l1111qu,:--.. an d i11t, •1-..·l"n l io n t o m 11'i111i1,1• fnmi lyl)_-,'-('<l ,,r1 ..,.., n11,,, 1n<l t:1>mpr tt>111·1-., l11r ,:.tr l~ ca ..., • ti m .linj!. ap prnpri:'11 e a nd prom pt
m.or1·c, 1·11 nt. prr•, n11oa 1hn•11ch ~If prut ("t.·ti •>n mc.•,,,ure" :tnd mo'<rp , ito v1:ct orcon t n>I rh1 11u r._. -1,·•J J, Al ~o, .. mm r•nt h tr.dtli 11ni1 111 J)Jrtm.:,-...hi p with t h<' mnyrn.
th(' muninral I m1111 ii .mJ th ,· -ill.t;.?•' (c., llt•d har.in~fl~ ) l·c,11111;i l "lll kL..J d n,,•1~ "ith th e
r e:~~n·h 1rani ,ind th, (.1mil1 ,,.._ :p. ,.,..-,• r;,I p :1 nk1p nt 111:-,· at·t111n :-l'J-.,io11:-. on 1wr,011.il :ind
aix.'--' r,•I.H,·tf , ...... u,-.. •nd pr,.l,I, m'- cen, ·r:11,·,J in,i~Ju ., o n factor,; affL-clin,; o ut co mes
of aC"ll'< • · ..~,I, t-. •inn I 1h->rat•1ri d i:i;:nri,i,. cf,,,•.,._,. ma n ai;:t·mL·n t. l:1 r-.. :11 m<mi1ori n g
anu :-1r, .m1 d,••n11~ ._knninJ,:. The n:,~·., n h,•r -< tng,•lhi-r ,,,1h t ht· n1m l h e.d t h tea m
leamt'<l ._,.._ ,•r.tl J, ......., ,n, no " h:, :wt h c ~-., ...,i det ect ion ,111 n 11~ t lw fi r-1 I w, 1 qua rt1 •r , of l h e
proJ"'<I ,. ,11 1J n,,, ""''r ,~,.,nil ....... ""~ 1wrc(•11 1 11f th,· P"JJ11la 111m . .: ve n 1( 111:1-,, blood
<un 1-. • ,, , n J r,n, 1n I h,• ,;JJai:, · \ , ·1w-< ;J nd da UJ?h t•] r' ~, ht>w c.r1• pn nu ul.irl v mot Iv., tcd
at l'r.•11na,: h ,ihh pr• 1•>01< n '>' 1h,·1r hrii1, .. h n ld:- :-h arc,J fomil: ri•:, h t H·.,. ;,'1,•r- goini;
thn ,111!.h ti .. c./11• .... l ion . "\\na1 ,, IL, pfl<•nin;: h,·n·r: - K:tp:i1,t ,d:im na darntin~ k;,~o p :ira
k"l.lmuh;, 11i:. dt1J.!"· .,ng 111~! ;i,,H,':t nam 111 at mi:a an:i~: n n l:il:i~·, :t~ :1.11 y111 11~, ,a h1111dok
P3ra m;1~ 1 .1111 ~111 d., .. . ~;i 101,)(1 l:tng, . n111:11.1k•J t m ;,gp;1k 11 h:i ng, tl11~" k;"l 111111, aki t
da~ Ltr•>~ ·111 11111•.1,i • f\\ 'h•·n u11r h11 •h:in,h :i nd .,,,n-. n•ali1r- t h;,1 \ <>11 an• nit 11i 11~ to
,:;et hlr><>d -..unpl,
tlwy wnnld "'" 11p thr- nir11 1111;i1r1 11, d,, "k.nng,111" la l:, n d d, •arin~
prc,~ ...11ir, t• · pn JHr•· 1h1 ,p,l•· (r.r upl,,11d f. ,nmn~J Th <· t n,th i ~ 1h1·~· a r•· a fraid I•> );Cl
1Jw-1r fllll( t r,. pn• ~•·d t..-c.,u,, :ir, t1rrf111 ~ 111 t lwm. i t , .. p :, inful.J Aft,•r u11 tl1 •r ...1:111di11g
fuU~ '"·II th, Jl(t-... 1l11li1, .111,J u,11-.,•<Jllf' n, , ,,., ,,{ dru ~ n •-.,...l 111w1· from vr rn l, i,· Ch I, , n ,q11i nc•
intal.. n hmi: n ,amh "" ,.,...,r and c l1111, 11r 11<,rll n, ,, mpl1t rn s, r, ( 111al:iria w i t hrn ll lhc
b<-11,-f11 ..1 l , borat, I"\ J ,. .:,n,1 ,.., \,1\1·, ., n<I \t111th pn, p<t...,•d n pti1111<,, l o 1·, p:11 111 familyba.-...,1 <»mp, :, nu,-~ " "'uni? tulun1.,11 l..am1 J>,,ra l..11m11 l,a n~ du~o. l..,1111i '"' an s.: g,:iha w.i .
At J~.1111 ,, ,,l.i na l..,t~• nlto. m.1):,1,1.!,n,,1 p,1 r111 11,1mm. p:i ro1 m :111111111~:111 di11 nng h11on~
bar.. n 1,..n • fl( ~,,u c;1 11 ll,Hh '" hi ,\, 1,, Rl'I h lr1od ....,,r11pl1•<. , ht· \," JI ,1,, tht· 1,1(,.,d ,;111c:ir
mll1-<t1nn .\n,t , , ,·n 1(~011 ;u, ~"111 " ' <,Jll<">llttnu•• d1,111_c 11. v 1 w,• 1·:1 11 h, •lp lh l· re..'-1
o: ti,, ,,11.,i.., t TI,, 1,,..~ tl ur. ~ •,1t1 ph.,.,.., ,,f th, p,1r11n p,, t ,,r)· .,ppn,:wh •·11hnnct'd
fu nl,, r i!u ,, 11wt1\ ,,,,.n 111 h•-1111 hl ,,.,d ,m, .tr 1111!,·t ' '"" · ., ... t lw, r1·,d i1t•d 111.11 ,nmc
mm11Hsn11, r, -,1d, Il l'- h.1.i rn •.tnn., p .1r.1,11f·, 1n 1hr ir hlrw,d
\ 't t th t• \' d id n ot
suff._.., rrum th.- d ..i.,1,· maJann t l."'\t•r ,m,J d11 JJ., d u..- tu t he di11ic-:i l plit:1wmc nc111 cnlkd
p., rtfa l 1rnmurur,. .Aftrr thr 'ne11t111 pan of tr:iinini i11 1<•noc;1ed fornily mcm hern on
nnd
i--,
,
~mr;ir,.
114
pre p a rn t ion o f b lood <i lll l"II rs. I he c•wcrt1:i;c cif :1cl ivc case detl'c l inn incrc;1s c:<.1 lo nlrrHJSl
11 in c ty - 11ini: 1wrel'11 t, wit h nl lll'r 1·om111111ii1y 111c:mbc rs tw in~ nu t of th e vi lfagc a l t h e
t jnw of h lo rid s 1111:<1 r n ill l'r·Li1 ,n . I >11 ri 11,i. p<-ritld <t wh e n fnm i lif"S s 11.s1w t· I members t rJ
have m a lari a . b lo od s nwnr:; w,·n· lnkc 11 , wit lr lab,,r;i l•i ry clin~nw{is d0111: in il i:il ly l>y
v ill;i~t· h t·:d l h 1vn 1•k .. rs :111d midwi vt •'1 w l1< 1were tr.rine<l while tir e rt•<,,:;i rc h wa-: <Jfl -W)ing.
Con fir111 a t inn of l:1 h11rn I , HY rJ i;1h11w,11- wa s dnne :11 1he prnvi n da I hos pital l:1h1Jra tory in
th e capil al 1n11 11 i1·ip:rli1 v ,,f Bani.:11t·d, :-:it ua tc d scvt•ra l kilorn<: lc·rs c1way th rou g,h the
Abrn Ri ver t h :11 sw1:lls 11 p d 11rl n;.; 1l1c rn i11v sras r)n . /\ccess proble m w;,1.-; ,idurcss c<.I bv
the c mp r,wc re d fa m il ies 111ilb:in i.; lht· ' loo k-1h irrk-11d pr.,,·, •ss 1hr1,11le(h th e 1vork grnup
n pp ro ach. ~l id, •.<; wr•r,• l ak1 ·n t•J tli t· pn1vi11ci;tl lahor.·11 ,,ry hy v1tl11 n l c·cr <''> rnm u n ity
n,c m hcrs who \Vo.: nl r,.,g111i,rl~ lc1 Ban)!,II P<I 1t1 huy )!,Oods anti f11r,d -;u pµly for tl1e ir village
s a ri -s ari st em ..:~ . Pa rt of t lw 'al'I i1111 · p h a s e n naly zc·d hr tlw w,,rk ,i.ro up::, wa:, th e sch e m e
w h ere l;, lm ra tory rcs11 h s were brcrni.; h1 h ack Jr, th e rurrt l h c;1l 1lt unil or w lhe vill age
h e alt h wo r ke r ( HII W) h y th e s:rmc enrn m u n ity m e mbe rs afte r l h ey we re don e with
morkctin g in Bn 11g 11c d .
1,..·H"v,il 111011ito ri ng 11ntl s l rc;1m clea rin)!;/clea n ing activitiesge ner.i ted additi o na I insigh t<;,
H;wi n g 11 11d,· n,1r11,d Lh c cpi tl cm io logy nf ma lari;1 m, p,1rl o f Ll1c: 1:apnhility-builcling
cxpc .-i<'n cc . s <1111 c male members of I he \·ill:1gc. who opted lCJ be in-,;harge o f larvaJ
111o nit rff i111!, in lh c t ril,11 Iar-ics of th e vi 11:ige s trc;1m , 11skc<l fa rn ily wo r k g.ruups why th e r e
wen· ~ti II 111:ila ri r1 <:a.'ws <lrspi Ir i nrr,•;i,;ccl c,, <;c d e t<'rl inn ,,·it h tre atm e nt a n<l regu lar
llfl C:('-:1-1\'t'"k 'i lrt·11111 cl1•;1rin g/ c: le;,n ing. Tht· 1111rse- r£'-t:'/lr('hc r g11 i<lc<l th e m th ro u gh
1111: ' lnr ,k -l hink -;u-t· eye-l e- 111 iliz in;.\ 1h c wrJrk 11,ro11ps' trn ining :md ,·omp<•t1~rH' il'J; l)n the
bi tm omics/ Ir fc cyclt• r1f the ,\ 11up l ,des nios qu i Lu vector of m a la r-fa: "An o !"a pa la g ay nyo
; 111g d :il1il.r 11 k 11 11~ !,;,ki t s a pag lili11 ii- rryo ng il,1g rni m,ar1 isa 1111. lingo 11y meron pa ring
nag kak c1s;ckil n~ n wl,11 ia s,, h;1ra11):\ay'!'' (Wh.rl tlo yuu tlr i11k is the n·ason " 'l ry clespile
thc onc~·-n-w~•r·k s tn:;, rn dc;1ring/c lcn ni rig. th e re nre s Lill mala·rin cases in th e village?)
:\ n:-ilys is nf th c re p ly ge ne r:11 cd th e " ·ork j;rnups' d c{' i:,inn lo increase th e freque n cy o f
s 1rrnm c-lc-:i ring/ cl,•an in~ to a l Ira oa t two Lim es ii week ;r nd sh iirc the ir com pctcnc:ics with
fo mil iL'S in r,l llt'r , ·il lug,·1-, nfte r l hc_\ reviewed wha t they lc.n rn ~d uho u t tlw hion o mics/
lifc eyc lr:- o f Ji ll' m n-<1p1iln v~·c-tni- of ma lu r ia. -111c conse ns us r,f th e work XTOup: - o;ipat
pa~ka 111ptt-: 11;i1 in~ maglini,; ng ilog / wai//,. l111)?,na n ku ng k.,ihrn ulil mcrong kili-kiti/
lxtlhalli k. ll;1k;1 knl:tn~ <Hl ~ niin s an isa n p; lin xgon)a\ p fl,l,\l ilinii; kun)I. ma v mga lam ok
ria 111a11gigi1lop. 1tl it , p i1~k,1 l:i p11" m1li11)1. m aglinis, Ka~i m~,1 1all(m!{ arn w pa Jang ang
ki ti- ki1i ,I\ 11rn.t.:i~i111; l,1111111-. na. Pu:- il1le rin na a n g m ga lamok sa ihang banl ngay ay
111:ik:ika lipnd .J itt , d ahil i:-allH kilo nwtro n il ).: k;iyn n ilnn J?. liparin. ·· {Soo n aft e r we have
<lun e s t r,·a 111 1·k•;1ri 11g / ch•a11 inle(. we n eed to c h ec k w h e n the re would h e larva e in the
stn·am agnin . The 0 11c;c -a - \,•1•c.k c·lc:aring/ c lc aning might n o l hf' arlrq u n tc if mos quitoes
l:1y C).:).:S :<1 11 111 aft er Wt' i:h•an 1111' ,,1r ,·a11 1. \Vith in l11rt'f' cl r1y-< , I h P la rvae bet:qme adu lt
111os q 11 itu l·s. II ii; alsn possible lhal rnosq u ilo es cn m e fro m othe r 1r1llagt,:; bt::cause
th ey ha\'l' a lligh l ra il)?,<' Ill° o n e k ilomete r .) A~ :, c o n,c q u e n ce o f the cy..:l ica l. iterative
' look - t h ink -ac t' <::-qwri c n cc, 1he work ~ rnups dedd,·d lo ~•xpa 11tl their activ it ies in o th e r
vi ll ugcs. T hrn11J.!. h t he ,,ffun s of the prnvi nl'ia l hcalt.h ofiic..:. th<;> <:ommun ity members
log,• tl wr wi lh till' ni ra l h,•:tlt h u n it :111d t h,· lt.':1dc•r!' ni th e ,illagc were trained by the
rad io rn an a,:cr lit prc parc :iud in laµ cs us in)!. family empowermen t experiences ;in d
com 1w 1, •nl· i~.._-: ;1.-; ::~·ri 111,;. which w,• rc ni ~d regu la rly lhroug,h tbc province-s upported
rad io p rn)!.rn m , DZPJ\.
ENHANCING INTERD ISCIPLI NARY AND I NTERAGENCV
COLLABORATION
Fo r m a n y ye;Jrs, nurses. o t h e r memb e rs of th e heallh le arn and organizatio ns h nd
been r e.I uct an l in es ta blis h ing rclalio ns h ips wiU1in l he perspective of"world n g togeth er'
liccn usc of tJ1c complc.-city of addressin g perso n a l and professio n al d iffe re n ces and
l.15
prc pa ral ion nf hl oml s m ears , t he covcrngc o f octh·c case dc lcction in creased Lo almost
n inety-ni n e pc n;cmL \~; th olhcr co111 11111 nity mcrnhe rs being o ul of the vil lage al the
tim e o f bl nocJ s mea r c:ollccl inn. During periods when fam.i lics su spect m embers to
ha ve m a larin, blmid s m ears we re taken, with Jahoralory rlia~ osis done initia lly by
village h ea lI h w<'>rkc, rs :i nd rn idwivcs whtJ were I rained whilt: the rcse nrch was o n--go jng.
Co nfirmutio n r,r 1.ibnra tory diagnos is was d r,nc a t the pro~;ncial hospilal labornlory in
th e capit,1 '1 mu n icip,ilily of lhln).\ucd . s ituated scn:rn l kil"'nctc rs away th rough th e
1\bra River t hat swells up during rhe ra iny seaso n. Access problem was addressed by
th e e rnpowerc<l farni lic:s u t il izing th e ' lorJk-th in k-nct' process th rough tht! work group
app roud 1. Slides we re tn ken 10 the provinc i11I lah nra11> ry by vo lun tee r community
me mbe rs who w e nt regularly ro Fla nguetll to buy good,; a nd food s up_ply fo r th eir vi llage
sari-sari s ln n :s . Pa r·1 or the ·acl irm' ph.ise ,ina lyzed by t he wr)rk gmu ps w a5; the sch eme
whe re la hor:ilnry resul ts wc,·e bro ug ht back to the rura l heal t h u nit o r to t he vil lage
h e::ilth work e r ( fl l-l W ) by the sam e co m mun ity m embers a fte r they were done with
m a rke ti ng in Jfang11ed.
Larval mnni I o ring:1nd s trea m clea ring/cleaning nctivi t ies j!,enert1ted additio nal insights.
H aving 11nd e rs tnod t he e pide miol ogy of m ala ria as part of th e capability-b uil di ng
expe rie n ce. so 111e male m embe rs o f t he village. \,·ho opted tr) be in-charge of laival
monilnring in 1he trib111a r ics o f the village s trea m , as ked fam ily work grnups w h y there
were s till m a la ri t1 cases dc r-;p ite in c rcar-<ed c,1sc detection ~,;th treat m ent and regular
o ncc-a-\,·cck st ream d c:iring/ c:lean ing. The n urse- resea rcher gu icled the m th r ough
the 'look- t hink-net' cyt'lc u t ili1.ing the work groups · trai ni ng :ind compe tencies on the
b ionomics/ Ii fe r·yc·k of lh e -\11opheles mosqui to vertnr o f m r1h1 ri a: J,\no /'.rt palagay nyo
a ni; aahi la n k1111~ h:i kit sa pagl ili nis nyo ng ilog minsan isang li ngo ay m eron pa ring
nagkaknsa kil ng m:da ri-a sa ba ra ngay?- (\Nl1at do y oll think is t he re!l,.,<;On why despite
th e once-a-week slTcam clea ring/ c lea ning, the re a re still mala ria cases in t he \illage?)
An nl ysis of th e rq, ly p,e n l.'rated th e work g rou r s' d eci~io n tu increase U, e freq ue ncy of
s t ream dcnring/ dcnni ng tn .i t leasnwo times ,1 week a nd shart: thei r competencies \v;th
fom il ic:- in o t he r villa11,es, .:ifte r th ey re,·i ewed w ha t they lc.i m ed abou t the bionomics/
life cyd c of th e m osquito vector of ma la r ia. The consensus of the work g roup: " Dapat
pagkntapws 11:it ing rnagl inis ng il<Jg/ waig. Ling nan k ung kailan ulit mer o ng kiti -ki ti/
balbal t ik. Bak;i kulang ang m ins an isa ni li nggong paglilin is kung may m ga lar:nok
n a m anµ i1;i ll1ig ulit . pai,;ka tuptis 11ati11g m ag linis. Kc1si mgn tatlong arnw pa la ng ang
ki ti-kili a~ 111a~i4i n~ lt1mok na. Posible: rin na ang mga lnmok sa ibang hRrangay ay
mn k:ika lipad t.lit n dnh il isang ki lometro ang kaya ni lang lipnrin. ~ (Soon nftc r we have
<lo n e slr cu m clo.::1ri11g / clcani ng. we need to check when the re would he larvae in the
slrcam again. The once-a-week clcnrin)!;/ clcnning mig ht n ot be ad equate if mosquitoes
lay Cf,)-\S ~oon afte r we d ean th e stream . V11ilhin three <lays, the hn·vae becom e ad ul t
rn m;q11i1 n..:.,; , lt is also p ossible 1lrnt mosq tntoes come from other vi llages because
they h aven ni1-1,h t r·;rnge of one kilometer.) As n conse<.juencc o r th e cyclical, ite rati ve
'look-thin k-net' experie nce, the work groups d ec ided Lo expand their activities in o ther
villages. T hro'l1gh the e fforts or the p rovinc ial health office. the co mmu nity m embers
together w iLh th e n.ira l b l'a lth u nit ;im.l the lcad t::n; of the village we re trJ ined bv t h e
rad io m :.r nager lo p repa re a udio tapes usin~ ra mily em powe n n e n t experiences' a nd
co111pclencics as sc ripts, which we re aired reiularly through tb e province-supported
rndio progrnm. DZPA.
ENHANCING INTERDISCIPLINARY AND INTERAGENCY
COLLABORATION
For many years, nurses, other me mbers of th e bealth tea m a n.d organizati ons had
been re luctnn t in est ablishi ng relations h ips wi thin the pe rs pective of' working together'
beca use o f th e complexity of addressing perso nal and professional d ifferences and
-
115
potent i:,I loss of conlr ol. Wit h lhc increas ing co mplcxi Ly of h en Ith proble m s, increasing
cos ls f11r ins Iit ,,tion- Lrnscd health cn rc/ hcu lthscrvicesn ncl incr e:1singe xpertjse lo audre :;s
s p cdl ic lwall h n eeds. prohlems 1111d issues. the re is e nha n ced mo1iv.11ion for in itiatir1g
o r gl'l lini; in volved wi th inl t•rdiscip li na ry n nd inle.ragc n cy coo rdina t ion that fnd lit ate
inlegrati o n ofsh :n-c<l ).\oa ls and n'sourccs lo inc rcase e ffc,·ti vc nc ss a nd ti fficiency. wh e r e
rnson rcc:- : 1l'l' li m ited or inacccssiblc. (Pl>livka, 1995). Utilizing pa rt nc r ship concepts
nnd t ill' partidpa lo ry uppro m.:h, cconllict rc:,;vlulion mech a nis m s. optimum in fornrn t inn
excl1an ~c up p u rtunilic,:, e 11h anced decisio11- 111nkiog proces~es a ncl q ual ity intc rngcn cy
comnrnnication can b e achieved Lhrnugh mu tunl tnLst and respect a nd s h a red vision.
THE ESSENTIAL INGREDIENTS OF PARTNERSHIP
P,u-Ln e rship is n ty pe of rdntionshi p churnctedzed by a close coope ration belween
p:1rtieia h av ing svecitied and j o int r ights a n d responsibilities as tJ1ey t ry to work o n a
common venlun:. lt is nn egalita rian rcln tmonship w h ere pm1.11cL-s cons ider each other
as co-equals in s o far a :s th e in tr ins ic \,·ort h a n d access to r ights :111d 1)ri vileges of th e
gr o u p arc concern(."<.l. They p ni-ticip,1te eq1Lally in ass uming 1·esp on s ibi1iti.es to achi eve
t he ob_iecti vcs und goalsjoint l_v ide 11 titicd. Such a genuine pM"lic ipntion is not commo n .
Healt h worke rs ore ofte n faced with the reality t h ilt pil rticipa nts i n commn.nily h ealth
d evelopmen l work (i.e.• me mbers of the commml.ity, representatives of i1ge11.cy
r esources, and the h ealt h wodwrs th e m selves) n eed lo l earn l1ow to wo d ~ togeth er as
real partners .
Jn ordertoengage in a partners h ip thnti!, characterized as a mutually g rowth -promoting
rela tionship, the parln ets nee<! to internalize tl1e following essential ingredients :
1.
belief in egalitadan re latio nship;·
2.
open-mindedness;
3.
respect and tn1st; and,
4.
commitment t o enhan ce each others capabilities for partners hip.
Belief in EgaJ;tarian Relationship
Partnership can not be a reality u nless a n egalitarian r elations hip is considered vital
by the identified part11ers in health d evelopment. The health worker m ust firmly believe
that in order to achieve personal, p rofessional o r o rganiz-ational goals and obje cti ves,
sh e/he mu s t engage in an egaJitarian r e lationship w ith m e m be1·s of the community
and others involved with d evelopm ent work. Communi ty members n1ust also 1·e-alize
that for health services and programs to b ecome m ore effective and accessible to
their fam ilies, they must be co-equals of h ealth professiona ls in commu nity health
development work.
Open-mindedness
Individuals who are gather ed together to do partnership on a common ven t ure carry
with them their past experi ences which affect the way they s ee, analyze, and un der stan d
things, even ls, n nd people. As practical beings with limited fun ction s and duties t o
pe rform, they are inclined to feel intensely the importance of th ese duties and the
significa nce of the situations that call th ese forth. '111us, some actions of others 1nay be
judged as stup id, useless or bad by those who have become so used to doing o r se,e in g
things in an e ntirely d iffere nt way. People m oy become so absorbed in t h ei r particu1ar
116
c;,,-pcric nces and 111oclcs of actions to b e open to 01'11er ways of doi n~ or looki:ng al t hings
and eve nts. He nce, Lbc danger of presuming to decide in nn nbsolu le \Wl)' on the wor th
of oth er people's condi tions or ideals.
Pc11·t ncrship requires that participants lenrn to be open-mi nded in order lo sec rind
u ndcrs 111ntl thini:;s. events, and people ,-.ithout limitntions imposed by prejudices ond
itl iosyn c.rnsics . Part ners arc ex pected to po:=:scss the skill lo view things a ncl exper ie nces
fro m each ol'h t:r's p erst)Cctivcs to a rrive at a more relevant and npprnf)rintc! snlu tion Ill
any problem that concerns the m both.
Respect and Trust
Fo1· persons to he able lo e ngage in ;111 egalitarian re l;itionshi p th ey n eed lo h nvc
r espect for each o th er's worth and trust on the potentialities ;md c,1pabililies of c:1 ch
one despit e difforl!nces in beliefs. vnl11cs. and exp eri ences. P:irt nurs may come from
1111 sectors representi ng a cross-section of s ocio- economic. cultur:il. ed11calional
or political backgro und s. These backgrounds may nffcct rho partners' expect:1tio ns
an d p erceptions o f each othe r. A co ncret e cxn mplc is what can be obsun•ed du tin g
community a sse mb lies. The poor and the le.ss ed 11c1.1ted go to the m ect in~ with th e
e~pertnrion th at t he p rofessionals a ncl other beller-ed 11catcd mcmh<-'rs will nnni rally
display th eir ve rbal prowess ;md dominate t he disew,sion. Likewis e, t he prnfr ssionals
v.rill e xpect t he pnor and t he less educated to be pass ive, submissive, anrl subsc' rYic nt
m em bers. These expectations become such a self-fulfilling pr()pbecythatt hc desig natcd
pa rtners could not learn to have respect for the capabilities and potentiaUties o f each
oth er.
Respect and t,,.1st also form the basic ingredients of a relationship where each p artner
does not use th e other to gel the honor or rewai·d only for himself. Many hea lth
p1·ofessionals and the organizations Lhey represent are no t too encou raged Lo engage in
a partnership because past experiences proved that others get the recogni tion for tJ1e
success of a n endeavor, th e e fforts and investments of which had been a shar ed acti vity
in the first place.
Failure to earn respect and trust is one major cause why iJ1jtial experiences 011
establishing partnership can not be sustained through the working phase of the
relationship. A sustain ed commitment to the partnersh ip is a result ofrespcct and trust
that partn e rs earn by -~uch actions as doE.ng one·s sha re of the work to the best o f one's
ability, keeping promises and appointments, maintaining a hvo-way communication
and b eing sincere and honest with one's relationships.
Commitment to enhance each other's capabilities for partnership
As mentioned earlier, not everyone designated to engage in a p,irtuership has th e
necessary skills to do so. Beliefs, values. feelings, idiosyncrasies and prejudices affe ct
the partne 1·'s capabilities to initiate and sustain an egHlitarian relationship. Partners h.i p
l'equires a co-responsibility. Participants must constr\lCt together the foundation of a
mutually growth~promoting re lationshi1) using thems eh·es as "bricks". Each pa rtne r
must be ready to help build up a nother and he, in turn. s hould be wiJli.n g to b e h elped
build up himself. If a member does not haveth eeapability necessary for him to perform
his share of th e work, the partner must be able to d evelop such ca pability. Each one
m ust be able to pull up the othe r to u level of functioning where both of th em c.111 work
as co-equals. Each parlner mu.<;t have t l,e commitment tn bring n11 t t he best in the
other as much as he brings out t he b est in himself. S uch a commitment is 111:!cesso ry to
s upport each oth er through th e grm,ving puins of establishing a viable p,1rtn crship.
117
CAPABILITIES NECESSARY FOR PARTNERSHIP
In order to develop a co m p lex s kill, the p e r son m ust u ndersta nd conce ptually a nd
beha,;orallywlrnt t h e s kill is. By h avingclea r and concrete ideas about th e skil ls n e cessary
for part n ership , t h e p1·ofessional health worker or the change agent ca n iden tify and
utilize t he best op portunities or m ethods to develop t hese ski11s. A discussion o n the
capabilities necessary fur partm:n,hip shall he la ken up in th is section . These are of two
maj or ~i,cs: (a) skills necessary to work wi th others in o rder 10 fu n ction effectively as
an int egrat ed unit; (b) s kills th at t h e professional health worker a nd the oth er partn ers
need to perform togeth er to attain community health developmen t.
Skills Necessary to Fu n ction as an Integrated Unit
These skills incl ud e the capabilities n ec essa ry to be able to work t o gether as a
coordinated uni t . The foUowing arc major e:-:amples of t h ese s kills:
1. The S k i ll Necessary to h e Broadminded ol· Opcn-J:\fioded. This involves
b eh1g able to see and understa nd t h_ings. even ls, an d experie n ces from all
pers pectives. It therefor e, entails being genui.nely willing to e nler another's
private world and see how th ings appea r from l1is poi11 l of view - with o ut ad ding
any personal evaluation.
2.
The Skill to Develop and l\'[aintain T rust. Al~cording to .Joh nson and
Johnson , the crucilll clements of trust are openness, s h ari n g, accepta nce,
s upport, and cooperative intentions.
a.
Ope nness is the sharin g ofinfom1ation, thoughts and feelings on the
issue the partners are pursuing.
b.
Sharing is the offering of resources in order to help :move the group
toward goal accomplish ments.
c..
Acceptance ismakingt h e other person feel t hat h e and h is con tri b ution s
are h ighly regard ed.
d. Support is making tbe other p erson fee l. that he bas the strength and
the capabilities n eeded to m anage productively the s ituation h e is in.
e.
Coope rative in tentions are expressions of expectations t h at tl1e
partners are going to behave cooperatively t o a chieve the group 's
goals.
3.
Group Skills. T h e partnersh ip approach is effectively s u stain ed t h rough
work groups which nre utilized as the basic componen ts o f the organiz~tion al
structure in comm u ni ty healt h development. Grou p slalls a re, therefore,
importa nt components o f pa1·tn ership, These iacl utle the capab ilities n e c essary
t o h elp t1Je group ach ieve its tas ks (tas k functions) and b u ild r e la t ionships
and cohesiveness among memb ers termed g r oup building a nd mai ntenance
functions . (.Johnson and J ohnson 1975, p p. 26-27).
a.
TiJpes of behavior under tas k.fu11ctio11.s include the follo wing:
1.
118
Starter: P roposes goals and tasks to tnitiate action withi n the
g ro up.
2.
inform ation and Opinion Secker: Asks for fo clS, informatio n ,
opinions, ideas, a n d feelings from other members to help
group discussion.
3.
Coordinator: Shows refat ionships amon g va ri ous ideas by
pulUng them together a nd harmo nizes acti v ilies of various
s ubg roups and members.
4.
.Information and Opinion G iver: Offe rs fo cls, o pinions,
ideas, s uggestions, a nd relevant info rm a tion to h el p grou p
d iscussion.
5.
Direction Give1·: Develops plans on how lo proceed a nd focuses
attention on the task lo be done.
6.
Summarizer: Pulls together related ideas or s uggcstioDs and
restates and summarizes majo1· poi nts discussed.
7.
Realit1· Teste r : Examines the pr,\cticality and workability of
ideas, evaluate alternative solutions, and a p p lies the m t o re al
situations to see how they wi ll wor k.
8.
Diagnoser: Fig ures out sow·ces of di fficult ies the group h as in
working effectively a nd the blocks to p ro gress in accomplis hing
the group's goals.
9.
Evaluator: Com pares group deci!s.ions a n d accomplishme nts
with group stand11 rds and goals.
10.
EJaborator: Building on previous comm ent, giving examples,
enlarging on it.
11.
Energizer: Stimulates a higher quality o f wor k from the
group.
12.
b.
Consensus Taker: Checks the group to see if the members are
re.a dy to make a d ecision or to t ake some action.
T ypes of behavior under group b uilding and maintena nce functions
include the following:
1.
Communication Helper: Shows good communication s kills
and makes sure that each group member understa nds what
other members are sayi ng.
2.
Encourager of Participation : Warmly e ncourages everyone to
participate,givingrecognition for contributionsdemons tr ating
acceptance and openness lo i.deas of others, is fdendly a n d
responsive to group m embers.
3.
Active Listener: Liste n s and serves a s· an int ereb1:ed audience
for other members, is receptive to other's ideas, goes along
with the group when not in disagreement.
119
Jntcrpersonal Problem Solver: Promotes o p en discussion of
conflicts between grou p members in orde r to r eso lve conOict:s
a ntl increase group togeth e rn ess.
Sto ndartl Sellei·: Exp resl'.csg roupstandards and goaJs to make
mem bers nwa re of th e directio n of the work a n d the progress
being made toward th e goal and to get o p e n a cceptan ce of
gr oup no rms a nd procedures.
I .
6
·
7.
Trust Builder: Accep ts and supp orts opennes s o f other
gr oup members, reinforcing risk t aking and encouraging
indivi duality.
Harmo nizer and Compromiser: Pers uades m e mbers t o
analyze constructively their differences in opinion s , searches
for common cleme nts in conflicts , a nd tries to r econ cile
disagree ments.
Tension Relieve r: Eases te ns ions and increases the enjoyment .
of group m embers ·by joking, s uggesting breaks, and proposing
fun approaches to g rou p work.
Proces
s Observer: Wa tches the process by which the g .-oup
9is working and uses the observations to help examine
e ffectiveness.
B.
l 0 . Evaluator of Emotional Climate: Asks members how they feel
a bout th e way i.n which the group is wo rking and abou t each
other.
4.
eommurucation SlciJls. All cooperative, integrated action is continge nt
upon rhe use of comm unkation skills. Through these skills, partner s reach
some understanding of one another, build trust, coordinate the ir actions, plan
strategies goal accomplishmen t, agree upon a division o f labo r, im ple m e nt
and evaluate actjvities. Th ere are two major types of commu nication skills.
The following ~ubscction discusses important exa mples of comm u nication
skil ls under each type.
a.
Sending messages effectively. This involves being able to make others
underst and clearly what one wants to commuojca te, whether in verbal
o r writ ten form. Some examples of this type of commuojcation slo11s
include the follmving (,Johnson and Johnson 1975, pp. 114 -115).
1.
Making messages com p lete a nd s p ecific_ The sender should
include clear statements o f all necessary information t h e
receiver needs in o rd er to understand the m essage. This means
the se nder needs to communica te t he fra m e of r efe r e nce he is
taking, the as~umpt ions b e is making, the inte ntions he has in
communicating, a nd tl1e leaps in t h inking be is making .
2
Making t h e messag,e appropriate to the receiver's fra me of
reference. vVhen explain ing concepts and ideas, the sender
sho~l_d use words, anaJogies, a nd examples t h at the receiver is
·
fam1J1ar ~,ith.
120
3.
Making verbal a n d no nverbal messages co ngruent wi th each
other. Co rnmu n ic:;_ilion prublerm; arise when Lh c S(!n<.le r·s
verbal a nd non ver bal messages a r c contrmlic:lory. If an
individual says "Herc is so me d at a lhat mny he of h e lp to yo u"
,vith a s corn fu l look oa his face anti:, mrn:ki ng to ne o f voice,
the rece iver is confused by Lhc m ea ning of t he state m en t
because o f the twu d iffe ren t m1;;5sagcs being s imu ltaneous ly
sent.
4.
Exp ressing owne rs hi p for m essages se nt hy w;ing pe rsonal
p ro.no uns such as YI ",md my". Te r ms imc:h ns "som e p eople,"
"m os t indivi<lua ls," "our grou p me m bers" make it d ifficu lt lo
determine wheth er tli c !>emler rea lly thlnks and feels wh at
he is saying o r whethe r he is jus t rep•~aling th e thuughts a nd
feeli ngs of olhe rs . Pe rson al owne rs h ip includes clcarly taki ng
r esp ons·ibility for tb e ideas and feeli ngs tha t are ex pressed.
5.
Ge tting feedback ,concerning th e way m essages are bei ng
r eceived. The send er m ust d eter mine wha t m ea n ings U1e
r eceiver is attach ing tu h er m essages by seeki n g feedback o n
how the message is being i.nte rpreted aad processed.
6.
Payi agcl oser attent io n to oneself, to o the rs an d to t h e situ ation
in which on e finds on eself relating to o th ers. Th is kind of
awareness of perception e nables the se nder to un d e rsta nd
clearly the "wha t " and U1e '"w hy" of the message before he
comm un icates this to the receivcr. By bein/!, clear about the
cont e nt of tl1e message and the feeli ngs it gen er ates, the sende r
can ch oose th e best way to mak e th e receiver u n ders ta nd
co ncretely the message the sende r wants to co mmunicate.
7.
Us ing va ried methods a nd opportu nities to communicate the
sam e m essage. The sender can hel p th e receiver und er stand the
messages better by repe;i ling them mo re th an o nce and using
more th an one channel of co mmu n icat ion. Examples include
us e of diagram, p iclu~·es, written reports, a n n o uncem en ts,
ve rb al cues, and gestures.
8.
Res ponding with immediacy . This involves discussing with
anot her p erson directly and mu tua lly where th e se nder stands
at t h e p resent i.n his relationshi p with anoth er and where
h e sees this other person s tanding in h is r elatio n s hip to th e
sender (Egan 1977, pp. 235-246).
0
b.
Receiving messages effectively. According to J ohnson and J oho.soo
(1-975, pp. 115-116), this includes two basic parts: (a) communk ating
the in tention of wa nti ng to u nderstand t he ideas and feeli ngs of the
sen der; and (b ) understan ding and interpr eting the sendeI"'s id eas a nd
feeli n gs. Examples of rece iving s kills are give n below:
1.
►
Attending skills. These include be in g actively present to
another person. By us ing ob serva tion a nd listeni ng skills, th e
receiver can learn to b e attenlive to the person ....,; th whom she
is having a discussion (King a nd Ge n ...;g 1981, p . 70).
2.
Parnphrasing accurately nnd non cvnlu a tivcly the con ten t
of the mcssnge ~ind the feeling..<: of th e sender. Th_is invo lves
restating the sender 's expressed ideas and feeli ogs in one's own
words. 1n do ing Lhis , the receiver must avoid any indicatio n
of approval o r disapproval. He mus t also refrain from adding
to o r s ubtractin g from the sender's m essage (Johnson a nd
.J ohnson 1975, p .116).
5.
3.
DescribiJ1g what is pe rceived as t he sender's feeHn gs. An other
receiving skill is describing what is perceived as the sender's
feelings. The description tontat ivcJy identifies those fce)ings
without attcmpri ng to inte q )ret them o r explain their causes .
It communicates th is m essage to the sender ... H e re is wha t I
u nderstand your feelings to be. Tell m e if I am correct. "
4.
Stating o ne's interpreta t ion of the sende r 's message a nd
negotiating with him until t h ere is agreement as to the
meaning of the message. W h e n paraphrasing the content of
a mes/:age d oes li ttle to communicate o n e's under s t andi ng of
Lhe message, th e receive r n eeds to negotiate '"'ith tJ1e sender
th e a ctua l m eaning of the message. The re ceiver may wish to
preface his n egotiation for meaning r esponse with, "\'\That 1
th i nk you mean is ... " If the receiver's interpretation is corre ct,
he makes n corr esponding reply. If his interp r etation is w ro ng,
ll1en the sender is. given an opportunity t o restate the message
until the r eceiver can state what the essential m eani ng of t h e
message is.
Skills o n t h e Man agement o f Conuni ttee or Task G roups . Co mmittees
or task gronps are organized in order to car ry out the goals, objectives, and
fu nctions of gro ups or organ izations . A productive committee or task group
is a res ult o f adequate baJ1dling o f committee dynamics and m echanics. The
foll owing arc exam ples of th e s kills on t h e manageme n t of committees o r task
groups (Cox and others 1977, p p . 255-265):
a.
Selecting appropriately lhe chairman and m embe r·s using as a
guideline the purpose for wh ich th e committee or· task gro up was
formed . A g ro up o f mon~ th a n 15 mem ber s can liardly e n courage
adequate participation of all members.
b.
Ensuring adequate Pre-meeting Preparations:
1.
Preparin g t he age nda well.
(a) Selecting th e topics properly such that t he issues can
b e discussed ndeqm1tely· '1--vithin two hou r s. Beyond
th is lime, m e mbers may feel exhausted to carry on
effective ly wi t h d ecisio n making a n d problem solving
processes.
(b) Defining each item in ~he age nda as explicitly as
122
possible. Th is s h.all guide m e mbers on wha t exactJy
will be taken up i n tbe meeting. This can he]p them
identify concrete aspects to p rep a 1·e for, sucl1 as
loo ki11g U(J facls o r figures in advance. Us eful d evice
for heading each item (e.g., "For information. ~ ''For
discussion," or "Fo r d ecis ion .. ) can guide m embe rs a s
to where t hex are trying to get to.
(c) Sequencing the items p roper ly. The followi n g are
some guidelin es that ca n be followed . Ite ms that
n eed urge nt d ecision ha ve t o come before those that
can wai t t ill next time. Since it t akes awhile for the
group to g et it s mind in gear. the firs t it em sho uJd be
t hat which is most accessible to the m ind (e ,g., ite m s
tlrnt are. in teresting or cnsy to handle) . An ite m that
need s m e n tal e ne rgy, bright ideas, and cle ar h ea d s
sho uld be p laced high up oo the lis t to coinc ide wi th
the live ly, creat ive atm osp here of the meeting. It is a
good idea to find a unifyi n g item witl, wh.ich to end
the m eeting - one which will u ni te the meeti.n g in a
common fron t rn ther than d ivide t he group m e mbe rs
on e from a nothel'.
2.
Ci rculating in adv:mce, background or p 1:op osal pA.pe rs
together .vith th e minutes o f the previous meeti n g . These
papers prepare m ember s for a p roductive discuss ion wh e n
they a tte nd Lbe meeting.
3. Ensw·ingattendan ceofth.osewhoshall make vital contributions
for effective decis ion -m t1 lcin g during tl1e mee tin g . This is
accom plis hed th rou gh adequate communication with and
follow-u p of these people.
4 . Enstuing adequate prep arations for tl1e p hysical facil ities
su ch that they are conducive to ancl supportive of a p roductive
d iscussion .
c.
EJJectiue handling of comm ittee meeting pr·ocess. ln order to make
sure th at the meeti ng nchie ves valuable objectives, t he chai rman 's role
as facilitator itwolves assisting the group t owa rd the b es t conclus ion or
decisio n in th e most efficie nt manne r pos si ble : to interpret and clarify;
to move th e discus sion fo rward; a nd Lo bring it to cl resolutfoo th a t
everyone unders lamls a nd accepts as bei 11g th e will of the meeting.
Tl1ere are two tasks necessary for the facilitator to ha ndle effe ctively
the committee meet ing prQcess. T hese a re : (1) dealin g with the t opic
or agenda; and (2) deal ing with members (Cox a n d others 1977, pp.
266-269?.
1.
Dealing with the topic. The following skills a re necessa ry in
order t o keep the m eetii1g pointed towards its objective/s:
(a ) Utilizing a n "Order o f Business " so that members
a re clear about the s equence of t opics or ite m s t o b e
discussccl durin g the mee ting. The following guide
maybe used:
123
►
\
•
The meeting is ''called to order " by the chairman
or th e. pr_e siding officer;
•
The m inutes of the prev ious m eeting ru·e read
by the secretary (if a copy of tl1 e minutes has
not been given out to each member prior to the
meeth1g). T he minutes may he approved .as read
or writ ten or may be approved with additio ns or
corrections;
•
Business ar ising from the minutes are discussed
ne;,,.1:. These include prog1:ess reports ou the items
discussed in the previous meeting;
•
Agenda items a re ne;,,.-t in li ne. These may e ither be
reports of standing and/or special committees or
othe r to_pics e ither for information, for discussion
or for decision;
•
Financial statement report is
treasurer;
•
The last item in the "Order of Business" before
"Adjournment" is "Other Matters." These include
announcements or other items , vhich members
feel s h ould be s hared ¼'itl1 the rest of the group
but have ool been pa1·L of the agend a items;
•
"AdjoUTnment" is made after the group has
decided on tl1e date, place, and possibly, the
agenda of the next meeting, if these bave not been
previously made or agreed upon.
read by the
(b) Making it clearwhere the meeting s hould try to get to by
the e nd. The members should know if they are hoping
to make a clear decision or firm recommendation or
if they are only making a preliminary deliberatio n in
order to l1ave something to go away witll and think
about. T he cha irman can give the members a choice:
"If the group can come u.p with a cou r;:;e of action
now, that's fine. However, if it s h all be difficu lt to do
so, then we can set up a working group to study tl1e
problem and recom.mend possible solutions before
ou r next meeting."
(c) Making sure that all members understand the issue
and why they are d iscussing it. Sometimes the issu e
is obvious <:ir that the group may have been throu gh it
before . If not, t h en the chairperi;oo or someone who
knows the issue or has bee n previously briefed on it
can ex.plain t he fo)]oV'.ing: (1) some indication of th e
reason why the top ic is on the agenda; ( 2 ) the history
of tl1e items a nd its present s tatus; (3) wh at needs to
be establishe d, r esolved, or proposed; and (4) some
124
indication of Jines of inquiry o r co urses of action that
have been s uggested or explored, as we ll as a rgume nts
on both s i,des of th e jgsuc. Once a ll of these a rc clear,
the members can utilize a structnrc for th e discussion
of the item or problem, specially if it is goi.ng to be
long or complex.
(d) Using a logica l order for the discussio n of a problem
or an issue. This includes: (1) identifyi n g wha t seems
to be the trouble; (2) gathering ..in cl a nal.y .dng lbe
pertinent or re levant backgro und /facts in order
to d ete rmi ne how things stan d al lhe m o num t ; (3)
d iagnosing t he proble m based on estnblis hed facts ;
and, (4) choosing a course of action d e rived fro m a
numbe r or well th ought -out, col1ere11 t, and s ens ible
optio ns. I n following t h.is s .tr ucture , the cl1<1 irma11
should listen carefully in case m embers jump too far
ahead (e.g., star t suggestin g a course of a ction b e for e
th e grottp has ag1·eed on th e ca use/ s or th e p ,·oblem),
or sta rt re11eating poin ts that h ave bee n made t!arlier.
The chairman bas to end discussion of irrelevant
topics o r sterile areas (e.g., th e rights a n d wrongs of
pas t decis ion s or actions that 11re too late to chang e,
or distant possibilities that are t oo remote to affect
present aclions).
(a) Preventing m isunderstanding and confusion.
The chairman's r esponsibilicy on t his a s pect
can be done through: (1) s eeking clarifi cation
from the speaker if she does n ot follow a n
ar gument or understand a r efere nce; (2)
asking p eople for facts or e."q)erience that
perhaps influ ence their view but are not
know11 to others in th e meeting; and (3)
making a n interin1 summary t o help s o me
members who are getting out of th eir depth_
(b) Discussing a draft document. The group
shouldnever redraft the document during the
meeting. If th ere are fau lts in it. the member s
sbo\lld agree on what the faults are and the
c11airman should delegate so meone or a small
g roup to produce a new draft late r.
(c) T erminating the discu ssion ea.rly eno ugh.
Once the group has effectively reached an
agreement, t h e chairman should termi nate
the discuss ion on the item b e fore it goes
nowhere at all . The chairman should also
t e nninate t he d iscus s ion if: ( 1) th e members
need more time to think about the topic
and possibly d iscuss it with colleagues;
(2) the discussion has revealed that views
of people n ot present during t h e meeting
125
are vit:cil: (3) more information are n eeded
before fui-the1· progress can be mad e; (4) the
meeting, does not allow enou~h time to go
over the Lopic proper!>' or a<lequa Le l)'; (5) the
events ;1re l'hauging ::md like ly to modify or
clarify tl1e ba~is o f the decisio n quite ·soon;
or (6) it is h ecoming cle.:11· that tw o or three
or th e m e mbers can se ttle t h e ma tter or ll1e
a.J!'gument ou ts ide lhe m eeting w ithout taking
up the t ime o f the oth e rs.
(d) M11king a brie f and cle ar s u1nman1 of what
has been ag,-ecd upon. This ht:lp:-p~l th e item
on 1·e,.::twd and makes people reali-:e wha t was
achieved as a result of the discussion. lf the
summary involves :ciction by a memLer, h e
shm1ld h e asked to confir m his acceptance of
t h e task.
2)
Dealing ·with people. Th<.1 task of th e cha irman .as fadlitator
is to h elp Lbe gro u p proceed to attain the objectives of tbe
meetfog in the most effident m a nner possible. The following
are examples of skills necessary to achieve t his objective.
(a) Managing oneself for effective conunittee m eeting
process. I n 01·der to be effective ,viU1 ber l a sk, the first
person the cha irman has to deal with is herself. She
must lean1 to manage h e rse lf such tb at maximum
m c mhe r-inle r action is encouraged. She must b e
able to h a ndl e h er needs and feelings in o r der l o
be sensitive to Lhe needs, feelings, a nd thoughts
of m embers whit:11 affect U1e committee meeting
proces:-,. He1· clearest danger signal of yielding to t he
te mptation or indulg ing in a pleasurable inflation
of the ~go is he;_1ri1.1g heTself talk too much during a
meeting. Engaging members in a heated aq~un1ent
is tmother example of a behavior that reflects her
ina bility to o vercotne the n eed to impose her: will on
the gr oup.
The ch airm.an acts as the model of the group on such
aspects as punctuality and respect for members.
For examp'le, whe n the chainnan s tarts and ends
the m eeting on time, she emphasizes punctuality as
a virtue; sbe also shows the g rou p the impo1·tance
of respecting prompt rnember's allocation of time
for specific activities. l'vlem ber s who are punctual
in attending m eetings expect that their :rnhsequent
ac tivities du.a·ing th e day a r e not affected by a p1·evious
meeting which h as to end late because it started late.
(b) Focusi ng t he e nergy of the grou p on
group's goal/objectives. When members
126
t he
are
well-oriented t o t he fact that the objectives of
the meeling arc effectively 11chicvcd only through
group decis ion - making. th e clrnirman ca n elicit
t h e h elp o f m e mbers in <lcaling with certa i n ty pe s
of pro hl <' m part icipa nt s. JJ~· rocu sing the gro up's
attention o n its go als/objectives and n n h ow the
members are 11:;ng to a c hieve them, the ch ai rman
c.,11 e ncourage pnrti cip,rnt s lo u ca l ,vith specific
proble n, mem bers. Thcs,:, indmlc pcr> f>k, who talk loo
much a nd dumi n;.ilc th .: 111ccli11~. members who kl.' CP
b·rin gin)?. u p th.- !:Cam e JNint un!r ,rnd over ag.iin, thusc
who cnnsmanlly whisper to neigh bo rs and th ose who
s ta rt l a I king be.fore o the rs a rc finish ed. The dw irman
can bring g ro111> m embe rs to loo k nl th e cxpc rit:n cc
th ey arc goi ng thrnug h 11si11i; s 11ch II tcC'hni quc m:
sayin g. ··1f our ~0,1I is g m11p dl·<'is io n on ,_whnt can
you say nbo ut how we are r,, )ing through thc process
of nchi evi ng this g~)a)T '"' ith this inlt!rvc ntio n , t he
c h.iirm nn ca n e 1u:ou1·a ge m e mbers l o ,111aly'l.e t he ir
mv,1 p arl it'ipa t ion during the m ee ting. J\,Jcmbcn;
increasingl y bccoml! obscrv,111t ;m <l se n s iti,·c lo
pa rti cu lar bcli.wiors Llta l d 1.: lay or imped!! progre:;s of
a mee ting. Th l!) e ,·cnl11ally lcarn spcci fil' s kill s un how
to be "partne rs" in o rd er to achi eve t h e grot.q>'s goal.
without having to s pend so much time and ene rgy
putting up ,,"ith p roble m m e mbers.
(c) Helping th e group find " i n/win solutio n s . Quite
often, m eetings are used by group members as
hattlegrounds to fight for th eir ideas in ord er lo m eet
their socio-psyt· ho logicnl need s for statu s , prestige,
powe r , and the like. Tl1cy u cspc ratcly feel th e need
to ,,rin, no m.i ll e r· how much Lime 11r t:ncrgy the
group spend s lo put up wit h unnccessn ry de bate or
argume n L. To han d le such ~1 s ituation . th e clrnirman
must help the g roup attain a win/"in solu tion. This
strategy makes everyone feel t hat h e has won. The
grnup comes up with a solu tion that every member
con acce pt ,,i tbout feel ing that he is losi11g ,rn yt hins
important, or co mpromis ing any s trung conviction.
The chairpe rso n can help group m emb ers lis te n
earefuUy a nd analyze varying viewpoi nts in o rde r to
understnnd their underlyi ng assumptio ns . T he n, s he
can guide th em to look for ways t.o combi ne or m odify
these viewpoints in order to arrive ;it accep table
alte rnntives wiU1 objective and logica lly sound
foundations. Sh e, t herefore, encour~1ges the group to
always work towa rd turning objectio ns into positive
alternati ves.
By using the \\;n /win strategy, the chairperson uses
the meeting as a venue for helping members learn the
''how~ of parb1e rship. Group m e mbers ;1 re encouraged
to be open- m inded enough and unclerstnnd an
opposing viewpoint first b e fore evaluatin g it. They
127
►
fr . fro m squashing ideas a nd s uggestion
lel,rn to r; 1!~~ns to provide a supportive a tmospher:
T 1e grou b, ·s protect others fro m attack.
w here mem er
·
(d)
. g pnrtici pation . By establishing a positive
Encourogm .
portive a tmosphe re d u rin
'
non-threaterung, s up
g a
. .,. the ch nirperson hel ps m e m bers express
mect111~.
tl
l
tt 11
thcmsclv<'-" ei:;pcciolly
, c s_ lf, :1a irba y quiet
ones SJie can promote p arttc1pa tion y making
·
emhcrs re.ilize th at everyone has an eq ual
group 111
d.
t d"
oppor ttmity to be 1_,ear~ a n 1s pro tee e ,ro m l)Crso,,al
a ttnck. p ,11•t idpat 10o 1s also e n couraged whe n the
has a vital
group ,· -~~ 11113de ro feel th at
. each member
.
contribu tion to make which h e 1P~ all~n1 t 1le group's
go· rl ¼'h en each one feels 1hat he 1s a n important part
ofLl~e h'Tou p , th1: nu mber o f uninvolved m_e mhers are
minintized. Exa m ples o f t hese m e mber:- include the
cu rly lea ver who Ienves before the 1neeting ends; tbe
dropout \\'ho s its a t the back ?f thl: room, does7:1 •~ say
:rm t lring . a nd gets preoccup1ed with o ther a Ctivities
lik~ rcadi11g a boo k; a nd t he busybody w ho always
gets in and o ut of the m eeting, con stantly receiving
m essages, 1us bing out to take a p ho n e c all or deal
with a cris is.
SUMMARY
The chapter explicated partners h ip concepts a nd the participatory action
met11odology that e nhance t he nu rse practitione r's com pete nce and confidence to
J1urture, s uppo r t ;,nd sustnin the communi ty's desire a nd effort to assume o:wnership
of t he challenges t ha t create llcal th and hum a n care possibilities through cycles
of capability -bui luing towards comm u nity competence as the n u r se e ngages in
collaborative in terd isciplina ry o r interagency efforts, where needed.
REFERENCES
1.
Ashford LS and oth e rs. (2006). Designing the Programs to R each the
Poor. N,v: Population Reference Bureau.
2·
Cody VVK. (::?006). Values-basecf Practice a nd Evidence-based Car·e: Pursuing
Fu'.1dame1!tal Qucst1:011s in 7!ur-sing Philosophy and Theory, in J/11'.K" Cody, (Ed)
Plulosoplucal and 1'heorehcal Perspectiuesfor Advanced Nursing Practice,
s- 12. M:.issaclmselts: J o nes and Bar tlett Pu blishers.
Constantino-David K. c199 ) c .
.
.·
5 · ommumty organizing in the Philippines· The
expenence ofdevelopment NGOs · G Cr .
· .
Participation and Deuelon . t ' m
aig a nd M Mayo, (Eds) A Reader m
;-men , 1 5 4-167. London: Zed Books.
4 . Cox FM a nd o thers (1977) Ti .
Itasca : F .E. Peaco~k p b' 1. ·h acnes a nd Techniques of Community Practice.
u 1s ers, Inc.
3-
5.
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Egan G. (1977). You and li1e: Th e Sk'
Others. Monterey C:tliii
·
rl/s of Commu nicating and R elating to
•
orma: 8 rooks/Cole.
6.
Johnson OW and J ohnson FP. (i997). Joining togcth e l': G1·ot1p ·Theo,·y and
Group Skills (6th ed.) . Boston: Ally n a nd Bacon.
7.
J ohnson OV\7 and Johnson FP. (1975). Joi11ing Togeth er: Group Theoi;y a n d
Gr o up Skills. New J ersey: P rentice-HaJI, Inc.
8.
King VG a nd Gerwig NA. (1981). 1-lwnanizi11g Nursing Education:A Co,iflurmt
App1·oach Th rough G,-oup Process. Wakefield: Nursi ng Resources.
9. Kock T & Kralik D. (2006). Pa,·ricipntory Action Research in Health Ca re.
Q,-_-ford: Blackwell Publis hin g
'
10. Laverack G. (2001). An identffication and intcrpret-ario11 ofthe 0t·ga11izatio11al
aspects of community empowerment. Community Development .Jounw/. 36
(2), 134-145.
u. Maglaya AS. (Ed). (2004). Nrwsing Practice in tire Com m 1mit.y. Fourth Edition.
· M a tiki na City: Argonauta Corporation.
12.
Maglaya AS, d e las Llagas LA, Anch eta CA & 13elizario VY. (1.999). A family
fiealt/z e mpowerment intervention model towards J)re1Jen/-im, anrf con.h·ol
of malaria in the Philippines: the loca l gover11nre11t 1111it/ rttl"a/ hea lth
unit perspective. l'vlanilu: Dep arlmcnt of HcaJLh-Essential N a tional Health
Research.
13. M aglaya AS. ( 1988). Behauinral Catalysis: A Theory of Nursing lnte,·vention
ih Family Health Care. The ANPHI Pape1·s, 23 ( 2), 14 - 20.
14. Parse RR. (Ed). (1995) . Illuminations: T he Human Becoming Theory in
Pra ctice and Research. New York: National League for Nursing Press.
15. Polivka BJ . (1995). A Concepll.Lal Model for Community I11teragen cy
Collaboration. Image: Jou,-nal ofNursing Scholarship, 27(2), u.o-u5.
16. Ross M. (1967). Community Organization: Theor·y, Principles and Pr·actice.
(2nd Edition). N ew York: Harper and Row Publish ers.
17. World Bank. (2005). World Development Report 2006: Equity and
Development. Wash ington, DC: Wodd Bank , 5,142-143.
18. WHO E.xpert Committee. (1984). Technical Report Series No. 708.Education
a nd training ofnurse teadiers a nd managers wit·h spe.c ial r egard to primary
health cai·e. Geneva: World Health Organ ization .
19. World H ealth Organization. (1978) . Alma Ata 1978. Primary health care.
uH e althfor All" Sel'ie:s No. 1. Geneva: World H eal th Organizatio n .
129
Chapter 6
DEVELOPING
COMMUNITY
COMPETENCE THROUGH
THE WORK GROUP
APPROACH
Araceli S. Maglaya
INTRODUCTION
The concept of community as client can be difficult for the community health
nurse, especially whe n the emphasis of a community is a location in space and time of
aggregates or groups of people. Precisio n in explicating community as client-partn er is
attained when nursing practice is focused o n comn1u11ity competence, as both p rocess
and outcom e of integrating individual selves into function ing collectives. It is rooted
in social in teraction, where each participant in th e in teraction becomes p a rt o f lhe
other, learning not only h is or her own part but the part o.fthe oth er as it is experienced
or understood. Sustained social interaction results in increasing ly congruent mutual
perception among members as they d evelop a generalized conce pt o f tJ1e group or
community which shap es U1eir expectations and actions (Cottre ll & Mead, 1980).
Within this social interaction framework, t he community as clie nt-partner can deve.lop
or enhance its ability as constin.1ent pnrn to create ,md 1,1i;;e :1tnicturl;!s ~nd l?Chemes t.hat
allow it to address problems, issues and challenges related with its colJective life such
tha t its members can eKperience improved psychosocial adaptation, socioeconomic
productivity or better quality of life. Working with the community or iL'> aggregate
parts is facilitated when the nurse-partner understands the psychosocial processes in
the life o f community aggregates or groups as members go through a 'lived' experience
of interacting with each other in addressing proble ms, issues and challen ges as a
functioning unit.
This chapter discusses U1e concept and dimensions of community compet ence and how
the nurse catalyst-partner can work with the community as client-partner to develop,
enhance or sustain its ability to address issues or manage problems related to its
collective life, using the work group model as strategic approach to an e mpowerm e nt
tract. Stages of group develoJ)ment will he d escribed in order to understand the
behavior of the group as a funct.ioning unit. Specific interventions to facilitate group
growth towards the work group stage a r e included. The work group model can facilitate
the community's confidence and com.mitment to pursue empowerment challenges.
130
COMMUNITY COMPETENCE
In the last three decades, th e concept of commu nity competence has been u tilized
as bases for developing, implementing o r evaluating programs, projccls or strategies
within the global in itiative of ' health for a ll' through primary healU1 care. Cottrell
( 1 976, p. 197) refi ned Lhe concept and d escri bed a competent community as one in
wh ich its interdependent parts can: ( 1) collaborate effectively in identifying the
needs and p r oblems of th e community; (2) achieve a wo rking consensus on goals and
priorities; (3) agree on ways an d m ea ns to imp lement the agreed-upon goals; and (4 )
collaborate e ffectively in carrying out the actions. Cottrell describes eigh t essential
conditions that must exist to some degree in a community for it lo function effectively.
Stolte ( 1996, pp. 271-272) used Coltrell's concept as guide in explicating wellness
nursing diagnoses for communities. She describes Cott rcll's e igh t dimensions as: ( 1)
C0MM1TMENT- lndividua1s can see that the community has
impact o n their lives
and that w h atever affects it will affect them; they believe thul t hey have a significant
role in th e commu nity; and they see positive results from their community efforts; (2)
SELF-OTHER AWARENESS- Each communitycomp!me nt knows its iden tity and h ow
it relates to the o t her componen ts of the community; (3) ARTICULATENESS- Each
component o f the community can s la te/ fonnulatc Lts views, a t litudes :rnd in tentions in
relation to other components of th e community; (4) COMMUNICATION- Components
of the community can send messages/ transmit information as well as see how their
message or information will be recei ved or u n d erstood; (s) C0NFLICTC0NTAJNMENT
AND ACCOMMODATION- \~hen conflict exists, it is "kept in bou nds .. a nd efforts at
resolu tion continue s uch t bat interact;on among community g roups are s ustained
despite differences in opinions or perceptions; (6) PARTICIPATT0N- As components o f
the comm u n ity inte ract, they b ecome c.o mmittecl, define goals, and find ways to reach
those goals; (7) MANAGEMENT O F RELATI0NSWlTH THE I.ARGERS0CIETY-An y
commun ity is a part of a larger social system and m ust determin e how it fits within that
system. A competent community uti lizes the input/resources/supp ort from the larger
system while ;icting to reduce threats fro m Lha t system. When necessary, it stimulates
the cr eation a nd use of a ltemative or supplementary resources; (8) MACH !NERY FOR
FACILITATING PARTICJPANTINTERACTI0N AND DECISION MAKING- Co nstant
monitoring throu gh flexible a nd r esponsive formal/infor mal proced ures that facilitate
interaction/communicat ion for decision m aking.
,tn
THE WORK GROUP MODEL AS STRATEGIC APPROACH TO
COMMUNITY COMPETENCE
Comm unity competence as a process is rooted in social interaction to enhance better
options for a collective life. Community members relate with each other as aggregates
or groups to a ddress ·issues or problems, whicl1 can not be effectively done or sustained
otherwise. Within tMs operational framework, community health n u rsing practice is
facilitated when the work group model is utilized as a strategic approach to develop or
enhan ce the cornpetence of the community as client-partner.
·
Realities of p ractice challenge many community projects or activities when members
realize that the group undergoes dissolution before they can learn the uniqueness o f
group life as a natural phenomenon occurring in smnll group processes. Tbe n u rse
catalyst-partner can faci litate development of the competencies of t he gro up to work
together as a productive functioning unit, The empowering potential of the community
can be e m erged to transfor m isolated individuals into interaclional groups. Specific
interventions enhance t h e group's experiences through the s tages of group growth
till the wo1·k group stage, t he arena for optim um group productivity as a consequence
of enhanced rel atedness among group members while they experience affirmation of
131
each other·s con tribu tion to gro up output/goal and respect for each other's differences,
idiosyncrasies or uniqueness.
THE STAGES OF GROUP DEV ELOP M EN T
The Stage of Orientation
The two tasks confronting grou p members during the initial stage are: first, t h ey
must determine a way o f achie,;ng their primary tasks -lhe purpose for which they
join ed the group: second, th ey ruus t find a place for them selves in Lhc group, one that
wi.U not only p ro,;de t he comfort necessary to a tt ain their primary task. but ,vi.lJ also
result in additional gratitication from the pl easure of group m em bership. In achieving
these t"·o t asks. the group member's behaviora l patterns are basically attempts at
warding ofT anxiety. The main concern of the m e mbei-s is whether they are ujn" o r
"out - of the group. Th ey search for a role for themseh·es in the group, wondering if
they will be tiked and respected or ignored and rejt-x.:led. Tu ham.lie an~iety, they invest
most of their energy in a se.trcb for approval. acceptnnce, respect or d ontln ation.
Co nseq uently, the conte nt and the style of communication d uring the initial stage
are r elatively limited, repetitious a nd reslr.l ined. Lt is not surpris ing to observe that
during this st age members are c.:i reful with their choice of words becau se they are not
sure how th ey \,; 11 be taken by ot he rs in tbe ,zroup. Members may e ndlessly discuss
top ics of apparen t I~- little substa ntive in le rest to any of the participants; however, these
topics serve :is vd1.icles to explore h ow th c.y a r e p e rceived by co-members. With t hese
exploratory atte111pts, a member eventually discovers wJ10 responds favorably to him,
who sees th ings the way he does. wh om to fea r, and to resp ect. Gr a dually b e begins to
formulate a picture of the role h e will p lay fo the grou p.
Another common experience in the group is the search for similarities. Members try
l1ard to let others kn ow t hat they are sim ilar-with everyon e in the group. T rus experien ce
offers great supp ort to members and prnvides part of the foundation on which group
cohesiveness will eventually develop.
Givingandsceldngadviceisa.nothcrcharactcris t ic oftheear]ygroup.Members atte.mpt
to share some type of practical solution; however, this is rarely of any fu n ctional value
except as a ,,ehicle through ~vh ich n1embe:rs can engage i n social relationships in the
group.
Thus, the early group can he described as a groping, testing, reluctant group. It is also a
dependent one. The members e..,:pectth e leader to pi-ovide th e group v.it h structure and
answers. They "look to t h e leader for app rC>val and a cceptance. M embers demonstrate
b eha,ior which in th e past has gained approval from a utho rity. The leader's early
remarks are carefuJly anal)r.1ecl for guide)ines about desirable and undesira b le behavior .
Ma ny of the commen ts in th e gr oup are directed nt or through the leader. T he lines
of inter;iction w:ithin the gro up are leader-cent ered as illustrated in Figure 6 .1. The
arrows indicate that tbe li nes of interaction are from th e leader to the members. The
responses of the members are in turn directed back to the leader . Int eraction s among
members are rai-ely observed. Oftentimes the leader need s to .initiate the opportunities
so that members are encouraged to respond to others in the group.
132
1,e~er or Facilitator
Figure 6.1 Lines o f I nteraction wlthln group when leader -centered
The Stage of Conflict
This stage is characterized by the group·s concern over do mi n a nce . contTo l an d
power, Toe e.x perience on con nict is be hveen members o r b etween membe rs a nd th e
leader . Each member tries to establish for himself his prcft::rrcd am ount o f initiat ive
and power, and gradually a control hierarchy within the ~roup is establ ished.
Members become judgemental of others . Negative comments and inter-member
criticism b ecome m o r e frequent. M embers make su"estions o r gh·e t1dvice, n ot as a
manifestation of acceptance a n d understanding but as part of their attempts to establish
their places in the control hierarchy wi thin the group.
The struggle for control is p art of the dyn amics of every group; it is always present.
sometimes too tranquil to be recognized, at o th er times s uppressed, and a l some other
time m a y become a full blown eiq>ression akin to a blazing fire.
The emergen ce of hostility toward the leader is a n ineYitable occurren ce in the life
sequence of the group. Wbile host ility toward t he leade r may be prese n t even as early as
stage one, h ostility toward the leader b ecomes more ob,-ious in sta~c two . T ho.: sources
of hostility toward the l e ader become clear wh e n we recall Lhe m embe rs· perceptions
of the lead er in stage one. TI1e m e mbe rs ' e xpect ations of h im a.-; a powerful being are
so limitless that regardless of11is competence, he will d isa ppoint th em. Grad ually. as
the recognition of his limitations becomes obvious, members st.art tn fct•l di,rn ppointed
about his behavior. By no means is this a cl early couscious process. The members may
intellectually a d vocate demo<.-ratic group which draws on its own res ources. However,
they may on a deeper level wjsh fo r dependency and a tte mpt first to create a nd then
to destroy an authori ty figure. The leader r efus es to fill t he traditio na l authority role:
he d oes not lead in the ordinary m anner; he d oes n ot p ro,idc ans wers and so lutions;
he urges the group to explore a nd to mobilize its o wn resources. The m embers' wish
lingers howevel" and it is usu~y only after se,·eral sessions ·tbat the group comes to
133
realize t h ey nre wish in g for n n ·'old lime'' le ade r .
Anol11e r s ource o f rese n bnen t towa rd th e leader s te m s from th e g ra d ual recog n ition
by eacb m emher th a t h e wi ll n ot b e th e leader's favorite "group m e mbe r " . H e b e gi n s to
reali1.e tha l lJte leader i.s no more int e rested in him th o n in the olhers . This leads t o th e
emergence o f rivalro us . h os tile feelings toward the other m e m b e rs .
To ove rcome tb e anxiety that l11c m e m b e rs experie n ce a t th is s t age, c o u nte r - d e p e nden t
exp ressions (fight) begin to rep lace th e o ve r -depe nde ncy s ta ge. T h e group m ay b e
clivid eJ into co m pe ti ng g roups - ench s ubgrou p is unnb le to give up power . Vvitb ou t
prope r inle n ·ent ion. this may le ad to a grou p that moves rapidly to w ard eJ1.- tinctio n ,
wh ere th er e is spli ntering. i11 lo lwu u r three s ub groups. :Mo re ovt?r_. drop o ut ra te is high
at this poi n t as grou p m c.mbe.i:s Lh nt a re n o t comm itted to eit h e r subgro u p a tte m p t t o
h and le a nd ceSl)lve their contlic l by leaving the grou p .
W ith the necess.ti:· in te rve n tions employed. lhe g ro up can b e help ed to r e s olve the
issu es o n d cpendc.nce (s tage o n e) a n d a u thority (s ta ge two). New values and b eh avioral
p a tterns e merge ou t of t he e mot ional expe rie n ces of s ta ges one and tw o . The g r o up
mem be_rs b egin to ..1ccepl Ule ir full s hare o f t h e r espon sibility for w h a l h a p p e ns in t h e
g ro up . T he gr ou p begi ns t o ex pe rie n ce i n d epe n dence as it goes th rough th e la st two
stages o f intimacy and i11terdepe nd eo ce..
The Stage of Cohesiveness
Fo llowing the previo us p eriod of confl ict, t he gr o u p g r ad ua lly d eve lops in to a cohesive
un it. Duri ng this st age , lhere is a n increase o f m orale a n d m u tu a l tn.Jst a s m e mbe rs
feel g rou p belo ngingness. Co nsequently . members are \,,1ling lo s hare m o r e a b o u t
themselves lo oth ers in Lhe grou p . There is inte nsifi cation o f p e rs o n a l in volvem e n t , a
growi ng awa ren ess an d mutu a l recogn it io n o f tbe s igni fi cance of t he g roup experie n ce
in ter ms of perso na lity growth and ch a n ge. Th e chief concern o f t h e g r o u p is with
intimacy an d closeness . ,\n.xieties h a ve to d o w ith not b ei n g liked o r clo se e n ough t o
people, or with being too inti.male.
Although m em bers experience a gr eater freedom to ta lk abou t themselve..5, t h ere m ay
be co m mu n ica tion restrictions of s om e lcind : often l he gro up s uppresses aJl exp ressio n
of n ega tive feelings in o rder to m ai n t ain a h a rm o n io us at m o~phc rc . T h e m e mbe rs ,
in a sense unite ::tga ins t th e world. wi lh much inte r -m em ber supp ort, mu c h p ride in
the group. an d much co nde m na tio n of th e me mber's ~en emies" <Juts id c t h e ~ r o up .
Eventually . howen!r , the ~rou r·s coh esive n ess o r feelings o f unity ,.,rill seem ri t ua lis ti c
unless tl1e hosti li ty in the g ro up is permi tted to d evelop. OnJy wh e n a ll feeli n gs ca n
be expressed an d const n 1cti-ve ly wo r ked thro ugh in a co h esive g ro u p d oes th e g r ou p
become a mature wo rk group.
The Work Group Stage
During t his !ttage, th e u n iqu en ess o f th e membe rs a nd th e leaders are s e e n and
expect ed. Me m bers ca n accept one ano t he r "s d iffe re nces \...-ith o ut associating ·'good n
a n d Jbad • \\-it h Lhe di ffere nces. They become aware o f t he ir o wn in vo lve m e n t, and o f t h e
othe r aspects of gro up p m ccss , withou t bei n g ovc rv,il1 el mcd o r Ala rm e d_ Co nfl ic t e xis ts
bu t th ese a re o n s11bsta n tive issues rather t han e m o tio n al on es . Con s e n s u s is r e a c hed
from a ratio n al d i:-<·11s .,io n ra t h er tha n Crom a com p uls i\'C att e mpt nr 11 mrn im ity. The
gro u p becom e..'- a feed b ack \'Chicle wher e m embers ca n clarify a nd evalu a te e a ch
oth er's pe rceptio ns ~in d th e grou p p r ocess. There emerges a grou p sy~-cem fo r m u tu al
support for indh; d uality; and, wh ere n eed e d , the.re d evelo ps in the gro up, co nsistent
134
control when individu a l. behavior b ecom es grou p -destru ctive. F rom a sense of group
identi ty comes a sen se of individual identity.
TI1e state of t h e mature wo r k grou p may l'ast for the r em ai nd er of the g roup's life, with
periodic short-lived repetitions of earlier s tages. During t he stage of adva nced work
group o·r true tea mwo rk, th e tension is between "workr or progress, and regression t o
a n earlier s tage.
The nursing inte rve ntions, tasks, and techniques can h elp minimize t he group 's
tendencies for regression a t an earlier stage, or these can h elp minimize the eff~ts of
regression on group m embers or on the group process.
The Termination Stage
After being together and working on sp ecified "tasks·~, m embers of groups experience
a sense o[ en ding. Sometim es this can be temporary as when a particular session or
meeting ends. At oth er times this can be a permanent one, when the group's reason for
being ends, a s when a p roject or program h as been acco mplished. According to Dunphy
(1965, pp. 384-399), tl,e tasks of the group at th is stage may include: fi nishing the
agend a , es tnblis hing key decisions and completing the grou p product, tying up loose
ends and wr iting oft unfinished b usiness. The k ey emotions a re joy and sadness. The
group celebrates for t he work and achlevements done. However, there is emotional
coping \.vitb th e loss o f valued personal relationships. There is a joking, laughing, ritual
(parties, graduation, etc.) and expression of sorrow or withdrawal_
The Various Stages at W ork
Although the s tages can be described as such, the developme ntal sequence shoul d not
h e t aken li terall y. The stages are rarely demarcated. There is considerable overlapping
of the bounda ries bcnveen them. The group may go thro ugh th e various stages i n one
sessio n. 1t may. howeve r , CJrperience the manifestations of on e stage quit e domin ant in
o n e session a n d t hose of lhe next st age in a s ubsequent session . It is to be made clear
also th at rnrely does the group pemrnnently graduate from one stage. In describing
gro up formation o r group growth, Wilfo1m Sch utz ( 1965, pp. 123- 135), uses the a nalogy
o f tighlenlng the behs of th e wh eel one a fter another just enough so that the wh eel is
in p lace; th e n the process is repeate d, each bolt tightened in turn until the wheel is
e nt-ire ly secure. In a s imilar fashion., the stages of a grou p emerge, become dominant,
a nd th e n reced e, only to have th e group return again late r to dea l ,vit h the same issues,
conce rns and problems wi th grea ter tJ1oroughness. The group returns to the same
issues bu t each time from a d ifferent perspective and each ti me in greater depth. The
natu re a n<l extent of the g roup's expression of interpersonal issues, conflicts, needs,
a nd problems depend u pon the d egree of cohesiveness existing in the group during the
initi a l s t age of its formatio n . A group whose m e mbers had worked effectively together
on some activi ty sometime in the past, may ex-perience mo re depth in d ealing with
in terpe rsonal concerns and proble m s tlian a gro up whose m em bers are meeting only
for t h e firs t time t o do teamwork on a tas·k or p roject .
INTERVENTIONS TO FACILITATE GROUP GROWTH
The d iscussion on the stages of group forma tion provides a means for understanding
th e dynamic processes tha t go on in groups. It can h elp the nurse identify whe re
the group is, to predict in wh at direction it might move, and to identify the assets
within the g roup th at might be utilized or m ax:imi.z ed. The interventions, tasks, and
techniques that shall be discussed in the following subsections are all directed towards
135
developing a nd maintainu,g work groups. These interventions, tasks and tech niques
can help group members to handle t he psychological processes - the interplay o f valied
p ersonalities, feelings, needs and concerns -that b ri ng about anxi e ty or discomfort.
To facilitate cbanp.e nnd growth in the group, Lhe amdet y lhat everyone ex-perieaces in
various degrees shou Id b e kept tu a level that e nhances rational nnd effective decisions
and actions. The individuals must feel the rewards for working Logether ra ther than
h aving to resort to a,·oidance of the discomfort (that the anxiety b rings) by leaving
the group, being p assive members of the group or being overwhelmingly aggressive to
other members.
Tbe n ursing in lerventions, tasks and techniques e m p h asize U-1e impo rtance of
working on feelingi;, ne eds and communication. Since mos t acts of problem-solving
in social spheres a rc acts of commu n ication , helpillg community members handle
the psyd1ulogical processes as e:...1>erienced in t he gToup can enhance or strengthen
their capabilities for l!ffecli\'e prubJem-solvi ng. As group gro"vth r eaches tl1e s tage of
independence, thccnpability ofth egroup for p roblem-solving increa:;t!s. As t he pers onal
relations am ong group members change from depe11dency to conflict, t o cohesion, and
eventuaJJy to interdep endence, the resources of the group improve such tha t more data
are available t o help t h e g roup go througll effec tive problem- solvin g. The group has
easy access to tJ1e necessary ideas, tools a n d materials needed for rationaJ decisionmaking, effective im p lementation a n d eva1 uation of activities, pi-ejects and p rograms.
fnlaf:ventioAs, ta5ks, and techniques lr.i.ctude the .folk>wTngi
'·
' .
ma ne'8SSary orientation, str,ucture and directions.
' .
eet'i'nemberS' Interpersonal needs.
tfa~ and re,olve conflicts to evervonits s~tfsf~cti,o n.
,
i:He effects 9f own behavk>r,on the group: .use the se-:ff for' group
to apply learning on another situation
Provide the Necessary Orientation, Structure and Direction
During the stage of orientation and dependence, the level of anxiety can be decreased
by h elping provide the necessary orientation, structure and direction to the group.
Jn instances wl1en th e g.-oup me mbers do not know each other, tl,e preliminai-ies of
intro duction s sho uld b e made . There is a great positive impact on group members if
they got intrnduced by the leader or facilitator. They can also be encourage~ to get to
know one nnoth er b y making them introduce a co-member. T h e time to interview comembers should be provided in this instance. Opportunities to clarify or elu cidate on
the goals an d purposes of U1e·gro11 p, the expectations and perceptions of eve1y members
as regards role$ a.nd respons ihililics should b e max imized . Certain s tructured l ea rning
exercises o o grou p decision-making and consensus may be utilized to h e lp gro up
members experience p e rforn1ing the various t:.tslc and group-buiJding or maintenance
functions necessary for effective g r·oup work . These exercises also provide opportunities
to rele.a se, tJ1rough a game, t h e energy generated by anxiety. Moreover, tbe dependence
that is aggraw1ted b y certain socio-cultural tendencies to b e submissive a.ad author ityoriented ca n be minimized early in the group's e xperience. Tbe lines of in teraction can
be changed ma rkedly from th e leader - cente red to group-cen t ered (see Figure 6.2), as
members learn how to corumunicate effectively and participate actively in discussions
and group work.
136
teader or Facilitat o r
/ 0,
CT' ~~~D
. 'O,.,,..
/
Figu re 6. 2 lin es of Interactio n within a group when group centered
The facilitator or leader creates an ,1tmospheNi for productive group work when
members' interpersonal n eeds are m et t o a satisfactory d egree for each one. Meeting
these interpersona l needs may be initiated by th e leader. ln time, members learn to
initiate his modeling beha\>ior and they, eventually h elp meet the interpersonal needs
of co- m embers.
H elping group mem bers meet their interpersonal needs to belong and to b e a part of
the group can be em:ouragetl by acknowledging the im portance oftheir prnsence in the
gToup an d contributions they m ake. The leader should communicate the message tl1at
each on e is importa nt in the achievement of group goals.
During ex-periences of he ightened level of anxiety, the mentbers concerned. should. be
provided ·with the n ecessa111 emotional support by acknowledging the discomfort being
experienced, and by eliminating or minimizing the sources of anx1ety o r its effects. The
leader m ay avoid maki n g dema n ds 1mtil group an1dety has ab:ited.
Members "open up " when Chey feel secure in expressing iliei r attitudes a nd ideas;
when they know they won·t be ignored, ridiculed , criticized or otherwise embarrassed
b y the other g roup m embers. The Jeader ·s tasks and techniques (,Johnson and Johnson
1975, p. 283) may include: 1) liste ning allenl ively lo whal each is saying; 2 ) not judging
the contributions of memb ers or commenting on every cnnt rihution m ade; 3) doing
away with preaching, teach ing, or moralizing; and 4) avoiding forcing members into
participation befo1·e t hey a1·e ready.
The leader can encourage productive p a rticipation (Joh nson and Johnson 1975, p.
283) by: 1) observing for signs of a member's e fforts lo be hea rcl a nti giving her an
opportu nity to contribute; 2) being sensitive in identifying Lhose too eager to talk as
they can take up all the group's time; 3) e ncou raging and s upporting all members who
participate; 4) summarizing a n d cla rifying the co ntributio ns; and 5) not monopol izing
the discussion or commenting too frequ ently. He s hould show enthusiasm for U1e
discu ssion aod a sincei'e interest in the gr oup m embers.
In a discussion group, there are eiiperi.ences when a member obstructs the functioning
137
-
l)f Lhe gro up. And qu ite frequen tly, t he 0 U1er group me mbe rs are n ot ab le to solve
th e p roblem cons truct ively ; they eith e r s u p port t he obs t.n1c lur o r re j ect him - b otb of
w hich arc unde:-irnblc . The lea d er m ay have to in te rve n e if Lhe con fli c t s il u utio n is to
be himdled productively.
Process, Negotiate and Resol ve Conflict s to M ember 's Sa tisfaction
111c d)11a m ism ch aracter istic of the wo rk g ro u p is m a in t ain e d if t h e h ostili ty a n d
con nicl in U1e gru up ore pt:nniltcd lo d e\'C:?lo p . Howeve r, stab ility , in Lhe fa ce of
turbule nce. cannot be s us ta ined 11nlcss g r o 11p rn.c mben; have th e necessary attitu d e
towa rds co nfli cts a nd t he com pett-nc ies necessary to ha nd le o r m a na ge Lhem. Specifi c
inte.rvt>ntio ns focus on developing t he m e m ber·s competenc ies t o h a ndle confli ct
cvnslrut:tively:
• Help members underst.Jnd the nature of conflicts
• Help members so through the coping process of conflict resolution using t he
problem-solving approach.
• Help members pnerate new ways of looking at the sit uation or problem.
• Help members analyze the here-and-now experien ce.
1.
U nderstanding tl1e Nature of Conflic t s . Gr oup m em.be rs Jear11 to develop
a positive atUtude towaid conflict whe n they r e alize that it h a s t h e foll o vvi.n p;
char ac teristics :
a.
I t is a nat ural part of any re latio n ship and of an y gro up. It i s in evi ta b le
in a proble m-solv ing grou p p rimarily b ecause p er son s d iffer from
each oth er i n m a ny ways -needs, moti ves, i nterest s , ideas, and
perspectives .
b.
Conflict is d esi.rable and e,,._ tre rnely va lua b le for several 1·e aso 11s,
acco rdin g to Johnso n a nd J ohnso n ( 1975 , pp. 14 8 - 153):
•
It encourages inqu iry, pro m otes objectivity a nd s h a rpe n s a n a lys is
since it provides fo r a g reater dive rs ity of opiniu 11s , in l e 1·esls,
v;ilues, a nd ide as a m o ng gr o up m e mbe rs . T h us when conflict is
ha ndled constructiv ely , Lh e group is ab le to come up wi t h c r e a tiv e
and h igh -q uality decis ions aod sol utfons.
,
138
•
Conflict s tim ulates in t e rest a n d curiosity, a n d i nc reas es tJ1e
m otiva tion and e nergy of g ro up me mbers . T h ese, in t urn,
e nco11ra~e acti ve iuvolve m e n1 a nd commitme nt o f m e mbe rs to
gro up functioning .
•
It can greatly reduce t he na t u ra l tensio n a n d fru stratio n o f
wor kin g togethe r. Co n tl ict a llo v,rs for th e expressio n o f e m otions
s uch a.c; indign at io n a n d a ng er t hat wou ld i nterfe r e w i lh g r oup
wo rk if s uppresse d. Feeli ngs tJiat an: un n:so lved nfl d .;ire n o t dea lt
with make for b iased, non-ohjcctiv c judge m e n ts an d a ct ions . They
affecl the m embers' pe,rceptiu 11 o f cvc11 ts a11d i11 for111a t io n. T hey
lead to dis torti o n o f oth er·s id eas o r mi.sin tc rprc t.nio n o f their
actions. T h us. if membe rs with dra w from conrlict s . re ln1io ns h ips
wi th in the gro up b ecome so fragil e 1h a t mcmhc rs cr1nn o t s to n d t h e
s tra in o f prolo n ged d iffe ren ces.
c.
•
Members d erive r>e rso na l benefil.s fro m lhe experience of confl ic t.
An indiv id ua l in th e gro up is pr ovided a n opportu nity lo nchicvc
gre<1tcr sclf-11 nd erst:1nd ing :is a result of working thrnugh a
co nfl ict with co-m cmhc rs. HavinJ?, to tal k abou t his position anrl
th ink more c:ire fil lly about how smm d itis often ge nerates greater
awaren ess o f va lues a nd iden ti ty. Conflict ;:illows th e individual to
test u □d assess h imself an<l experience the pleasure of using full y
and actively his capabili ties.
•
Con flicts b r-i ng inforrna ti nn to members about where th ey 11 re,
wh at is important to each of th em , h ow the group work can be
m a <le effective, and how thei r rehllionshi ps ca n be imprvve<l.
•
Wh en the confli ct is h andled as it is being experienced by me m bers
in the her e-an d-now, a rgu m ents nre kept u p-le>-date . This h elps
group members avoid being bothe red by th e past, whic h they
cannot ch,mge. J\1eru ber s who ;;irguc regula rl y and constructively
need not carry a load full of grievances. All past d iffere n ces or
d isagreemen ts lwve be:en deal t witb so tllat members do no l
constrain working toget her an d a ppreciating one anothe r in the
present.
Any conl"lict can b e b and ied cons tructively by the group when the following
asp ects are considered :
•
Me mbers s h ould develop specific gro up nonm; o r rules to c rea t e
an atmosph ere co nducive to h ealthy rnanaS?;ement of con fl icts.
E,xamples of such gr o uJ) no r ms o r ru les are: l11e cou.J1icl should
be over iss ues and not hctwecn perso ns; m embers who disagree
with other s ruus t unde rstan d both the positio ns ancl t h e frame of
1·eference of their opponents; t he situational power (e.g., being
more verbal, havin g a louder voice are h aving m o re power)
sh ould be balanced :;uch tha t negotiations are con dltcled between
"equals".
•
2.
Conflicts a re managed effectively byencouragin g grou p cooperation
and by using the p rob lem-solving approach. The h asic s teps of th is
approach a.re d iscussed in t he nex1: sub-section.
Conflict Resolution Th.rough the Problem-Solvin g Approach. A
con flict can be a nalyzed, negotiated, an d resolved utilizing the prob lemsolving app roach. Tl.le bnsic steps (J ohnson nnd ,Johnson 1.975, pp. 182- 269)
o f th is appro ach ru·e: a) clarify the b;,isic rules; b) diagnose the causes of the
confl.i cts: c) explo 1·e ways to settl e the con0icls; d) decide upun mid impleme nt
a n agreemeul that is satisfactory to all members; c) eval uate t he success of tl1e
;iction /s taken .
a.
Clarify t he h asic is..c;ues. The o pposing viewp oints m ust be dear to every
mem ber of the grou p. I Ll o rder to do th is , each member wis hing t o express
an opposing viewpoin t m ust first have an accn rarc person::i l unders tanding
of bis own needs, goals. position s an <l prop osals. Once this is done,
the m ember can be helped to com muni cat e accu rately the unde rlying
assumptions and fra me of reference of h is viewp oint. This p r omotes
1 39
►
C'larity. predicwhili ty. a nd m u t ual u n d e rstandin g of posiUoo s, feelings,
and frame o f refere nces. Consc4111mtly. th e g rou p is a ble to ide ntify the
opposing viewpoi nts of co ul cove rs ies.
b.
Diagnose t he tlimensio n ~md Ctlllses of conflict. The object ive h ere is to
define t he na t·ure a nd m.ig ni t m.lc of l he forces that bring about the conflict
a nd forces t hut mi11imize th e c011flicl. These fo rces m ay be cognitive o r
intellectual in nature as wh en fl1e cu nfli cl is u,·er s ubstantive issues. These
include r.J iffere nt"es in in fornrn t.ion. heliefs, o pinio n s, assuniplions, and
ideas. Forces mny also be p ~·yclmlogieal c,i· e m o tional in 11a tu 1·e such as
interperso naJ lllc!Cds. m otives o r feelings. Once t hese forces are listed , the
group is ready to take the n e'-"t step i11 the problem-soh ; ng a p p roach .
c.
Explore wnys to :-et t ic the cortflict . Ther e a i-e fou r sleps to settle t h e confli ct.
First. is e limina te o r reduce the furces t h nt bri ng nhout the conflict and/
or s tre ngth cn/ inrrease the forces t hat m inimize th e co nflict. Second, is
to in teg ra te posi ti ons or ideas \hat are s i111ih11· s u ch a s t h e di me nsion or
magnitude of the conflict is r ed11ceJ . The thir d step is t o h e lp t h e members
anal~?.e if the opposing v iews can b i:! taken by the g ro up as its decision.
If t he group is constrai ned lo t a ke only o ne viewpoint, the members can
b e h elped to go thTo ugh th e n ext c.o mponen t o f the problem-solving
app roach .
d.
Decide upon and imple ment an agreemenl sat.isf»clory of the group. 111e
oppnsi.ng viewpoi nts ca n be lis ted. t ogethe r with the pos i1 ive a n d n egative
aspects of eoch. in :1s fo.r as Lhe g ro up·s goals a nd tasks a r e con cerned . Then,
ide ntify the resoun.:c:, needed Lo UtrTy o ut and impleme n t the a lternatives
to operatio na lize ench viC'wpo in t. Evaluate how realistic th e alternatives
ar e and the pr obabilities o f s uccess a_gainst t he cost o fi mp le menta t io n . Try
to anti<.:i pate all the blocks to i mple m cn tation a n d how th e g ro up members
w;IJ ha nd le the m . Once tl1 cse. a n:: all ide ntified, the group can n ow decide
whi ch ~;ewpoin t Lo La ke based on mini.mum resources that s hall g ive the
max im um ben efits to th e. group. \-vhe n n de cis ifJ n is m a d e, tJ1e group can
put the ideas and activit ies into a time sequence w ith lbe specifi c dates for
uctiv iliei, \o Qr,;r,;w ·, Iviembers c;an be given specific ass ignments in order to
imp leme nt t h e agree m e nt.
e.
Eva luate the su ccess of th e net io ns ta ken. J n o rde r th at the gro up learns to
be dyna mic in pursuinv. its goals, it h as to learn to evaluate tJ,e s u ccess o f
its aclions s uch th al J)wvisions for .replanning a re a d e(l u ately cons idere d.
Jf th e rl1·cision to t1-1ke A pa r ti c ular viewpoint as its cou rse of a c tion does
not provP. s uccessfuJ, th eJ1 the gro u p Cfl n be nrnde to realize tl1 e b ene fits of
going t h rough th e problem-solvfog a pproach on a n oth e r viewpuinl. Tb.is
cyclic process is done unti l the g roup is able to find the b est sol u t ion to its
conflicts .
Alth ough connicts resolution is outli ned as such, tbe group d oes not
necessa rily h ave t o go t hrough all the s te ps b e fo re it ca n co m e up ·with a
consensus. The step s nre <mLlincc.1 in t his man.nc 1· so Lhat group members
are gu ided uD h ow lo arrive at· a co nsem,us. The group m ay be able to co me
u p with n consens us without ncr.cssn r ily going Lhrough all tl1e s te p s . In
m a ny insta nces grnup membe rs learn to g ive up th e ir i<leas in favor of a
brigh ter) more c realive a nd w or ka ble pro posal by a nolher member once
tl1crc is muh1a l unders ta n d ing 11nc.l rrcdi ctahili ty of ass umpt ions, frames
140
of refer ences, positions, and feelings.
I n utilizing t h e problem-solving str atet,,y for confl ict resolu tion, other
interventions, tasks, on d tech 11Jiques cnn be employed to maximize the
group's capabili Lies to define ,tnd a nal:n,e the ea uses of the conflict a n d
d evelop ;:ilte n n1t iv1c:s Lo solve Lhe problem. These interventions, tasks, and
techniques are p rese nte d in the follow ing suhseclions.
3.
Generating New \Nays of Looking at the Situation or Problem.
Du ring experiences o f conni ct amrn1g group members, a feel ing of frustration,
tension, and discomfo r t can result from th e gronp':-; failure to produce an
adequate a lte rnat ive to r e.-;olve the conrlid . Qui le often, memhers feel the need
to w ithdraw from the issue. As part o f the group's defe nse mecha nism to attain
cqlLilibrium during such a st1Jrmy stage, me mbers may d.rop off the issue,
consc io usly or un cons ciously hopin g Lhat some form of quiescenc:e can be a
good reso lution of th e co nflict. In li te absen ce of t he better al ternative, such a
coping m echanis m may be often resorted tr., hy Lbe gro up. This c._rn eventually
lead to a permanent incapability of the group lo h andle .ind r esolve co nflicts
to everyone's saLisfoct ion. T he r elationshir, among group 1111;:mbers r e m ain
superficia l as expenses revolve on ly around routine or proced ural concerns/
prnblems. Gr o u p member's enthusias m and co mm itment may eventually
become a ffected because the };roup bas lost the very reason for its vitality -its
capability for dy nam is m.
During s uch expe1-ie nces on fmstrations and de<1d ends brought about by the
group's incapability to handle conflicts, the nu rse as a facilitator of group
growth, can help t h e mem bers look at th e situation/s or data from various
perspectives such tha Lnew o ri entations and insights can be derived from them.
The facilita tor ca n c.n co11rage group members to have avai lable diverse ideas
tl1at can be flexibly p ut together in to new and varied patter ns. This m ay require
changin g perce ptions. finding new ways of looking at things and changing ideas
and conrepts that membcrs h a ve t·cl igiou5ly a dhe red Lo in the pa$1:. Threat a.nd
excessiv e te msion i.:an res ult from u ccepting the challenge of questioning the
ideas and beliefs firm ly based upon how w e linvc n icognized. clarified, defined,
la be.led a nd analyzed e:q)criences in the past. T hreatsbrin?,about defensiveness
and redui.;e bo th tolerance toward tllnl1iguity and receptiveness l o tbe new
and unfomiliar. Too mu ch tension 1ea<ls stereotyping of t·hought process es. In
order lo h elp group members break away from thinking tradition and accept
1.h e challc.11ge of ch anging perceptions and providing new ways of looking at
experie nces on confli ct, t h e facilitat or need to develop conditions tha t aJlow
concerns, issues, and problem s to be reform ul ated. During group discussion,
the a t mosphe re must be such thnt m em b e.r s a re given tll°e freedom and support
t o h ave the self-confidence needed to enle1t a in ant.l express novel ideas (that
m ay initially seem wild ,me] implaus ible) without being afrait.l of cens u re. They
should b e given the freedom to question initial assumptions or the framework
with in whic h the problem occurs- Each group member also needs to become
sufficiently detach ed from her original viewpoint to be able to sec the problem
from n ew p erspectives. To help group m embers gel detached from ideas and
viev,i,oints and analyze/resolve conilkls lhal act as psyd1ological barriers to
productive group d iscussion, the fo,llowing are some practical teclmiques that
can be ut-ilized :
a. Mo re often members react t o and e:q)erience conflict with persons (com embcrs), not necessarily b ecause of their ideas, beliefs, or concepts.
Con.flicls can be minimized b y helping m embers isolate/separate the
L
141
1,r rd1·rr·rlt'I" ,, ,,,,,,jIi,111,. :111d f1:r• liIIK,I;,
I11 11! 11 i,.I 11g t fir• pr olllt•111•<:<Jl\' i11r. ,;t r:111•;,r for cnn rli"I rP">11l11li<>n. ot he r
i11l1· rvr•11 1iu11 'i. la,.b•. a11rl l1·• lrn i'(IW~ 1·;111 hf' r•m pl,,v,,d lo ma ximize lhr~
1•,rr,11p',; 1·11p:il 11lilw· 111 tlf'f1111· an d ;111: liy 1 1• 1111' rnn~, .., of the rrmflict an<l
11<-v,•lop 11 lt1•n i;1 I 1..-1 ·•, , , , '>olv,· 1111' pmbl1•111 'I la•<,•• 1ntcn;cntinns. tasks. and
1,•c·l111iq111•:. .irr• 111'"·•·11 11'<1 in 1h1° t,, IJ n1°,irn: •,11li•,te<"l iirn s.
G c 1wrn1i11J: N c.: w \o\l;ry~ of J,1111ldng :i i t lw Si t uatio n "r Pro b le m .
1)11 ri11J~c•:p<'ri, 111·,• <; r, f 1'011l lirt .1111011;~ ,~m11p nll'rn h•·r,. :, fc·clinr, nf fnr , lrntion,
1c 11, i1111. :111d <lh1·11111f1J1i ca n 11",1111 frr11n rlw ~r1 ,•, 1p\ f.11iun l" rr<1duce an
:u lv q 11:it1 · 11l1, •r11:rl 1'1° ' " ll" ,,Iv, llr•• , ..,11rlH'l. l,)111:i: 1;ftf'n 111r·rnb1·rs foci 1hr. need
to \d I hd r:11\ t n,111 t 111• 11,~111·. 1\ !i p;1 rl , ,r IIii· ;;11 ,up·:, di·f•·w,c tnN:ha ni.~m t<, :itt:iin
eq11dihri11111 d 11ri111'. -;111·h :r ~11,rm,· ·<tai;,- rn1•mlwr•, m.i} drnp off thE: issue.
,....,mw i1111°, ly 111 1111c:tJ11~1·i1111sly liopi11,: t li;il " Jm 1· form 1J( qui1-<.rcncc r a n be a
w;11d n.:.-.ol11li11n n fllw c1,nll 1l'l. In th•· r,b, ,·nr·r· nft hc lw tt1•r;1ltcma1iv 1 •. ~uch a
copin~ 1111·t·ha11i.,111 111ay Ill' 11fl,, 11 n·sorlr·d l•111, th•· f.r'"U f' Th i-. ran r·•.c,n u 1a lly
lend 111 a p•Tll l,1111·111 rnc·:,pahilit ), "' the· ~r()llJl tr, ha11 Jlr· iinrl rr,-;olve <'nnflicts
w 1·vcry1t11••·<; ~.,1 1,;l:,i·tirn1. The r('la1i,, n,l11r amon~ group mcmbf.lr~ remai n
s 11rwrtir-i,d a:i c,1w11,,-, n",'lh:1• ()11 ly :,round rr,u t im· , ir prr.,1.cdural <:fJncems/
prohl1·111,.. C:rnup 1m·111lil,r \ crllhus i,1.sm anti cnmmitmcnt may eventuolly
bc-crirn t• nffcttl'd h1'l'fl\l~C the l!,rr,up IHI '-' l,.,.,t tlw Vf'r) n,a.,;rm for its ,;wJity •ilS
capal,ilr1,· frir ch namr,-111.
0
Du rin}I " 11d1 1•~r•·ri,-ncc•<; o n fni" trntiorH, nnd dend ends brough t about by the
grw11p·, 1111.:q1,1biht , 111 handle· lt,nll ic 1•, th (' nur<;<: ll" a iacilirnw r ll( g roup
i:rnwth. r:111 l11•lp tlu· nll'nih••r< lrlllk <11 llw ,.,;,u,,tirm/, or data fm m ,-a.rious
pcr-,p,·t·l" ,., ,u, It tli,,t '"'" 1,ri••n1a I j,,n,; nnd in~il!,h l" ca n b,, clf'riw·d from 1hcm.
·1he frir11i tatnr c,rn e11r11u ni~L' ~rroup 1nr:111l>cr• lr, ba\e ;1,·;11l.1 bl!> di,erse ideas
11i:1t ,·an 111· 11,-"1,1, p 11111,g.-tl wr i11l<11w,, ;wd ,·nr iNi rattrrn ~ Thi~ rnny rl.-quire
d 1,111g111g 1,..rn•pt ,, 11,. Irr I lmi: 11cw w;I\,. nl Ir11,ki 11~ nt tlii n~ 1nd ch,1n,i;iniz ideas
,111rl 1·1111, ,•p1,. 1h,11 111, 11 h, r~ ha,,. r1•ligir111;;I \' ,1dh1·rPcl 1r, tn th1• pn:11 Th reat and
,·,rr·,,I\·,· t.- 1i-11,r1 ,•;,n f'l•,u lt fr11rn ;w,·.-pt in)( th <' ch~ lle111cw uf que.,tirming the
i,1,•a, .rnd h,•11..t:1 hr1111' ha;;1•d upon huw ,..-,. ha \'e rero~ ni,cd. d,1rifil'd, defined,
hil 1,·l,·tl 1111 I ,1n.t h t1·d ,., 1wri1·t1t ,•.., i 11 th,· l'""l lh n·,ll, hrmr. ,1h11u I defcnsi vc ne.,;s
111d n•d 11,·, l111t l1 t•, IPr,u11·L· t,J1•:nrd :1111lii>!lltly nml n•ct:p1h'c11css to the new
,ind 111 11.1111111.11 1'1111 11n11·h t1· 11,i1111 h·,,d, ,1,-rl·11t11>in!! 1ii lho11gh t pmccs.~es. ln
1111!,,1 J., 1..-11' ,:r•111p m ,·111hL"1" h1 ,·uk aw;1~ fro m 1l1111kin~ trad ition and accept
th,· d1111l,•11g1• 111 ,·h,t n)!IIIJ.! p,• r, r·ptio n, :ind 1,111,idin~ 11"'-' wa::• nf IMking :tt
,·x1w1·i,·11 , 1 •:- ,111 n ,111111I, th,· l,H"iltt.,tor n,•,·d 111 d,·H•luµ n111dit1011s tha t allow
1·u11,·, rn,•. ,,,. u,·~- and pr,1hl1•111s tu lw r\'111mrnl,1i,•d P11nn}c ~1111 p clic;cu.si.ion.
I h,' n I11111..,pl 1r ·re 11111, 1 Ii,· ,11d1 I h.1 1 111<'111 hc·r-, .1rc -:h rn t hi: t'n:cdom and :;11 pport
ln h.1\ •· 1111• s,•ll•<'•J11 ilcl,· nn' m·,•d, 1d to 1'nt crt ,1in nm! l'\IH<'~" 1H1\ l!l idens ( th at
1111,y in iI ia ll y ~, ·,·111 \, iltl :111d implausihl,•J 1\11hout Iwin~ .,frair.l <,I c.: cn<mre. They
,-hnu ld b,· )( l\1'11 t h t• lr,·,•d11m t11 q1JC•.,11011 i11111.1l .1~-.:11rnp1 i1111~ o r 1he framework
1,i1hi11 wlti1·lt 1h,· pr11hlt·111 111-r11 r, F,1,·h gm11p mc·rnl-i,·r .1!,11 nePru; to hec-ome
s 11l'lki,·11 tl, rl ..t.,dll'd frn111 hr1- t>n1:rn,il ,·i"" poi nt tn h,· :ihl,• to s;:,• th e pmblem
rro111 11 1'\' p,•r-:p,•,·li, ,., To ltt•lp ~roup 11 11•111h,•r,; ):\t'I d...r11rlwd from iJeas :i_nd
\'il'wpoi111, ·111d .wah / ,·/ 1,·-.,1h e c'tmlli, l~ th.it ,rd ;is P'-''Cholo~1nil barriers to
p111d11rtiw group 1li ..t·11:-:-,i1111. tlll' folio\, ing art? ~OnH, pr..aclit:al tedm iqucs tbRt
l':111 l,l. 11tili , ,·d ·
a. 1'l•JJ<' 11111•11 11w111h t·1..., n •;icl tn .1111! expc rn:11re 1:011llict "ith per.suns (com.-111\wr,). nHI n<•c·,•--s:i rily IM'<'alt.~e of tllPir ideas, belief.,, or concepts.
Cuullicts <'.lll be 1111111mi1,•d by helping members isolate/se parate the
0
0
1111
iuuas. b eliefs, and con cepts f rom tl1e p e n;o n s advoca ting th em . One bes t
way lo do lhis is lo put ;i ll id eas, beliefs , and conce pts o n the hl ackboa rd
or othe r ,risual mater ials. This s hall free the gr o up ru ember s from always
associaling these ideas \\rilh the p erson s, e verytime they h a ve to look at
those concerned when t h ey discuss t h e issues/conflicts.
b. Rol e reversal is anot her way to h elp grou p m embers understand each
oth er's posit ion a n d frame o f' refere nces. '11iroug h role r eve1·s al, membe~-s
cnn be encouraged to rc- crea tc exactly h o w it is for th e other person. This
111cans ac tua ll~• trying to see t he idea from his point of view, to sens e how
one feel~ about it, to put onc:s:clf in nnother person ·s frame of r e fe r e nce .
c. Certain structured exercises c.in h el p gro up members unde rstan d and
appreciate t h e n ature of co 11flicts and som e ways to r eso lve tb e m by
gene rating n e w ways of lookin g H.1 s it11,1li()n/s and c.iq:>e rie n ccs. One s uch
e.--.ercise is called " Breaki ng Balloons Exercise " (Joh nson a nd .Johnson
1975, p. 187). This exercise seeks to d e monstrate a non -ve1·bal conflict.
The foc ilitntor's procecJur e is as follows: have each p articipa n t b l ow up a
bnlloon a11d tie it lo ltis a nk le with a strin g; th en, w h e n a s ignal is give n ,
the participants are to try lo bllrst one a n other's balloons by stepping on
them. The person whose balloon is bw·st is "out" and must s it aod watch
from thesiclelines ; the last person t o have an nnbu rst balloon is t h e wi nner.
The pnrticipnnls can then d iscuss their fee lings of aggress ion, u efc nse,
defeat. and victory. S trategies for prolectiug th e i1· ba lloons while attacku1g
oth e rs s houlu L,e noleu. During t he group d iscussion o f the exercise, let the
members an 0Jy7-e the nature of conJHcts. by relating their ex-periences o n
th e exercise wilh "personal" conflicts they have wiU, neighbo r s s ignificant
oth ers, co-wol'kers or co-memb e rs. Relat e the strate gies u sed i n the
exercise wit h tl1eir b eh av ior dur:iag experiences o f con nicls. A variation
on th e exer cise .is to have t ea,m s wit h different colored balloons compete
agDi ns l each o lher.
An other exercise is called ''Coanect the Dots" (Johnson and Johnson 1975,
p. 163 and p. 330) . 111is struchu-ed exercise can h e lp 1ne mhers experien ce
the need to detach themselves from usuaJ ways of solving pl'oblems. The
exercise requires the grou p to be creative in a ttem pting to solve it. The
facilitato r shall a sk the gro up to be divided in to tr iads (g r oup o f three).
E:1cl1 triad's 11ssignment is to con n ect all nine dots (Figu r e 6.3) v.ritb only
four s traigh t and connected li nes. The correct answer is illus trated in
Figure 6-4.
•
•
•
•
•
•
•
•
•
FIG 6.3 Connect the Dots
1 42
L
FIG 6.4 Solution to Creativit y Problem
The abili ty to solve the problem is based upon the ability to go ()utside tJ1e
obvious bounda ries in reach ing the solution. During the group discussion,
let Lhe members d escribe a nd analyze how they tri ed to connect the dots.
De,·ive ins ights from their experiences on th is exen :ise, hy helping them
sec how rigid adherence to original vie wpoints, beliefs, fr,u ne of reference,
assumptions, and p.ist experiences can retard t he group. members
capability lo reach agTeed-upo•n gm1l und objectives. Going outs ide the
obvious boundaries is nnnlogous tr, going b eyo nd the boundaries of r igidity
and explore n ew ways of looking at situation/s or data to resolve conflicts,
which on close examination can be considered as by products of thinking
traditions.
4.
Helping Members Analyze the Here-and-Now EA-pcricn ce. The third
intervention to keep t he g rou p an a ly7.e, negotia te, and resolve conflicts is to
focus on tbe feelin gs and experiences of the mem bers in the present moment,
in t h e here-a nd-now. During experiences of conflicts, tension a n d a nxi ety c,in
affect gro up process to a degree that indiddual members feel the need to do
something about the situation they a re in . Members can learn to assume the
respon s ihility for sustaining t h e vitality of the g"oup and to gain control over
tension-laden experiences by helping them reflect back on the reasons why
tl1ese experiences or events happened.
Essentia.Lly, this intervention helps members recog1ilie, examine, and
understa nd the "bow" and "why" of interact ions or behavior soon after they
a re ex-perienced by tl1e group members. Through a focus on the h ere-and-now,
the blocks or b arriers to gro up progress are pinned down an<l analyzed for
possible alternatives, re-direction or behavior chan ge. Sample communication
techniques that shall help the facilitator initiat e/utilize the h ere -and-now
-process illuminat ion include:
-
a.
" Is there an_ything you can feel/say about how we are going through this
group eJ\.-periencc?
b.
"Can we describe what's happening to our group for the last few
minutes"?
c.
"What do you thinJ< are the reasons why we feel we a re on a dead -end
since a few minutes ago"?
d.
"How have we been discussing theissue/s? What are the feelings generated
in us by this gl'oup experience? Why do we feel this way"?
143
c.
"vVh at im;ights cau we d e rive from this experience? Wha t arc lhe
imrilic.1tions of o ur insights tu h el p us ide ntify alternatives'?
Before s uch ;111 intervention ca n b e utilized , the " fac ilitator must le arn t n b e acle pt
a l identifying hcrc-an<l- nuw cxpcri c11ccs that need lo be analyzed/proccsst:d.
Some pr::iclical lessons Lh a t can h e lp h e r to be sensiti\'e t·o these events include th e
following:
a.
Keep on eye or concc n\Tn tc not o nly on the content of the group discu ssion
but on how th e m essages ,ire sent and received. The faci lil,1lor s h ou ld n o t
o nly he concern e d with con nol.1lio ns a nd lalenl cle m e nts of m essages.
.Metnco111municatio11 isanotb crai;pectc>fo m essage tbat n cetlto b e analyzed.
Metacomm11nica tion r efers to n com nH111icalio11 a bo ul n c o mmunication.
Yal o 1u(1975,p.122-1 2:_$)exp lai11s1ha t it is :, 111csf;;1gc:1 ho11 l lilcnaturl! o fth e
relatio ns h ip b t!twccn inleracti ng mcmbcr·s. Fro 111 t h e re la t io n s hi p aspect,
for example, Lhe fo i;i lit a lo r can a naly%c, wliy is the me mber maki ng this
statemen t at this time, to t h is perso n, in this 111a11ne r? T he process behiJ1cl
a scqm:ncc o f s lalc111cn t rnud c by ;1 membe r o r hy sev e ,·:il membe rs can
help th e facilitato r determine th e r e latio n,;h ip betwe e n one member and
th e at.her memlJe rs , or behvcc.m clusters or cliques o f m e mbe rs or betwee n
the membe rs nnd th e leader, 0 1· finally. between th e group as w hole and its
pri mary Lask.
b. Be an active par ticipant of the here-and-now e;,,.'Perience. Focus on how
the interaction is affecting you as a gro up m ember rather tha n on w hat
you fear or hope will b appe11. or wha t y ou s ho ulc.l s ay next afler a member
or two h ave talked. By concentrating o n th e h e r e-m1d-now, the facilitator
str enbrthern; her gut-feeling. This h e lps h e r a chieve an awareness , an
objec tive assessmen t of everything in the s ituation bei n g faced. The
choice of an appropriate intec.·ention is gu ided by the g:rou p proces s as
experienced in th e h e re-and-now by the facilitator.
To help m e mbe rs expeiiem:c confl ict a.nd analy-'e the here-aud-uow even t it brings,
U1e facilitator can utilize u structured exercise which is n mod ification of t h e one
d escribed in Appe ndi,-; I). Instead of just t ask and -maintenance l"Oles l o b e playe d
by th e gro up members, som e self-ser ving roles can be incorporated in Enve lope 1
of th e ex1:1rcise, J\.ny number of t he follo·wing self-serving roles ca n be ndde<l to ·the
structured exercise (Wilson and Kneisl 1979, p. 444):
144
a.
Aggressor: Deflates status of others by expressing d isapproval of their
values, acts, or feelings by attacking the group or :the problem it is working
on. or by jok ing aggressively.
b.
Blocker: Tends to be oegati\le and stubbornly resista nt. Atte1npts to
m ain tain or bring back issu.es after the group bas r ejected or by passed
iliem.
·
c.
Recognition s·e eker: Calls a ttention to self through boastin g, reporting on
personal uchic\'cm ents, acting in unnsual ways, or s truggling to pre vent
being placed in an "inferior" position .
d.
Self-confessor: Uses group as audience foT expression of personal, non
gToup-oriented feelings, insights, or ideology.
e.
Playboy: Dis plays look of involveme nt. in group's h o rseplay, and o ther
m ore -o r-l c.ss st1Jdied forms of inelevant be h avio r.
f.
No m inator: T ries to assert autho rity or s upe ri ority by e ngagi ng in
fl a tte ry , cla iming s uperio ri ty status o r rig ht to a tte ntio n , giving directim 1s
au th o rit,i tively , and interrupting con tributio ns of others.
g.
H el p se eke r: Atte mp ts to evoke sympaU1y response from o th e r group
m e mbe rs o r from the whole group, through expressions o f ins ecurity ,
pe:·son al co nfusion, or self-de pre ciation beyond "reason".
h. Sp ecial inte rest p lo1dcr: Sp eaks for some underdog - the "s mu ll businessp erson", tb e "grass roots community", U1e "ho usewife~, "labor" 1::lc.
-u s ually cloaking own prejudices or biases in s t ereotype tha t b est fi ts own
ind iv id ua l n eed .
o uii ng th e gr ou p dfacuss ion of this m odified s truc tured exercise d escribe d in
AppendL,._ D, th e follo wing qu estio ns ca n be a dd ed t o the lis t:
a.
What a re the effects o f the self-serving roles on th e group and its capabili ty
to attain its goal?
b.
What a r e the feelings gen erated by these self-serving roles?
c.
What arc the insights t hat can be d erived by the grou p members having
others assume self-se.r ving roles?
The Conflict Reso lution Model (see F igure6.5) illustrates specific interventions t o
help h a ndle the intra pers on al a nd interpersonal asp ects of the "conflict expe rien ce"
while supporting the group towards productive outcomes.
Be Aware of t he Effects of Own Behavior on the Group: Use the Self
for Group Growth
'n1e nu rse as the facilitator or coo rdin ator of group discussion exerts an influence
on th e beh avior and experience of group members. As described earlier, membe rs look
u p to the facilitator or leader for approval of certain behavior, responses or action s.
'n1e fncili la l'or b eco m es the m od el of the group as regards behavior that is expected
or acceptable . This i s exemplified by such expe riences as being on time for m e etings,
keeping appo intments a nd promises .
Another insta nce is wl1e n tl1e facilitator lbandles conflicts, especially when the group
associates tbe conflict a nd its sources 1Nith her. The facilita tor must utilize every
availab le opportunily to m aximize group growth ·by making sure that she does not ran
road the group's decision. T his requires a,n ope nness on her par t as s h e tries to be free
from th e t endencies to be proud and authoritat ive ; she must allow the group's decis ion
to dom in at e gr5mp life.
·
It is, therefore, vital that the facilitator becomes aware of h er own beh avior aad its effects
on t h e group. Otherwise, h er behavior m ay pote ntiate or mitigate su ch e..'C])eriences a n d
expr essions of aggress io n , passivity, aad rebellion. When these are allowed to happen
a n d a r e n ot hand.led effectively, the group may not be allowed t o grow from the earlier
s tages, or it m ay eventu ally undergo dissolution.
145
.. - - -- - - -.- - - - - - - - - - - - I
NURSE'S INTERVEN TION S
To handle emotions
(own & participants')
r1ddeenntltiityvtithhleeiip;j'.:roobtilie!'rm
nl~--.soetine the is SU e
I
t
t---- - - ~ Develop e.xpectancies
for win -win outcomes 1
Identify own feelings
•
Create a saf e
and ca ring
envir on m ent
•
Encourage
shared
responsibility
& owner s hip
of pro b lem
and o utcom es
•
Separate:
>
people
before th~y are
e>cpre.ssed:
•
listen
caref ully
•
Dlscern wisely
•
Focus
consciously
Be aware of
own interests,
issues, motives/
int entions,
feel ings
from
p r oble m
Generate
creative options
Encourage:
•
Understand
partici pants'
m otives,
interests,
feelings
Sharing or
validation of
perceptions
Ana lyze reasons
fo r disagreement
•
Re.statement s
•
Reframlng of
Combine options
to win-win
solutions
>
facts
from
opinion
Encourage:
•
"Big picture"
per.sp ectlve
•
Multiple
options/
so lutions
issues
Redefine
rema in ing areas•- of disagreement
•
Points of
convergen ce
Yes
I
'
Jointly acknowledge
agreement
I
~----------------------------- --~
fie 6.5 COnflict resoludon model. (Adapt9d fl'Dffl Uttletleld, L , Lave, A., Pe c k, c.,
& Wertheln, E. {1993]. A fflOdl!I forrM01v1111 confllct: same thearetical, e mpirical,
and pracdc:al appficiltlons. Australian Psycholosfst, 2813), 80-85).
14 6
Act as the Group's Completer/Resource Person
I n ord e r 10 max:irniw thcgrou p's cap:1bil ity fordecisio n-rm1ldng nnd prob lem-solving,
th e neccssn ry data, ex peri1,ncc, and resou rces mui;t be made ,wail uhl c• to the grouµ.
Jf not on e amo n g the Al"Oup members con provide what th ... group rteccls al an yone
time, the f.-1dlita tor is expected 1. n acl ns Lhe grou p'::, complete r ::incl cnsmc th a l the
m issing aspeels are made av:1ilable lo the )?;roup. One exmnplc of 1.hc fodlilalor acting
as th e g roup's comple ter is wh en she perfu n11s the necessa ry task fun ctions or groupbuilding fu11clio t1s uo l being performed by the memhe.rs. Another instance is when the
necessa1y exper tise or information is not avail able a nd the facili tator acts as a resource
person to h ave this accessible to the g1·oup for good decision-making.
There, may bl:! s ituations when the faci li tator does not have the expertise needed by
the group to d o effective problem-solvi ng on a pa rticular situa tio n o r area of concern.
During these instances s he may help group members iden ti fy and mobilize resources
of the oute1· reality, the world o uts ide o [ the group. Sh e .tcts as the group's completer
by making s u re that the missing uaLa, ex pertise or resou rces a re m ade available o r
accessi ble to th e group.
Derive Opportun;ties to Apply Learning on Another Situation
Gronp experiences provide vnrh:d learn:ing opportuni ties for membe rs. 11-lore often,
the b asic concepts and princi ples for effective group life are re-lived in various group
exper ien ces. Members ga in more depth in understanding group process as they realize
that the co11cep ts and p rinciples previously learned in handUng a pa r ticular issue can
be applied in an other situation dealing wit11 a differe nt issue. A sample communication
techniqu es is: «111 analyzing whal we are !;oiug th rough cight now, is there anyth ing we
lea rned from the group's eiq:>erience io our previous sessions that can help u s b etter
understand t his present experi ence.''
·
This µarticuJu r i nten>ention is also helpful when t h e facilitato r h elps th e grou p undergo
successfully the stage of te rmination. Mor e often, the e:'1.-perience on separation brings
about overwhelming feelings of sadness. hurt, and other unpleasa nt emotions that
affect people's capability to est ablis h re lationships aga in at so m e future time. By
deriving th e leaTni 1,g opportun ities that 1rroup life offereu lhe mem bers, the facilitator
can h el I) them real i:tc that t he advantages of investing r esources, efforts and feelings for
a successful gro up ,,vork far ouL1.veigb the u npleasant emotio ns o[ separntion , though
how real t h ey may he.
WORK G.ROUP : HUB OF COMMUNITY ORGANIZATION,
COMPETENCE AND EMPOWERMENT
Vvork groups representing various geogrnphical segm.ents and socio-cultu,ralpolitical units can b e the hub of community organization p rocess for competen ce a nd
empowerm ent. Operatio nally done i n CI-IN practice, ,vork groups can t ake any or both
types: ( 1) Structural o r organizational sub-model such as fom 11:1lly cre11ted committees,
task/core/sti.1d y gr o ups, dubs or other commu nity o rganizations; ( 2) Functional
s ub -model wh ere community res idents demonstrate commi tm ent t o participate in
community projects/program s to create and s ustain th eir own health initiatives, but
they do so o ut o f a sense of connected n ess a nd <·ommitment t o improve collective life,
not necessarily beca use o f a responsibility as co mmittee or club officers or members.
Strategically designed to rep resent the voice of several sodo-econo mic-political units in
the comm u nity, th e wo rkgr o up's poli tical wiU a nd connectedness can be or chestrated b y
►
147
lhe nu rse c.tl Alyst-par l ner and th e co mmunity as client-partne r to en ha nee a collectiv
life of compet e nce and empo werment. The iU us tration below s how~ a s cheinatie
diag ra m of how U1e com munity, rep resen t ed by Lhe b~~ cii·clc, _<.:an be organi?,e d int~
w?rk j?,rnups ._ r epresented by tbe _sn!~I _cii:-dcs, to m ob1hzc the mflu~n cc and political
\-,JI of th e neighborh ood to s us tam m1liut1vcs and s upport efforts a l 1mpruv111g health
car e a n d scn ;ccs in a coDecli ve li fe .
The bou ndary of the b ig cir cle is rep resented by hro ken lines to e mp hasize sernipermeability. allowing fo r cxchangt- of r esources or linkages with other socio-economi c poHtical un its or outsid e i;1ge.11ts and institutions t o enJ1an ce growth or make avai lable
robust options lo a ddre ss problems or ha ndle change.
As work groups e:,.-perience the d im e nsion s of commu ni ty competence, t hey fee l
m otivated an d confide nt in p ursuing e m powerment domains as areas o f inilnence that
a 1Jow community reside nts to ,11ork togeth e r a nd m obilize tbcmsclves to ward in creased
criti cal consciousness. level of con tro l and choice over heal th, h e alth c.:.are/ser vicc/
prog ra m decis ions and n ptions . I~-iverack (2ou5) describes these empower m e n t
doma in s as: (1) improved participatiCJn; (2) developed local leadership; (3) incr eased
p roblem assessment c;:ipaci ties; (4) en hanced abi lity to 'ask why'; (5) im prove c.l resource
ruo bili zal ion : (6) strong orga n izatio nal structa.u·es/su pport groups; (7) strong lin k s with
o ther o rg,rnizalions and p euple ; (8) egalitaria D/eq uitable relationship betw e en the
commun ity and out.side a gen t; and, (9) i11crc:ascd control over p rng ra m 1n nnage m ent.
REFERENCES
148
1.
Boyd MA. (2002).PsychiatricNursing : Con te mporary Practice. Philadelphia:
Lipp in cott..
2.
Cottrell LS. ( 1976). The com petent community. In Knphln BH & Others (Eds),
Furthe r Explora tion s in
Social Psychia uy. New Yo rk: Basic Books, p p
195-209.
3.
Dunphy D. (1985). P,-occsses of Group Po111(dot io11. Adapted from Tuckman,
E W . Developmental Scqt1e11ce in Sm all Group. l'syc holo~h:al llu llctin , 6~.
4-
Eng E& Pa.rker J.::. (1994) .Measuri.ng ComrnunityCornpetencein theM ississippi
Delta: The Interfuce between Program Ev;iluation and Empowerment. Henlt.b
Edu cation Quarterly, Vol. 21 (2), pp 199-220.
5-
GoeppingerJ, Lassiter PG&Wilcox 13. (J982). Community I £cnlth is Co mmunity
Competence. Nursing Outlook. Scptembcr-Octubc:r, pµ 464 -467.
6.
Helvie CO. (1998). Advanced Practice Nursing in the Community. Tho usand
Oaks: s.,ge Publication.
7-
Hendricks VV. (1991). How to i\1'an nge Coriflicc. Kansas . Na tional Press
Publications, Rockhurst College Continuillg Education Center, Jnc.
8 . Jedlicka AP. (1977). Orga11i:mtio1tfor Rw·al Developmen t: Risk Taking and
Appropria.te Technology. New York: Praeger Publishers.
9.
,Jolmsnn OW and J ohnson PP. (1997). Joining Together: Group Th eory and
G1·011p Skills (6th ed.). Boston: Allyn and Bacon.
10.
,Johnson OW and ,Johnson FP. (1975). ,Joining Togethe,-: Group 1'/1eory and
Group Skills. New ,Jersey: Prentice-Hall, Inc.
11. Laverack G. (2005). Using a 'domains' approach lo build community
e mpowerment. Commw1hy Development Journal, p p 1-9.
12.
Lltllefield L and Others. (1993). A Model for Resului11g Co,1/licl: Some
Theoretical, Empirical, and Practical Applications. Anstralian Psychologist,
28 (3), 80-85.
13 . Lundy S. and James S. (Eds.) (2001). Community Health Nursing: caring for
the Public's Health. Massach.usetts: Jones and Bartlett Publications.
14. Maglnya, AS. (Ed.) (2004). Nw·sing Pl·actic~ in the Co mmunihJ, Marikina
City: Argonauta Corporation.
15. Payne Rand Cooper CL (Eds.). (1981) Groups at Work. New York: John Wiley
and Sons .
16. Stolte KM. (1996). \<'Jell ness Nursing Diagn osis for H e;ilth Promotion.
Philadelphia: Lippincolt-Raven Publishers, pp 271-272.
17. Sch utz WC. (1965) Interpersonal Underworld. Havard Business Review, 36.
18. Thelen WR. (1954) Dynamics of Groups al Work. Chicago; University o f
Chicago Press.
19. Watt S, H iggins C & Kendrick A. (2000). Community pnrn c1pation in
the d evelopment of sen,;ces: a move towards community empowennent.
Community Develop ment Journal, Vol. 35 (2 ) , pp 120-132.
--
149
Chapter 7
ASSESSING COMMUNITY
HEALTH NEEDS
Luz Barba ra P. Dones
INTRODUCTION
In community h ealth nursing, the co mmuni ty is not simply a context of the existe n ce
of the nurse's clien ts n or is it just a setting fo r 01Lr nursing intervention s. Spr adley
( 1990) emph asizes th at the co mmunity is the prim ary c lient fo r n vo main 1·easons.
First, the community has a direct influence o·u the h ealth of the individual, families and
s ub-populatio ns. Secon d, it is at this level th.at most health service provision o ccurs .
111e hallmar k of community h ealth nursing :is t he fact that it is population-focused
(Cla rk, 2003) and t hal the pr:imary client and recipie nt of care of the nurse fo a group
of people in the communi ty.
The community healU1 nurse gets to wo rk w:i t h d ifferenttypes o f clien t in h e r pra ctice.
She may b e in volved with families, populutions or sub-grou ps, each has d istinguishing
characte ri stics that the nurse must recognize in ord er t o direct h e r nursing involvement.
Clark (2003) makes th e following d istinction:
Pop ulation r efers to t h e general public or society or a collection of communities and
generally do n ot display social action amon g its members (Kuss e t al, 1997 ). Within
the population are smalle r s ubgroups oftea referred to as aggregate, neighborhood,
and comm un ity. Aggregates a re defined by their common cha rac teristics an d concerns
but similar 10 popula t ions, I hey may not inte ra cl: or w ork togeth er to address t h ese
concerns. Aggregates a re often seen as population having hig h risk fo r certa in healt h
conditions. (Helvie, 1998) Some examples of aggregates incl ude t he children under
five years old, the school-aged children , the adolescents and the elde l"ly. Matteson
(2000) desc ribes a neighborhood as more homogeneous as a con seq uence of having
common langua!!,e or cultura l t raclil:ion b ut may not have s pecific physical or geogn1ph ic
bounduries. This is especially true in the Philippines w hen p eople from the rura l a rc.as
migrate in to the met ropolis but are drawn togeth er \Vitl, o t her people whom they sl1are
dialect o r t raditions with to form a neighborh ood. As different neighborhood s converge
and expand, t h e ne ed to institute a system of governance becomes crucial. T his give
rise to communit ies that Sanders (1958) a nd Cassells { 1993) define as a collection of
people , a place and social system.
Com munity h ealth nurses need to know the defini ng ch a racteri sti cs of a commu nity
(see Chapter 1) becau se th ese "set" t h e stage in understandi ng the different a speds
tha t directly o r indirecl'ly influen ce t he h ealth status of the community. The community
health nurse ,viii also deal with these co mmunity cha racteristics in p lanning and
developi n g s p ecific programs and in ensuring the delivery of effective healtl1 services.
THE COMMUNITY DIAGNOSIS
Caring for the community as client starts w ith detem,ining its h ealth status.
150
community h ealth diagnosis in nurs ing co ns ists of two im portant parts (Muecke
19 89). T h e nu rse collects data about the community in order to identify the different
factors t b a t may d irectly or in d ircdly influence lh e health of the population. Then,
she proceeds to analyze and seek exp lanations for the occurrence o f hca ltl1 needs
and p roblems of th e community. This is the fi rst part of the community d iagnostic
process culled th e comn1unity assessm ent and is con sidered to be the "keystone- of
com m u n ity hea llh nu rs ing process. ( Free m an a nd Hei nrich 1981; Muecke J989) TI1e
nurse utilizes these c1ssessmcnt data to derive th e community health nursing diagnoses
and b ecom e the bases fo r deve loping and imple m e nting community h ealth nursing
intervention s and strategies. TI1is process com pletes t he commun ity diagnosis.
Ecologic A pproach to Communi ty Diagnosis
Th e ecologic approach to community h ealth diagnosis (Payne, 1965) recognizes the
fact th a t the healtl1 status o f the community is a product of the various interacti ng
elemen ts such as populat ion, the physical and topographical characteristics, socioecon omic and c ultu_ral factors, health and basic so cial services and th e power stn1cture
within t h e community. The interrelationship of these elements will e.xplain th e h ealth
and illness patterns i n l be community. F ayne (1965) attributes much of the failure
lo address t he h ealth p roblems o f the community to this lack of ecologic approach.
Comm unity healtl, problems are often viewed as technical problems that need technical
solutions without regard to th e interrelatedness of all factors a nd forces that are bearing
down oa comrnw:tityheallh.
According to Freeman and Hein rich (1981), community heal th d iagnosis is based on
thr ee interdependent, inte racting and constantly changing conditions:
1.
The healt h stat us o f the comm unity, including the population's le vel
of vuln e rability
An est imate of the health status relates the characteristics of two factors,
namely: th e people and. the environment. This is consis tent with the
epid emiologic a ppr oach that Finnegan and Ervin (1989) described as a
model for community assessment in which measurable variables to describe
the person, place and time s upport the presence of an actual or potentia l
cmnmunily health probh::m.
Person variables include demograp hic characteristics as age, sex, ethnic group,
occupation, income o r e ducational attainment may explain pop ula tion grov..1:h
trends, death and illness experiences as well as identification of vulnerable or
s p ecial risk groups in the population.
Environmental factors include not only the physical environment (e.g. air,
water, hous ing, and climate) b ut those of biologic envi ronment (j.e. plant and
animal life) and social environm.ent (e.g. presence of war or armed conflict,
poverty) associated with disease development. · ·
2 . Community h ealt h capability or t h e a bility o f th e community t o deal
with its health pro ble ms
The commun.i"ty's capacity to pt·omote o r susta in h ealth depends on ilie
extent of its economic, institutional and human resources. The mere presence
or availability of sucl1 resources does not necessarily guarantee people's health.
People need to make out bow the_se resources can be optimally used to ilieir
advantage.
151
3. Community action potential, or the patterns In which the community
is likely to work on its health pr,oblems
Communities take different courses of action to address their health needs
and problems. Each develops i ts own approach to mobilize community
participation for health. The nurse assesses the comn1unity for its attributes
that determine the pattern of health action. Freeman and Heinrich (1981)
describe the following important aspects of community hea1th action:
a. Value people give to health over their other needs in life that
provide the forward motion for health action - Is the health
problem perceived to be important to the people? Is it perceived
to need immediate a ttention? Are there otber concerns in the
community that take priority?
b. Community's relationship with t he politicalsysten1 a ndgovernn1 ent
institutions that s upport health actions - How responsive is the
government to the health needs and problems of the community?
To what extent does the political system or government institutions
allow for people's organizations' participation in decision-making
about planning and implementation of heal th actions?
c.
Habits that the community has d.eveloped for dealing with common
problems - Is there genuine partnership among all stakeholders
to push the agenda of promoting and sustaining health in the
community? What are the different approaches or strategies that
they have developed and implemented?
Types of Community Diagnosis
In the assessment of the community's health status, the nurse considers the degree
of detail or depth of inquiry. Comprehensive assessment is normally done when the
nurse bas not h ad opportunity of working with tbe community and its people. The nurse
needs information to help hel' understand the community and facilitate its enabling
process. Oftentimes, the nurse is c9nfronted with a specific p roblem a rea llke a disas ter
situation or an outbreak of disease. In these insta nces, a problem-oriented assessment
wil l have to be co nducted. A nurse may decide to assess a specific population group in
the community, in which case, she may opt to conduct a comprehensive assessmen t of
that group and at the same time, focus on the specific problems of that same group.
It is important, therefore, to decide on the objectives of the comm.unity diagnosis, the
r esources and time available to implement i t.
Comprehensive Community Diagnosis
A comprehensive community diagnosis aims to obtain general information about
the community"with the intent of determining not only prevalent health conditions and
risk factors (epidemiologic a pproach) but also the socio-economic conditions (socioeconomic approach) and lifestyle behaviors and attitudes that have effect· on health
(behavioral approach).
TI1e following are elements of a comprehensive communi ty diagnosis and the basic
data t hat are needed to characterize each variable:
152
Jt,,.. Demographic Variables
The analysis of the community's demographlc characteristics should show the
size, composition and geographical distribution of t he population as indicated
by the following;
1.
Total population and geogr aphical distributio n including urban-rural
index and population density
2. Age and sex composition
3. H ousehold size
4. Selected ,.; tal indicators such as growth rate, crude birtl1 rate, cn1de
deat h rate and life expectancy at birth
5. Patterns of m igration
6. PopuJation projections
Jt is als o import a nt to know whethe r the re are population groups tl1at need
special attention such as indigenous people, internal refugees and oilier s ocinlly
d islocated groups as a con seque nce of disasters, calamities and development
program s.
B . Socio-Economic and Cultural Variables
There a re no limits as to the list o f socio-economic a nd cultural factors that
may directly or indirectly affect the health status of t h e community. However,
the nurse should consider the following as essential information:
1 . Soc ial indicators
a. Edu cational level whichmaybei ndicativeofpovertyandmayreflect
on h ealth perception and utilization patte rn of the community
b. H ousing conditions which may suggest health hazards ( congestion,
fire, exposure to elements)
c . Social classes or groupings
2 . Economic indicators
a. Poverty level income
b. Un e mployment and underemploymen t rates
c . Proportion of salaried and wage earners to total economically
active population
d . Types of industry p resent in the community
e. Occupation common in the community
f. Communication network (whether formal or infotmal channels)
necessary for disseminating health information o r facilitating
referral of clients to the health care system
g. Transportation system includi ng road networks necessary for
accessibility of the people to h ealth care delivery system
3. Environmental indicators
a.
Physical/geographlcal/topographlcal characteristics of the
community
• l and areas that contribute to vector problems
•
terrain characteristics that contribute to accide nts or p ose as
geohazard zones
·•
land usage in industry
• climate/season
b. Water su pply
•
% population with access to safe, adequate water supply
• source of water sup ply
c. Waste disposal
•
% population served by daily garbage collection system
•
% population v.~th safe excreta disposal system
153
• types of ,.,.-aste disp-0sal and gar bage disposal system
d. Air, water and land p ollution
• industries within the community having health hazards
associated ,vith it
•
air and water poUution i nde.-c
4. Cultural factors
a. Variables that may break up the people into groups within the community
such as:
•
ethnicity
• socia l class
• language
• religion
•
race
•
political orientation
b . Cultural beliefs and practices that affect health
c. Concepts about health and illness
c. H ealth andDlness Patterns
In analyzing the hea lth a n d illness patterns, the nurse may collect primary
data about the leading causes of illness a nd deaths and their respective rates
of occurre n ce. If she has access to recent and reliable secondary data, then she
can also make use of these.
·
1. Leading ca u ses of mortality
2. Leadi ng causes of morbidity
3 . Leading causes of infant and child mortality
4. Leading causes of maternal mortality
5. Leadio.g causes of hospital admission
6. Leading causes of clinic consultation
7 . Nutritional status
D . Health Resources
The h ealth resources that are available in the community are an important
element of the community magnosis mainly because they are the essential
ingredients in the d elivery of basic health services. The nurse needs to
dctemline manpower, institutional and material r esources provided not only
by the st ate but those which are contributed by the private sector and other
non-government organizations.
1. M a npower resources
•
•
•
•
•
•
•
cat egories ofbealth manpower available
geographical distribution of health manpower
manpower-popula tion ratio
distribution of health manpower accor ding to health facilities
(hospitals , rural health units, e t c)
distribution ofhea lth manpower according to type of
organization (government, n on-government, health units,
private)
quality of health manpower
existing manpower development/policies
2. Material resources
•
•
•
154
health b udget and expenditures
sources of health funding
categories of health institutions available in the community
•
•
hospital bed-population ratio
categories of health services available
E, PoUtical/Leadership Patterns
The political and leadership pattern is a vital element in achfoving the goal of
high level wellness among the people. It r eflects the action potential of the state
and its people to address the health needs and problems of the community. It
also mirrors the sensitivity of t he government to the people's struggle for better
lives.
In assessing the community, the nurse describes the following:
1. Power structures in the community (formal or informal)
2. Attitudes of the people toward authority
3. Conditions/events/issues that cause social conflict/ upheavals or that
lead to soci.al bonding or unification.
4. Practices/approaches effective in settling issues and concerns within
the community.
Pr oblem -Or iented Community Diagnosis
The problem-oriented community diagnosis is the type of assessment that responds
to a particular need of a target group. (Spradley, 1990; Clark, 2003) For exam ple, a
nurse is confronted with heal th and medical problems resulting from mine tailings
being disposed into t h e river systems by a mining company. Since a community
diagnosis investigates the community-meaning, the people and its environment the
nurse proceeds with the identification of the population who were affected by the
hazards. posed by mine tai.lings. Then s he goes on to characterize t he biophysical,
psychological, physical environmental, socio-cultural and behavioral as well a s health
system factors relevant to the specmc problem being investigated.
COMMUNITY DIAGNOSIS: THE PROCESS
Community diagnosis consists of collecting, organizing, synthesizing, analyzing and
in terpreting health data. Before data are collected, the community diagnosis objectives
must be determi ned as these will direct the depth o r the scope of the community
assessment. It is fundamental to resolve whether a comprehensive or a problemoriented community diagnosis will accomplish the objectives.
The community health nursing process emphasizes the active involvement of the
clients in its ca re. The community is an active partner not a passive recipient of care.
The nurse works with and not for the community. People tend to believe that their
participation is only required when it is time to implement program activities. In
working with a comm unity in a diagnostic exercise, the nurse needs to be conscious
about the appropriate participatorym.e thods for mobilizing community participation.
The nurse does not operate like an e.xternal assessor of community needs, but as the
faciUtator working in a team composed of community members and leaders.
Figure 7.1 sumrnacizes a model of community diagnosis process adapted from F.J.
Bennett (1979). The community's involvement starts early during the assessment
phase to cr eate awareness of their health needs and problems. Their participation in
the community d iagnosis develops their commitment and enthusiasm to carry on with
the p lanning and implementation of health programs that address their needs and
problems. The nurse must ensure the community's input in the communjty diagnosis
considering th.eir capacities and limitations but with enough room to develop their
potentials.
155
Prior to actual conduct of community diagnosis, a rapid appraisal can be carried out
by the nurse to gain a general impression of the community. It is exploratory in nature
but can provide direction and focus for the actual community diagnosis. It is also an
opportunity for the nurse to immerse in the community a nd get to know its problems,
issues and concen1sthat will contribute in shaping the plan for subsequent community
organizing process. It is participatory (WHSMP-PC, 2003) because the data are drawn
from the people through focus groups and corroborate d by the com.muruty th rough
interviews of key informants and community leaders.
Rapid Ap prai
Commun!
Immersion
Esta Is war Ing re altonshlp
with community leaders and
represe ntatives .
P annTng ac.ti.on &
peclyng w tca n e
lnvestjpt ed and whe l'e
(objectives)
health program
ant grou ps an
hem o n lmplicatlons/
o~tion li'
·
Plannlns the ata colle~on
methods and toels (e,g ,, -survev &
q uestionn aire)
e wers
Rewot 1n1 ata•
collection fnstFUITferit;s
'!. •
FIi, 7,1 Thepnacess D'JCD1111nunltydfacnosfs.
Adapted from F.~. Bennett (1979}
STEPS IN CONDUCTING COMMUNITY D IAGNOSIS
In order to generate a broad range of useful data, the community diagnosis must
be carried out in an organized and systematic manner keeping in mind that the
community should take an active part in identifying community needs and problems.
The nurse plans with the community membe rs to create a team that will be responsible
in overseeing the planning, implementation of the community diagnosis. The nurse
emphasizes the importance and value of people's participation in the activity because
their detailed knowledge about the community will fundame.n tally shape health actions
156
that are responsive an d relevant to th eir needs .
The plan foC' carrying out the community diagnosis is based o n the res ults of th e
rapid appraisal. The breadth and depth ( compreh ensh·e ,•e rs us problem -focused). the
targe t population (entire community or a s pecific aggregate) an d the problem focus
are cla.rified and make it eas ier for t he nurse and the people involved to d evelop :in
arrangem ent th at will facili tate the cond u ct of tl,c commun ity diagnosis .
1. Determining the objecnves
Whe ther a compr ehensive o r a proble m-o riented community diagnosis
will be undertake n by t he nurse ;md the community, ii is c,;tic.'.ll to determin e
the occurren ce a nd distrib ulio111 of selected environ me nt.ii, socio-econom k
and be h avioral co nditi ons. ( D C\'cr, 1980) These are im porta nl in defi ning
the heaJth p r oblems of Lhc communit-y. Later o n du ring the planning phase.
these will serve as gu ide in d irecting di sease con t rol :rnd we llness promotion
in .th e community. In stati ng th e o bjectives, lhc following questions sh ould be
answered:
a. What is the pre.c;en t hea l t11 conditio n of the p eople in th e community?
(This will d escri be the pn:va iling disease con ditions a nd h ealtJ1 needs
of th e targel population)
b . Why are the people in the c omm unity ia s uch con d itio n? 'Nhat
specific problem s are et1 us ing these conditfons? (Th is will explain the
health behaviors or risk factors tl1at give rise t o the h ealth proble m)
c.. W11at arc the roots o f lhese proble m s? (This will provide th e nnalyses
r elated to the socio-economic, cultural a nd environm enta l factors
that s ustain or a llow for th e perp etuation of the hea lth problems of
the largetpopul a tion)
d. What sol u tions will ad d ress th e problem s? (Th is will r e flect the
p ossible solutions of the. health problem s based on the community's
capabilities a.nd resources)
2. Defining the study population
Based on the objectives of the comm u nity diagnosis, the nurse and the
community diagnosis team identify the populat ion group to b e included in
the study. It m ay include the entire population in the community or focused
on a specific popula tion grou p such as women in the rcprndu ctive age-group
or the infants a nd young childre n . If a complete e numeration of the desired
population is not possible, the d ata may b e collected dat a from a sample or a
subset o f the target population.
The example that follow shows the objectives of a community di agnosis
after rapid appraisal results led the nurse and the t eam to focus on the 0 - 12
population group.
157
Thefol.._
1. •t1ad• tt
M
2.
To
3.
s.
6.
1.
3. Determining the data to be collected
After the objectives and the study population have b een defined the
n urse togethe r ,..,,;u1 the colilJ11un ity members need to figure out a scheme to
rationalize the relevant data to be obtained. This is ach ieved hy developing a
data collection p l an. The data collection plan uses t h e objectives to guide
the data collecto rs to d ecide on s pecific infom1ation or data t o be collected, tb e
methods of data collection, the instrun1cnts or tools for data collection and the
possible sources of these data.
Data can be categorized as primary o r secondary b ased on the source. Data
that are directly obta.ined by the nu rse specilically to answer the community
diagnosis objectives a re caJ led primary data. Secondary data a r e existing data
that were obtained by other people whicb th e nurse can use t o answer the
community diagnosis objectives. There are a d vantages and disadva n tages o f
using p ri mary or !;econda.ry data. In the e n d, the n u rse decides based on the
desired qmil ities of data such as timel in es~ of data, completeness, accuracy,
precision, relevance and adequacy. (Mendoza e l a l, 2000)
4·
Collecting the Data
Different methods maybe utili2.ed togenerateheaJt h data. The nurs e decid es
o n the s pecific methods de pending on the type of data to be gener ated. For
exam ple, through an ocu lar s urvey th e nurse is able to detem1ine the p hysical
and topograph ical ch aracte ristics <>f the community. She may in t erview people
about Uleir healt h beJ ieJs or s he can r eview existing health records in the Rural
HeaJU, Unit. [n general, we use the follo\.vin g methods t o collect data:
a. Observation
15.a
Observation is extracting information from subjects by observin g
their behavior and their en vironmen t. Observation methods provide
an opportunity to check the validity o r truth of m any verbal statem ents
which people make. (Feuerstein, 1986) Observation techniques maybe
s upplemented or documented by the use o f bard equipmen t such as
videotapes o r cam eras to ta.ke pho tographs, s phygmomanometer to
measure b lood p r ess ure or weighing scale to determine weights of
ch ildren .
Observation is an important and useful method of collecting d ata when
informants are unable to direc tly supply information o.r may likely give
inaccurate information. Some resp onden ts may resist questions or are
unwilling lo am;wer questions or may have problem s o n recall. On the
other hand, there are limitations to t he use of observation in data collection
especially when observation perio ds are limited to a specific period of
time. Some events may not be accessible to d irect observation at the time
one schedules the data gathering. Sometimes, it is impossible to predict
occurrence o f events o r events occur red in the past. I n th ese cases, the
historical or "limelinc" approa ch- a participatory technique utilizing the
collective memory of community members, particularly, its older members
have proved helpful.
Prior to actual conduct of community diagnosis, t he ·nurse must have a
bird's eye view or a "feel'" of what the community looks like. This helps
t he nurse plans a nd directs the focus and tne depth of the community
diagnosis. A comri1on approach is to perform a rapid appraisal through an
ocu1ar s urvey or what others ca ll as win dsh ield s u rvey. (H unt, 2005)
It consii:;ts of walking aro und tbe community or in the case of windshield
survey, dtiving through the community appreciating wbat can be seen a nd
perceived as the people go along with their daily lives. Adm ittedly, th e
oculru· or windshield s urvey ,vil!l yield cu rsory or even t rivial data but that
can b e brough t to ligh t in the a ctu al community diagnosis.
A nurse in vestiga ting lifestyle patterns is likely to affect the people they
are observing and can cause "artificia!M behavior among them. Observers,
therefore, need to live and be fully integrated with the community they are
studying and be part of what is happenin.g in the community; This is called
p articip ant o b servation (Feuerste in, 1986).
b . Recor.ds l'Cvi.ew
Records a re written information that are kept in folders, files or books
which we o ften refer to as hard copies b ut they may also be kept on tape
or electronic form as database t o be retrieved o r access.eel for specific
purposes. Records or docu me nted sources offer the data collector savings
in time, money. energy and effort s ince data ar e pre-collected. How ever,
like any data source, one must recognize the I.imita tions of records or
written documents. Aside from completeness, accuracy, usefulness or
a ppi:opriaten ess of d ata, the nurse needs to evaluate the da ta's worth if
t h ey a re up-to -date.
Data may be obtained by reviewing those that have been compiled by health
or n on -health agencies from t h e government o r other sources. The nearer
one is to the source of data, the better. For exam ple, if the nurse is looking
for data about a sitio or- barangay, da ta sear-ch will b e more productive in
the ba.rangay or in the mun icip al records than when search is done at the
provincia l or regional record s.
159
c. Interviews
Interviews are the most common and v.ridely used method of data
collection. I t involves
asl-.-ing and answering questions follo-..ving a
systematic procedure aimed at yielding first b and information from the
subject of inquiry.
Interviews are categorized based on presence of face- to- face in t eraction
number of inte rview participants at a given time and interview structure'
(Tan and Dalisay, 1999)
·
Based on the presence of face-to-face interaction, interviews may be
conducted in person or via telephone inte1.views. Face-t o-face interview
allows th e person being i n.terviewed to seek clarifications a bout the
questions. At the same time, t he interviewer can p ick up non-verbal cu es
from the respondent to indicate congruen ce with his/her ver bal response.
Tel ephone interview has more limitations than face-t o - face interview
to be considered of use in gathering voluminous data. For one, telephone
calls are rather expensive wh en one calls fro m a mobile phone. Definitely
te.xt:messages can only provide limited data. Finally, p eople r espond bettc;
when they keep a n eye cont act with the person they talk to making the
interview more fruitful and constructive.
'
Interviews can be individual or group i nterviews. Individual interview
takes place between a respond ent and an interviewer a nd is most useful
when sensitive issues are being d iscussed . When a pei-son known to be an
expert or an authority on a .specific subject is interviewed, t his is known
as the Key Informant lntervic'W (Kil). F o r in~tan ce, if we want lo
know the program for integrated development of a mu n icipality, the best
person to interview would be the local chief execu tive or the tuu nicipal
development officer. But if one wants to find out the efforts to address
. health issues at tbe barangaiy level, the barangay captain or the kagawad
(councilor) for health ,-vill be the appropriate persons t o shed light on the
matter.
I
Group interview consists of one in terviewer and sever a l participants,
usually around 10 to is which aUow the interviewer t o gather data from
a good number of people a t the same time. It takes a very experienced
interviewer to be able to facilitate a good group interview and turn up with
a high quality data. A skilled interviewer must eosuc-e equal par6cipation
from the respondents and to b e able to prevent antagonism when tl1ere are
conflicts of ideas.
Interviews may be structured 01- unstruct u r ed. S-tructu~·ed interview
-f ollm,vs a list of questions caUed a n interview schedul e which becomes the
"script" in the conduct of the interview. A set of possible r esponses are
indicated in the interview sch edule from which the participants will choose
from . The interviewe, is expected t o a dhere to the interview schedule, and
is not allowed t o alte r tl1e sequence o f the questions, reword or rephrase
the questions . The set of respon ses s hould consider all possible answe rs
that the p articipants may articulate. Unstructured interview is useful
i n collectin g qualitative data that seek to desctibe opinions or per ceptions
of people focusing on a particular issue, problem or phenomenon. lt makes
use of open-ended questions and more often, takes off from the responses
elicited from the person being interviewed . In order for the interview to be
160
productive, the interviewer must he skillful not only in evoking respon ses
from participants but also in lead ing them to crysta.Llize their idea s.
d. Focus Group Disc ussion
The Focus Group Discussion (FG O) is a quali tative research techniqu e
u tilized for its value in understan ding and documenti n g huma n behavior.
(T a n and Dalisay, 1999) It is a very popular mctl, od app ropriate in the
community to elicit :ind e:-.-plore opinions of people, dete rmine thei r
attitudes a nd p ractices rega rding a li m ited set of concepts. Data collection
time with FGD is signili canlly reduced because a cc>nsidcrable number of
participants can become iJivolved ut a given time. The participants are
selected based onthevari.ablcs that are being studi ed. Fm· instnnce, we wish
to determ in e what factors in the child feeding practices in the community
will likely contribute to tl,e incidence and prevalence o f mal nutrition, TI1e
mothers a nd other child care providers ;:ire I.he probable participants for
the FGD as they are th e ones involve in the d ay-lo-day pursuit in ca ring
for the children.
In the conduct of focus g1·oup d iscussions, make s ure t o set the
characteristics of the participants in terms of
a . those characteristics that will be com mo n to them; and
b. those characteristics t bat will d ifferen tiate them from each other.
Such ch aracteristics may incl ude socio-eco11omic s tatus, demographic
variables as age, sex, civil status, educational atta in m en t, n:!1igious affiliation,
ethnicity and occupation. Th.esc arc importnnt factors th at ,,;11 dictate
variability in people·s perceptions and opinions about certain issues. As
in group int erview, a focus group discui:;sion will need a highly skilled
fadlitator with deep understanding of the iss ues being discussed; making
s ure th at everyon e con tnlmtes in to the di scussion, and with a ll a n gles
of the issue well-covered. It is also cru cial th at the facili tator can engage
the participants back into imp artiality when the d ebate b ecomes heated.
Finally, the facilitator has to summarize and synthesize the discussion
to make certain that the issues have clarified rath er than confused the
participants.
5. Developing the instrument
Instruments or tools facilitat e the nurse's data-gathering activities.
The tools or instruments to be used d epend on the method of data
gathering needed to supply the information for t he community
diagnosis. The following are the 1nost common instnnnents that the
nurse uses in h er d ata co11ecticm:
a. Survey questionnaire
The survey questionnaire, also called the s urvey instrument
is tlie form one uses to document th e data being collected . The survey
questionna ire m ay be in the form of a n interviev, sched u le o r a s elfadministered questionnai re. (Hawe, Degeling and H all, 1990) W11en
the nurse uses the interview schedule, sh e reads out the question and
records the respond ent's reply to th~ questions. If the respondents read
the questions and ,,Tit e down their responses, they are filling out a selfcompleted or self-ad.ministered questi onnaire.
Vvhether the tool is an interview schedule or a self-competed questionnaire,
161
it is importantthatthe instrun1ents are designed.ill a w ay that they generate
data thnt a re h onest, comple te and accurate.
EltAMPLE Of A S£LF-ADM IN ISTEQED QUESTIONNAIRE SEGI\/IENT:
A,
PANG-EKONOMIYANG KALAGAYAN
1. Pangkaranlwang bu~11ang l<ita: Lagyan ngtsek (") ang angkop na kahon na
nagsasaad ng kab1.1uang regular na kit.a ng lahat ng miyembro ng pamllya na m ay
ha nap-buhay
0 < 1000
0 1000 to 3000
D 3000 to sooo
0 5000 to 10.000
D >10,ooo
2. Pagsunud -sunUrin ang mga sumusunod ayon sa lnyong prlyorlclad na plnaglalaanan
ng buwanang bad~t. Ang bilang 1 ang itinutur lng na pinakamahaJaga o nilalaanan
ng may pinakalamalaklng baclyet
_Pagkain
_
Tu big at kuryente
Edukasyon
Komunlkasyon (bayad sa telepeno, ce ll pho.ne l oad)
_
Kalusugan ·
_
Pagpapanatfli ng kaayusan at kalinisan RB kabahayan
_ _ Pagpapanatili ng kalinisan ng katawan (sabon, shampoo, toothpaste,
sabon na panglaba)
_ _ Libangan o bisyo (banggltin)
_
Transportasyon (pamasahe, gasolina ng sasakyan)
_Pananamlt
=
3". M ay Iba pa bang pTnagkakakltaan llban sa regular na plnagkakakitaan 7 (Sideline)
D Wala
D Mayroon
Uri ng pn,3gkakakltaan: _ __
Tantifang lcaranlwang h-.tlaga ng klta sa isang buwan: _ _ __
4 . Mayroon ba ng nagblblgay ng suportang pamplhansyal sa pamllya? '
,.....
s. M ay m1yernbro bang pamllVil na kasapl sa n,ga surnusunod? Lagy.in ng tsek ang
l■hat na naaangkop na sagot. Banggltfn kung aneng benepisyo ang Jnaasahang
matansgap ng mlyembro.
0 GSJS
D sss
0 Pag-lblg
0 Phil Health
0 lbapa
162
I •
EXAMPLE OFAN INTERVIEW SCHEDULE SEGMENT
KALIGTASAN NG INUMING TUBIG
1. Pinagmumulan ng lnumlng tubig
0 Bumibili mula sa water refilling station (proceed to #6)
0 Mul a sa tubig na slnusuplay ng MWSS
0 Mul a sa tubig na galling sa dleep-well
D lniigib mula sa balon/artesian well
2. Nagsasagawa ba ng karagdagang proteksyon sa lnuming tu big?
D Oo (If yes, proceed to #3)
D Hindi (If no, proceed to 114)
3 . Paraan n g pagpapanatiling ligtas ang inuming tu blg. (Check as appropriate)
D Pagpapakulo ng 15-30 minuto
D Paggamlt ng w,ater filters
D Paglagay ng kemikal (chlorination, iodination)
D Iba pa, banggitin:_ __
4. DaflHan bakit hindi nagsasagawa ng msa nabangglt sa #3: (Check as appropriate)
D
D
D
D
D
D
Magastos
M atrabaho
Hindi na kallangan pa dahll malinls naman ang tubig
Hind, na kailangan pa dahil wala ng mga batang m aselan ang kalusugan
Hi ndi alam kung ano ang mga paraan upang mapanatiling malinis ang
i numi ng'tubig
Iba pa, banggitin:,~ - - - - - - -
b. Focus grou p dis cussion guide
The focus group discussion guide serves to facj)jtate the d irection
and flow of exchan ge of ideas on specific topics or concepts among the
participants. It should specify the objectives of the discussion and the
general characteristics of the participants. The facilitator does not need
to strictly ad here to the sequence of th e questions but makes certain
that all concepts are exhaustively discussed.
163
EXAMPLE OF A FOCUS GROUP DISCUSSION GUIDE
Focus Group Discussion Topic: Malnutrition
F<Kus Group: 10 - 12 mother s o r car e providers of children 0·12 years old seated
· in a semi-circular ari:angement; facili tators and persons i n charge of
docu menting the discussion w ill be seated among t he participants
Objectives of the FGO:
a. To determine the knowledge, attitudes and practices on nutrition of
mothers and care providers in Bar angay Sto. Rosario
b. To describe the perceptions or mot her s and care provi ders regarding
factors t h at affect children's nutritional status in Barangay Sto. Rosario
c. To determi ne available alternatives for mothers and care providers to
address problems on nutrition in Barangay Sto. Rosario
lntroductton:
Before the actual discussion, make sure that all partici pants including fac ilitators
have name tags . T h is is to ensure that participants are properly acknowledged when
th ey want to talk and for th e nole tak er s to properly documen t t heir contrib ution to
the discussion. Allow participants to be comfortably se ated. Greet the participants
and make proper intr oductions. State th e objectives of the FGD and th e general
rules of t he discussion.
Gulde Questions:
/1,. Perception of a healthy and well -nourished child
1.
S.a lnyong palagav, ano po ang katangian ng isa ng malusog n a bata?
Respond en t s m ay characterize a healthy child based on physical (mataba,
maliksi), mental (matalino) , social (bibo) and emotional (masaya)
parameter s.
2.
Ang lahat ng inyong nabangglt ay pamantayan ng malusog na bata. Ito ay
kar.inlwana resulta ng pagkakaroon ng wastons nutrisyon. Ang wastons
nutrisyon ay nasusul<at ng pag kakaroon ng was tong timbang ayon sa
edad. llan sa inyo ang nakakaa lam kung ang kanilang mga anak ay may
wastong timbang ayon sa kani l ang edad?
Responses of participants reflect their recognition of t h e importance
or maintain ing ideal body weight a s a nutrition parameter. Follow-up
questions may Incl ude:
a. Maituturlng bang malusog ang lsang batang sobra sa timbangi'
b . Okay l ang ba ang ba tang payat nga pero madalang nami ng
magkasaki(?
3.
Sa inyong pananaw, ano ang maaari ng mangyarl sa lsang bata na ang
timbang ay nananatiling mababa kung ihahamblng sa kanyang ideal body
we ight?
·
Summarize and synthesize re sp onses on consequences of below normal
body weight.
164
L
8 . Know led ge, Skills and Attitudes on Nu trition
1.
Ano po ba ang inyong p ananaw kapag slnasabi na ang isang b at a ay may
ma In utrisyon?
Responses will te nd to draw attention only to undernutrition. Try t o bring
them back t o earlier discussion about overn utrition and emphasize that
these are two forms of mal nutrition.
2 . Maaari ba ninyong ibahagi ang lnyong nalalaman tungkol sa kadahilanan ng
maln utrisyon?
Responses will usually focus o n ln t al<e of l nadequate amount of food based
on req u ired allowance. Make sure t hat the quality of required daily intake
of n utrients based on the food pyramid w i ll also be pointed at. Keep i n
mind that there are other reasons like presence of inf ectious diseases,
parasitism or diarrhea.
3 . Maaari ba ninyong ibahagi kung anu-ano ang inyong ginagawa up-ang
mapanatili sa wastong timbang a:ng inyong m ga anak? Saan po n inyo
natutunan ang mga paraang ito?
4 . Sa inyong palagay epektibo ba ang m ga paraang isinasagawa ninyo upang
m apanatill sa maayos na timban g at kal usugan ang mga bata? Kung oo,
sa paanong paraan nakatu long ang mga ito? Kung hi ndi, ano ang inyong
nakitang mga dah i lan kung bakit hindi nakatulong ang mga paraang i t o?
C. Socio-econ omi c, Cu ltural and Environmental Dimensions o f Malnu trition
1 . Marami sa atin ang naghahangad na mapanatill natin ang maayos na
ka lusugan at wastong panga ngat'awan ng ating m ga anak. Hindi lingid sa
Inyo na maraming ba gay o sitwasyon sa ating buhay ang nakakaapekto sa
ating pagsusumikap na brgyan sila ng pagkain naaayon sa wastong dami at
uri na angkop sa kanilang edad.
Try to evoke responses that relate to social, economic, cultural and
environmental factors that prevent them from giving proper nu trition,
Examples of these in cl ude poverty, popularity of fast food chains that
inAuence food choices, religion, l ack o f knowledge about required en ergy
and nutrient i ntake accordin g t o age, etc.
D.
Availab le Alternatives to Address the Problem
1 . Mayroon b a kayong nakikitang solusyon o alternatibo sa mga nabanggit
nating dahil an ng malnu trisyon sa ating komunidad? M aaari ba nlnyong
ilahad ang mga paraang pwedeng Isaga wa sa ating mga kabahayan?
2.
Sa bahagi ng health center at ng bara n gay, ano ang inyong nakikitang
maaari nilang maiambag upang maiwasan an g paglaganap ng suliranin ito
sa. komunidad?
Closing the FGD:
Summar ize and synthe size main polnts·of discussion. Acknowledge.and thank the
p.-rtlcipants' active Involvement in the FGD.
L
165
c. Key jnforman l intervie w .guide
Simj l ar to tJte FGD guide, the key i nfor m ant in tervie w or KlI g uide h elps give
d irection to t he p eI"Soo do in g the inte rview u s ing a set o f p r e1n1recl ques tions
o n a very i-pccific $11bjccl. The person be ing in te r-vie we d is selected for his or
her h_,iown exp e rtise or co ncern o n t h e s ubje c t m atte r. Fo r Lh c in t erview to
b e effectiv ely i; teer cd. t he inten; ewer must b e con versa n t o r a l least , h av e a
wo rking k n o w l edge about th e issue being d iscu ssed . Care m u s t be ta ken that
th e interviewer·s own b elie fs are no t imposed to the person b e ing in terviewed .
Pr esenting a pe rs p ective d iffe re nt from the p e rson b e in g in t e rvie wed s h o u.ld
o nJy sen ·t> t o h ighligh t h i~ ,:ie" l ) Oint o r stand p o in t.
EXAMPLE OF A KEY INFORMANT I NTERVIEW GUIDE
Key Informant: Barangay Captain; Kagawad (Councilor) fo r Healt h
Objectives:
1.
To determine the local leadership's perceptions of h ealth and health•
related problems in the community.
2. To determine the magnitude and extent o f these problems t o the overall
community's heal th conditi ons_
3. To describe the local leadership's percep tions o f the social, economic,
cultural, poli tical and envi ronmental roots of these health problems
4 . To d escribe efforts of t h e local l eadershrp to address the h ealt h p ro blems
rn the co mmunity.
Introduction:
&efore the actual interview, greet the key informant and introduce ones elf
State t he objectives of the Interview.
Gulde Questions:
1. Among the concerns in your barangay, how do you rank health of t h e
p eople In terms of impo rtance or priority? Why?
166
2.
As the b arangaycaptaln/kagawad for health of this commun ity, wh at do you
p erceive to be the most important health p ro blem/s of your com m u nil y? Do
you think the people recognize o r ackn owledge the exis t ence o f th is/t h ese
problems in the community? To what e,ctent this/these probl em s a ffect/s
the com muni t y? Can you cite possible conseq u ence/s If t he problem/s Is/
are n ot addressed?
3.
In your opinion, what are the possible factors/causes that hav e cont rib u t ed
to t his/these problems? Are the people aware of this/these factors? If yes,
wtiat have the people done to mitigate the effects of this/these pr obl ems?
Wf!I'e they effective In addressing the problem? If not, w ere there any
Interventions from the locial leaders to address the problem/s?
4.
A s the barangay captaln/ kagawad for health, how do you e n vision the
people and the local leader.s to work as partners to address t he i ssues and
-c.oncem o f the people related to solving the health pr oblem/s? Can you cite
efforts In t erms of programs or projects that your office or comm ittee has
undertaken?
s. How woul d you rate people's Involvement in communi ty de1telo pmen"t7
Why?
6.
What d o you think .should your a dministration lay em p h asis on to Improve
peop l e's participa tion on commu nity health a11 d developm ent?
d. Observation checklist
The observation checklist is a list of data that are manifestations or
indicators of a health need or problem . The list could i.nclude the physical
or environmental hazards where the community is situated; it could also be
indicators of health resources such as health facilities and presence of health
personnel and services .
EXAMPLE O F AN O BSERVATl t:>N CHECKLIST SEG M ENT:
Barangay
W ater Sour ce
A. Type of water so urce:
D Deep well/artesian well
D Dugwell
D Piped water from MWSS
' B.
C.
Location of water source. Estimat e distance from:
D Communal toilets
.
D Garbage du mp site
D Polluted bodi es of~;;0 Other facilities that can b_e_s_o_u_r_c_e_s of wat er cont aminati on,
specify ____ __
Protection of wa t er source
1. Deep well/artesian well
Depth, _ _ _
Human activities ;;:;,un'd t h e water sou rce
0 laundry
0 bathing
0 defecating or ur inating
D others, specify_ _ ~
Presence of protection from con~ation w ith waste w ater
0 drainage for excess w ater
D cement ed al t he base o f the pump or concret e slab t o
p revent waste water to seep unt o t he ground/soil t h at m ay
contaminate watertabl e),
D oth er s, specify _ _ _ __ _ _ __ _ _ __ _
167
6. Actual Data Gatherin g
Before the actual data gathering, it is suggest ed th a t the nurse meet s t he team of
people ·wbo "ill be invo lved in the d atn collection. TI1e instruments are discussed a nd
analyzed. If n ecessary. tl1 e in s trume nts m ny be moclified o r s im p lified in o rd e r not lo
overburden the people who may ha'"e Lim itations in t e rms of ed u ca tional pre p a ration
or available time to finis h data oollection . Pre-testing o f the ins tn1m e n ts is highly
recommend ed.
Th.e data collectors mus t be gh-en an orienta tion a nd train in g on how they are goi n g t o
u..o:~ the i~'-trtlrne nts in data gatheri n g. The n u rse ca n_as k the d at~ colle~t o rs _lo r o le- play
an 1ntel"'-iew sce ne so that they ca n p lace th em.selves 1n an actua l intervi e w si tu at io n. As
al1eni.ativl'-"' to th<' c,J.!-,nrn ri ry h o uSE'h o ld .su l"'\' t •y wh ich can t.tke lo n g to finish, t h e nurse
can teach the d ata collecto rs to use pa rticipat o ry t ools and ti:chn iques to faci li ta t e and
si.mplrfy data ~auwri ng . Cn?a l:i vc> ;in cl in11 a \·;1 ti'\·e m e th ods ,~i ll like ly inc r ease people 's
panjcipario n in d a t a cr,llect inn b...>ca u.sc n ( the ir n o n - I h n·:-i ltmi n g (ea h.lres. Amo n g o th er
participa to r) tvul!" or tc.•ch n iq ue.s fur data g a thering a re th e fo llowi n g:
Scm1-s 1ructured int e r.iews - infonnal, guided intervi ew sessions where
only ~o m e of th e qu estions are predetermined and n e w questions o r lines or
quc~ tfrm ing a rise during t h e in t.erview. in response to a n S\-~e.rs fro m those
intervic\•"t.'<i.
•
•
•
A.nalytfral games - a quic k m e.ans o f finding o ut a.a incli,ridua.l's or a group's
list o f prio ri1i c.<: o r pre ferences.
Sto rie,,md po nrai1s. a re c:hnr1 . co lo rful d escription s o f s it uat ions
encounte red b, the nu ro:..: in the field ur !'.1ori es r ec:o unted by people.
The:, de5-L n l><· ·111form a t i,m 10 " -ays rural people t h e m selves perceive local
condilfon«. nota hl}• problem s an d u ppu rtun it ies.
Diagrams • !.'implt:. :-chem;itic: d e, i cc..., " ·hic h presen t info rmation in a r eadily
undeP--tand,1\ile , i~unl forms . Thc...e a rc ana lytical prfJccd urcs; n m eans o f
com municnt io n t>et-, <:cn a nd :imo og di ffe ren t people.
\\'orkshop - nw11n~ of h nn~in~ peop le togeth e r and o uLr;idcrs intTodu ccd for
the ir s kil ls and e!\-peric nce, t() p a rti cipate active ly in reviev,•ing, a n a lyzing aod
e valuati ng the information g,ithered.
During the a<'tua l data gathe ring. th e nu rse su pervis es t h e data collecto rs by ch cckjng
the filled-up inst.rumenbi in te m,~ o f complete ness, 11ccuracy and r c l iobility o f the
iofonnation co )k,<"te-d. If th ere a re gaps o r problems i n acc.-u r acy o r r e liability o f dutu,
the nurse emphasiz~ th e nel!d to go back to the .sour ce o n d secur e tJ1e appropriate
in..f onn ation. Tb.is b lhe only way to maintain t he integrity and good qua lity o f datu for
the comm un i ty diagn<Jsi~.
1.68
7. Data Collation
After data collect ion, th e nurse and the tea m a re now ready to put together all facts
and figures to gen e rate Lnfonna t io n abo ut t he health s ta tus of the comm un ity. Two
types o f <lut., arc gcn c ru1cd. They are e ith er nu 111eric.1I o r descriptive da ta. Nu~erica l
data arc th ose whi ch ca n be counted like age o r how nwny children are th ere in a
family o r how many comm unal toile t;; ar c the re in the commu ni ty . Descriptive data
are th ose that ca n be d escd be d or th at ca n reveal characteristics of an observab le
fact. The nurse cxpl;:1i11s t he im porta n ce of data types a nd characterisLi cs to facilitate
data col.lation . Even befo re t he actu al da ta gatheri ng. the nurse and tea m s houl d have
a lready developed a p lan for d a ta co llat io n. This is don e by crea ting or cons tructing
categories fur classifit:alion of responses. In creating the categnries, rJne m ust make
sure that th ese are mutua lly exclusive and exhaustive.
Mutually excl u sive choi ces do not overlap. This m eans th at a re.,;ponse can only fa ll in
one category from a set o f choices. This is tnie fo r both nume rical and descriptive data.
Take n look a t th e exa mples:
To classify gender or seic:
0 Male
D Female
To classify monthly income:
0 Below Php 10,000
0 Php 10,001 - 15,000
0 Php 15,001-10,000
0 Php 20,001- 25,000
D Php 25,001 and above
Exhaustive c ategor ies a n ticipat e all p ossible answers that a resp ondent may
give. For example:
Question: What famfly planning method/s are YQU using?
C..l Lactational Amenorrhea Method
I.J Natural
o
Basal body temperature
o
o
ll
0
o
Artificial
o
O
O
0
o
Cervical Mucus Metho d
s.y mptothermal Method
Standard Days Method
Others (specify);
IUD
Pills
Injectable (DMPA)
Condom
Others (spe.cify):
Permanent
o
o
Tubal ligation
Vasectomy
169
How <lo you summnrize data from fixed response and open-ended questions? Fixedresponse questions provide choices the respondent will select from. These choices
will serve as categories for coll uling th e responses. In som e community diagnosis
des igns, dutn collcclors use fla s hcards to help the respond e n l choose his answer.
Tilis is espcciully useful if o n e is d e aling '"''it h very young respondents or respondents
whose levels of education arc li m ited. '111c fl ashcards arc assigned uum be rs or letters
corresponding to a specific category of choice. T he respondent will j ust call out or
point to the letter or number that match or is consistent with his or her 1·espon se.
Open-ended questio ns do no t provide choices o r categories. Unlike fixed-response
questions, categories a re only constructed after d a ta collection is over. Categories ai:e
cons tructed fro m responses in randomly selected questionnai res. For example, a nurse
wishes l o know Ute J'Cftsons why mo lhers do not b reas t feed the ir infants. Respo ndents
are expected to brive out a wide selection of responses. The respons es fro m randomly
selected questionnaires will be the b~1ses for constructing the categories.
QI__..Dfl ft. -1t hll'ldl ka n. .papasuso n1 lyon1 sannol~
Reiponse 10: Gumara~ alto ogoral contracepttve pllls.
Response 27: Pumapaolc 'na •~ sa trabllho:
Response BO: Ayaw nl mister, makalcasira daw n~ aklng,ftgur;e.
Rupanse 45: SUmasakft ans aldns uton1 pag nagpapadede.
Response 59: Bottle feedlnt Is more corwenlent.
Response &Ot Glna1amot ako npypn sa saklt ns bap.
Response 62: Naic.kahlya maaPasuso p.,a1~nasa l;abas ng bahay.
Response 67: Nakalalabala lalo na kung maramlng 1awalng bahay.
Response 77: Nalcakllwala rig ~ • ·
·
For these ~nses; pos,ible c:ate110rles Include:
Persorral convenience: Rwotues2'7, 45, ss, 67,
Mildlcal reasons: Responses 10, 60
~ • • persU8$10n/.l>elll!ft "~nses 30, 62, 77
The next step after categorizing the responses will be to summarize the data. The re arc
two ways to summarize data. One can do it manually by tallying the data or by using the
computer. Tallying involves e ntering the responses into prepared tally sheets showing
a ll possible responses. For example (Table 7.1):
stJPPLY,
When computers are going to be used in s ummanzmg results, a coding manua l
is needed where the responses are given numbers or codes. Using s oftwa re such as
EPITNFO, the responses are inputted into the computer for tallying.
170
for example:
Variable
-
Code
Male
1
Female
Roman Catholic
Protestant
11
h lesla nl Kristo
z
Sex
Religion
w
1
2
3
4
Jehovah's Witness
.
I·
s. Data Presentation
Data present.Il ion will depen d la rge ly on th e type o f data obtained. Descrip tive
dat a arc presen ted in narrative reports. Exam p les of data appropriat e for descriptive
p resentation are geographic d:1ta, hist o1y of a place o r beliefs regarding illness and
de.1th.
Nume rical data m ay be presented into table or gra phs. Tables or graphs are useful in
sh owinJ?; key information m aking it easier to show comparisons including patterns and
trends. The choice of graphs will depend on t he type o f data being presented, some of
w1,ich are shown as examples.
Type of Graph
'
Line graph
s ows . ata tren or c anges n
time or age with respect to some other
variab
For comparisons of absolute or r tive
counts and rates between cat. o, 14?$
Graphic presentation of frequency
Hlstosrani or frequency polygon , distribution or measurement
Proporti onal or component bar
hor lechar;t
Scattered d iagram
Shows breakdown of a group o r total where
the number of cate orles Is not too ma
Correlation data for twO variables
171
~ rn t!<l wilh CamSoa11q~1
Pie Chart
Pie Chart
•
Below
Poverty
Threshold
□ Poverty
Above
Threshold
83%
Proportion of Famllfes Below and Above 2007 NSCB Poverty Threshold in Zo ne 3,
lf'IY. Sto. RDArO-Kanluran : UPCN, Septembe r 2008
Souru: F1orendo et al, 2008
Bar Graph
B ar Graph
40.00
33.45
35.00
30.00
go 25.00
c,:, 20.00
I:?
~ 15.00
0
19.59
1 9 .26
15.54
10.00 5 .07
5 .07
2 .03
5.00
l
0.00 D,.:::,c:,t,u
H:;gl::~1
~,
~
a-a:.:! ;.i.:.e
..d
Colk-µ
·eot
,c:oi:;;,k-'~
C.01"-~
uu!e:.ce
'\·ou-tiou l
eocne
~
EducationaJ Attainment
Ed Cl!IIOl•
M• 7
! fl af.&4l4jljl,.G1 I -1t"8 %ane 3,, SID. llasario-Kanluran: UPCN,
la Ill a 2IINNI
~ - " il:I-IWllldi,h-et c,t 2IJOII
172
Bar G r aph
Alcoh ol fnLnk c
Tnadcqun tc Fruh t n tn.k.o
High Snit l);c1
Obesity
Furn Uy Mbtory o f C,rd lo\•:u,c ut:sr
Ol,u!n~~
-
r-:
FamJly Hi.!l tory o( H y pen en!'llO n • • • • • • L_ __
0
20
_
_ _ _ _ _ _ _ __j
40
60
80
F'orccntago of Hypertons lvo
Risk Factors for Hypertension, Zone 3, Brey. Sto. Rosarlo-Kanluran, UPCN: Septem ber
2008
Source: Florendo et al. 2008
Line Graph
--- -- Lin e Graph
25.00
:;;-= 20.00
-
~
!!!
a:
"' 15.00
¢>
u
10.00
.i
;:
e
CL
5.00
0 . 00
2005
2007
2000
2008
Year
Preval~nce of Acutl! Diarrhea In Chllclr'en of Masaprua. Pateros:; 2005-2008
.... ~.Jii&,i«al;20011.~ ,,,,_osls
-•·=•--•a ~ ~
&v,t:-Sm.Ana. Pat&Ol
173
9. Doto Analysis
Data nn alysis is t h e m ost crucial s tage in comm un ity diagnosi s. Tt in,.·ol ves
quan t:ifi cntio n. description a nd d assificatio n o f d a ta. S ince there are multi p le sou.rces
of d a t a w hich we re collected u s ing d iffere nt m e thods, consis t e n cy an d v;:ilidity of data
can be ch ecked. T his is = lied tri a n gi1l a tio n. Data are sorte d. classifie d in t e rms of
relat ain ess. a nd i nte rpreted for a ny sign ifican ce o r im plication. TI1is process aims to
est a blish I r ends a nd p a tterns i n tc rrns o f h e a lth n eed s a n d problem s o f th e community.
P a tt e rns in te rm s o f huma n r e latio ns. ti m e. a nd s p ace hel p the nurse view and anaJ:y7,e
which a re indicators o f h ealth p ro ble m s a nd w hich fact o rs gi ve rise to h ealth problems.
The m agni tude a nd e., -tcn t o f tl1e p roblems an d th eir implication can be d erived by
c omparing them w ilh standard va lues or n orms.
Data a nalysis s b o u.ld b e d one not only b y the nurse or tl1e t ea m c o nd ucti n g t he
community dia gnosis. It seems un th inkable tha t th e e ntire com mu n ity s h o u ld b e
"present duri ng th e d a ta analysis. but it can be done. 1t m ay n ot be t }1e e n tire pDpu la ti o n
but represen tatives o ft.l1esecto rs t h at comprise the com m unity. The nurse can fac ilitate
a simplified 1malysis u s ing t he l'ro ble rn T ree Analysis a p proach. (W H SM P- PC. 200 3)
The Proble m T ree Amilys is approach looks at h e a lth proble m s in t e rn1s o f t heir cau ses
a nd effects . .Ju st like a tree. \\•ha t o n e sees in Lhe condition of lbe leaves a nd b r a n ches
(whether they arc h ea lthy o r infested ' "; f h p ests ) are mnni festation s o f the overall s tate
of the plant a nd caused b y w hat it gets fro m the soil in t erms of n o uris hm e nt through
tb.e roots " Prob le m s indicate t hat there a r e facto rs that cause them.
The nurse ond th e team can facilitate t h e par ticipatory process in data analysis b y
,mting the data in colo r ed ca rt o lina o r constn1ction pape r c ut into 3 x 12 inc hes s ize.
Us ing adhesive tap e , p ost a ll th e ca rds in one area. In a ma n ila paper o r i n a board,
draw a ve ry big tree tha t d e t ails the leaves, bra nches, trunk and th e r oots. T he people
are the asked to look a t the d ata/informatio n ·written in the cards. Have them thi nk
which of these can be considered as the m a in o r central problem , the cau ses and the
effects of the problem. l\1ai n o r central p r oblems should be p o sted in the trunk; t he
causes are p ost ed i n the roo ts :md th e effects are posted in the branc hes or leaves.
The nurse a n d the tea m s h ould e nco urage t h e p e ople t o give opinion s , comments and
reaction s o r s eek clarificatio n on what and how the o thers viewed the data. Facilitate
the discu ssio n in order to deepen the analysis by posing questions such as:
•
•
•
•
10.
How are th e m ain or central issues or problems r elate d to one
another?
Which oftbe problems seem t o b e the most s erious or needing urge nt
attention?
Among tl1e roots of the problem, which are the easiest to address?
Which a r e the most difficult?
Which of the effects s hould n o t be allowed to continue?
What could possibly h a ppen if the n othing is done?
What should b e done?
Identifying the Community Health Nursing Problems
Data analysis should lead the nurse and the team to have a better gras p of the
community's health situation. Defining the community h e alth nursing problems will
help the nurse and the team to decide with the people what actions will effective ly
address and improve community's health. Community healt.11 nursing problems are
categorized as:
174
0•
H caltJ, s tatu s probkm.s - di.:scribcu in tenns of incre.1S<?d o r
decrcaS(.,'O morbidi ty, mortnlity, fertility o r reduced c.ipability for
" ·ellncss:
t,. Healt h reso u rces Jlroblem s - dc..'leribt'CI in tcm1s of lock of or
nbse.nce of manp11wer. mon ey. materials or institutions necessary to
sol.-c health problems:
c. H c a l!Jl -reln l ed p r•Jbl cm s - dcscrih~-d in temls o( exiJ;tcnce of i:.ocinl.
eco no m ic. em;ra nmcnt:i l ;incl political fncto r!l thnt nr.grnvate t·h e
Uln ess-induci ng !lit1rntions in Lhc co m11u111ity.
a\)0,-e procel>S is much like the a.-.scss111cnL phnsc of the PRECEDE- PROCEED
~:iel of Green and Kr_eutcr ( 1999~ involving sndnl. cpi<le1111olo~ic~I. ~nvior?-1/
r, wironmcntal. cduc;:1t10nal/ecoloy.1r:1l as:<es..<: mc nl ~
mu nd1111111st rn t1 vc/pohcy
ei ~cssmcnts. Using rh is 1m1dcl c1 mhll's no t rml\• the nu r.:c b ut nlso tJ11• lornl y.ovcmmcnt.
ass
' co11111111n1ty
. ns..-;,:.s.,s m cnt to '<l
' ' I
the people nm-J ol I1cr sectors ·mwJI v<:d 111
I cnt l t·y cr1hcn
as wh ere each co ntrihut~l to llt t· prnhlc m and poi111s whe n· they ,·an net to rc.,;olvc
: : problem. Th is will be d_isc,~sscd wit? more depth i11 the nc.~ chapter on plnnning
for community health 1mrs mg tnlt!rvent mas.
11.
Priority-setting
After Lhe problems have been identified, the next tas k for Lite nu rse nnd lhe
community is to prioritize which llca.llh r,rohlcms 1.'llll he (lltcndt d lo <.'Onsidcrin.g
available resources , limita tions and c.-onslr.:rints. In priority-sett ing. the n urse makes
use of the following criteria:
a.
Nature of the condition/problem presented - problems
~ire class ified as health status. hcaltJ1 resources or heullb-related
p roblems:
b. .M agnitude o f the probl em - rl;!fers to the severity o ( the problem
which cn n he measured in lerms oflhe proportion of the population
affected by the problem;
c. Modifiability of th e prob lem - refers 10 th e probability of reducing,
controlling or erad icating th c problem:
d. Preventive p otential - refers to t11e probability of conlrOUing or
reducing the effects posed by the problem;
e. Social concern - refers to ilic perception of the population or the
comm unity as they are a ffected by the problem and tl1eir readiness lo
act on the problem.
Table 7.2 shows the scoring system which the nurse can use lo prioritize health
conditions/problems.Each problem will be: scored according to each criterion and
divided by the highest possible score multiplied by the weight. Then the final score for
each criterion will be added to give the total score for the problem. The problem with
ilie highest total score is given high priority by the mtrsc.
175
r.
"""'
TABLE 7.Z PRIORmZING HEALTH CONDITIONS/PROBLEMS: SCORING SYSl'EM
Scor-e
Criteria
W eight·
'
;; Nature of the Problem
O
0
0
,.
liealth status
t-1ealt'1 resource
Health-rel ated
'
.
.
'' Modfffablllty of the Problem
iJ High
u Moderate
0
□
□
Low
4
'
0
··..:
Moderate
3
2
low
l•
.. -
176
3
2
1
','.,
~~
3
·.,,
Social Concern
Q Urgent community concern; el(pressed readiness for action
!J Recognized as a problem but not needing Immediate action
D Nol aco,r1munitV concern
~-
'
1
'
.
11
,.
'
4
3
2
Preve11tive Potentfal
•
0 Hfgh
'
l
J
u Not modiffabfe
,.
,,
.
.
Magnitude of the Problem
-, Affect ts 7S -100% of the population
I. '
C Affects 50 - 74'6 of the population
□ Affects 25 - 49'K, of the population
D Affects less than 25% of the population
-
'
3
2
1
2
1
0
source: UP Cnllege of Nur5lng, Community Health Specfo~y Group., 1989.
.
1
1
I
r
EXAMPLE OF A DATA COLLECTION PLAN SEGMENT:
- ;
To describe the demographic
characteristics of the 0-12
years old population
Proportion of target
population vis-a-vis total
community populati(111
Characteristics of the target
population in terms of age
and sex distribution
:no!{
DATANHDED
Tota.I population s11e of the
communfty
Review of municipal or barangay
records
Total population of the target
population, 0-12 years old
Household survey
7
Records review checkllsl
Survey questionnaire
Survey questionnaire
Household survey
Disaggregated population size
according to:
a. age
0-11 months
l ·S years old
6-12 years old
b. sex
male
female
l o diidlbe~ulth status Trends ,n the health and leading causes of deilths and Records reviewof the barangay
of children (0-12 years old) in illness pattern of the target illness of the 0·12 age group health center
group over 2-3 year period
over the past 2-3 years
terms of :
• common causes of
Illnesses
• common causes of
health center
consultal!on
• common causes of
hospltallliltiOn
• common causes of
death
-nutritional status
r
!.:
~
i
fl
t
• number of recorded deaths
• number of recorded heal th
centei- consultations
Records review checklist
Key informant Interview of
• earangay Health Worker
• Councilor for Health
• Health Center Physician/
Nurse or Midwife
KIi guide
Records review of health center;
household survey
Records review checklist; survey
questionnaire
Number of children with
• normal weight for age
• weight below normal
• weight above normal
Review of health center records
on nutritional status of children;
weight-taking
Records review checklist; weight-forage table
Magnitude of the problem
KIi of Nutritionist
KIi guide
- number ofrecorded
referrals
to hospitals and other health
facilities
Reported causes of Illness Incidence and prevalence·
among 0-12 years old
rates of diseases among the
0-12 year.; aid
E
~
Nutritional status of the
0-12 years old
....
...,
...,
........,
00
OIJECTMS
To aetetm1ne tilt socioeconomic, cultural and
envlronff\tntal factors
which contribute to high
preYalence of ARI and
malnutrition of chlldren
(0·12 years old)
INFORMATIONNEtOID
Risk factors/benaVIOl'S
that contribute to
malnutrition and ARI
DATA NEIDID
TOOLS
DATA COlLECT10N METHOD
Lil1!St'(le, n.ealln nan1ts and Screening; risk ractor
Screening, risk assessment and
practices that contribute
assessment; KAP Survey; visual KAP survey forms; observation
to malnutrition andARI
observation
checklist
Social, economic and
Socio-economic and
cultural profile of
cu\tural factors that
contribute to malnutrition fafl'lllles that lnftuence
and ARI
children's susceptibility to
malnutrition andARI
Household survey; KAP survey; Survey questionnaire; KAP survey
vlsual observation
form; observatfon checklist
Environmental factors
that may account for the
problem of malnutrition
and ARI
Environmental scannlnl!
Observation checklist
Environmental
charaeteri$tlts that
acco11nt for increased
cases of malnutrition and
ARI
'
Per(eptions of the people
regardingthe problem of
maloutritfon and ARI In
the community
it
g_
S°·
Extent of problem,
Perteptlons of the health cause/s1 perceived
workers/community
solutions and current
leaders regardingthe
actions to address the
problem of malnutrition
problems
and ARI in the community
&>
ij,
~
"~
-
Knowledge, attitudes and
practices of the people on
malnutrition and ARI
~
-
- -~
Focus group discussion of
FGOguide
selected mothers or caregivers
of children
Kev informant lnter\/iew of
local community leaders and
health workers
.. ".
KIi guide
.
APPLICATION OF PUBLIC HEALTH TOOLS IN COMMUNITY
HEALTH NURSING
Aside from the biophysical and social sciences, community health nursing also
synthesizes in its practice the concepts, knowledge and skill.s d er-ived from public
health. The population and wellness emphases of public heallh are the same essential
features of community health nursing. Tools in measuring and analyhing community
healt h problems such as epidemiology and biosta tistics were :.ipplied to form part of
our assessment tools in the diagnosis of communily health nursing problems.
TI1e health disciplines of demography, vital statistics and epidemiology a-re three
important tools that help the nurse in identifying t he commun ity's health needs.
DEMOGRAPHY
More than just being aware of how large a population is in a community, the nurse
also needs to comprehend the characteristics of the population that makes tJ1e people
vulnerable to certain health conditions. She can determi ne the nature a nd magnitude of
existing and potential communily health nursing problems if she possesses knowledge
about the population's s ize, composition and distribution in space. Demog.r apby, the
science of population helps the nurse find reasons or rationa le why or how a particular
population or group is influenced by a variety of factors resulting in vulnerability to
diseases.
Demography is the science which deals with the study of the human population's size,
composition and distribution in space. Population size simply refers to the number
of people in a given place or a rea at a given time. \'\/'hen the population is characterized
in relation to certain variables such as age, sex, occupation or educational level, then the
population composition is being dcsc:ribed. The nurse also describes the spatial
distribution or how people are distributed in a specific geographic location.
The three events descn'bed above are affeqted depending on bow fast or bow slow
people are added to the population as a result of births, deaths and migration occurring
in the community.
Sources of Demographic Data
Demographic •information can be obtained from a variety of sources but the most
common come from censuses, sample surveys and registration systems.
Census is defined as an official a nd periodic enumeration of population. During
the census, demographic, economic and social data are collected from a specified
population group. These data are later collated, synthesized and made known to the
public for the purpose of determining and explaining trends iu terms of population
changes and planning programs and services.
There are two ways of assigning people when the census is being taken. The de ju.re
method is done when people are assigned to the place where they usually live regardless
of where they are at the time of the census. On the other hand, when the de facto
method is used, the people are assigned to the place where they are physically present
at the time of the census regardless of their usual place of residence.
Since the census asks for a complete enumeration of the population, it is usually a
very expensive undertaking. It will requi:re money to pool together people and other
179
2.
Relative increas e is the actual d iffecence between the two census counts
expressed in percent relative to t he population size made duri ng ao
earlier census.
Pt • Po
Relative Increase =
Po
where:
Pt = population size at a later tlrne
Po = population size at an earlier time
population Composition
The composition of the population is commonly described in terms of its age
and sex. The nurse utilizes data on age and sex compositio n to decide who among the
population groups merits attention in terms of health services ,md progr ams.
1.
Sex composition
To describe the sex co mposit ion of the population, the n urse computes
for (he s ex ratio. The sex ratio compares the number of males to the
number of females in the pop ulation using the formula below.
number of males
Sex Ratio =-
- - - - - - - - X 100
number of femafes
The sex rntio represents the numb er of males for every 100 females in the
population.
2.
Age composition
There are two ways to describe tbe age composition of the population.
a. Median age divides the population into two equal par~. So,
if the median age is said to be 19 years old, it means half of the
population belongs to 19 years and above, while the other half
belongs t o ages below 19 years old.
b. Dependency Ratio compares the number of economically
dependent with the economically p roductive group in the
population. The economically dependent are those who belon g
to the o - 14 and 65 and ,1lxwe age grou ps . Considered to b e
econornicnlly productive are those "ithin the 15 to 64 age group.
The dependency ratio represents the number of economically
dependent for every 100 economically productive.
Dependency Ratio
= total populat!Ofl of the o- 14 and 65 and above a_ge group
- -·- - - - - - -
---
-
x100
total poPUlation of 15 - 64 age sroup
181
65+
'F
2
~
•
a,
<
60-64
55-59
50-54
45-49
40 -44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
l l
I
4
6
2
0
2
4
6
Percentage (¾) of P opu latio n
Figura 7.2 Popufatfon Pyramid for Zone 3, Sto. ltosarlo-«anluran (UPCN,
September 2008)
Sourre: Florendo et al, 2008
Population Distribution
The distribution of the population in space can be d escribed in terms of urban-rurnJ
distribution, population dens ity and crowding index. The measu res help the nurse
decide how m eager resources can be justinably allocated based on concentration of
population io a certain p lace.
t.
Urban-rural distribution s.imply illustrates the p roportion of the
people living in urban compared to th e rural areas.
r an
R•lon
ura
Popu at1on Dens y
fpersq Ian)
27 .
nao
183
Sc~mr~c.J wili1CamScanr11:;1
Fertility Rates
General Fertility Rate = __
n umber of live births
--·----------------midyear population of w omen,
_ _ )(
1
ooO
15- 44 y ea~s o f a ge
Morbid ity Rates·
number of new cases of d isease
In cidence Rate = _
--
_c:eveloplng from a period of time
_ _ .,, f
p o pulation at risk of devel oping the disease
-------
number of old and n ew cases of a disease
Prevalence Rate =
- ---. - - - ------- -------populanon exami ned
_ -,. f
Mortality R. tes
number of deaths
Crude Death Rate =
--- - · ····· x 1oOO
midyear population
n umber o f deaths i n a
Specific Mortality Rate _
- -
specified group
·- -- - - - - - ,c 1000
midyear popu lation of the same
specified group
--
________________..
number of deaths rrorn a
specified cause
cause-of-Death Rate =
mi dyear popul ation
deaths under one year of aGe
Infant Mortality Rate =
----------- --------··-number of live b irths
n umber of deaths du e-to pregoanGY•
delivery and puerperlum
" 1ooO
M aternal Mortality Rate =
---·-·----- -------numb er of live bi rths
th e t)l"'(':u:-n,·,· or nh:-.cncc of wh k h mny ,;crvl' ns llli111u lu11 tn lnil hll<' or purp ·tuttlc 11
d isc:1sc pro,•(•-..... 111is lrnpp c 11,; o nly w lH•n tht.' 11grn11 co rnc11 in co ntn<:t wi th n r;u,iccplil.ile
host :111d unolt>r prtlp<.'r e nvironme nta l r1111 rlitio11.s.
Ac•nt
E11arnpte
e1olog1cal
vlnn, bactl!f'fa, fungu,. para~ile
Chrrn1cal
!@ad, mt'rcurv. ln~«ttclde
Physical
hurnldtty, atfl\osph11rlc prOY11re. rlldlatto n
MC!Chanical
stab, trauma
Nut r itive
lrOfl or Iodine deficiency, cholesterol
A host is any organism that harbors uml provides 11ourishrncnt for ono thcr ori.ani:m1.
TI1e characteristics of I he hos t will affect l, is or it.s risk of cxpMnrc 10 sources of
infection and his or its s11sccptihility o r resis tnncc. The rcsistt111l·c 11f lhc hos t may be
specific or non-specific. Specific rc!'< istancc re.~111ts fr111n 11 11 i111mu11oln1,:ic experience
such as unde rgo ing immuni1.at ion o r vacdnnticm. Nu n ~p1.:d lic r(·~istanc:c re..sults from
an intact ski n, muco,1s membra ne, reflexes ns lacri malion. coughi ng, diarrhea. or
vomiti ng. They can be maintained U1rough 1:,ersonal hygienic prnctices, environmental
sanitalioi;t, p roper nut rition and n healthy lifestyle.
Since the nurse considers the community as /\ host she protects tb e hMhh of the
oommu.nit y by increasing its herd immunit}' · He rd imrnunily is the probability of a
group or comm u nity developi ng an epidemic upon introduction of an infectious agent.
It is the proportion of the immunes and the s usceptible in Lhc group.
The environmen t is the s um total of all e:..1:ernal conditions and in nuences that affect
the life and development of an organism. The environment both affects the agent and
the host. There are t hree compo nents of the environment:
1.
2.
3.
Physical environment is composed of th e inanimate surroundings such as
the geophys ical conditions or tbe climate;
Biological environment makes up the lh i ng things around us such as plant
and animal life;
Socio-economic environme nt which maybe in the form oflevel of econom ic
developmen t of the community, presence of social dis ruptions and the
like.
The three elements of the ecologic triad in teract 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 equ ilibrium provoking the appearance of a health problem.
Natural H;story of Disease
Describ ing the natural h istory of disease seeks to identify factors related lo the course
of a disease o nce established in order to determ ine its duration and the probability
-
187
Tertiary Prevention
Tertiary prevention limits disability progression. The nurse attempts to reduce the magnitude or severity of the res\dua\ effects of both infectious
diseases (e.g. hearing impairment from frequent ear infections or impaired vision from severe conjunctivitis and shingles) and non-tommunicab\e
ones (e.g. mental illness, cardiovascular-diseases, COPD). Day care centers and sheltered workshops are examples of opportunities to achieve the
objective of tertiary prevention in mental illness and drug abuse.
.
TABLE 714 NATURAL HISTORY OF DISEASE~ND ~PLIC!ATION p F DIFFERENT LEVELS OF DISEASE PREVENTION (LEAVALL & CLARK, 1968)
.
Events
Stage
.
Specific Interventions
Primary prevention: alms to prevent
development of disease
Health promotion
• Health education
• Nutrition counseling
• Adequate housfng
• Personal hygiene
• Environmental sanitation
• Family planning
• E>entai hygiene
Specific protection
• lmmuni2ation
• ChemoprophylaKis
• Protec.lion ag.ilnst lnJuries and
occupationalhai.irds
Level of Application of Preventive
. .
-
•
-
..
I
.
•
I Prepathogenesis
or susceptlblnty
•
Interrelations ofvario'us host,
agent and environmental factors
bring host and agent together
Disease-provokio¢•stlrnulu~ I~
prod·uced in the known host
-
•.
,,
•
it
•
g_
II Pathogenesis
S°·
· Early pathogenesis
&>
•
ij,
~
..i'.
"~
...
~
•·: '.
? •
Interaction of host and sumulus
Stimulus or agent b-ecomes
established (lfirifectious agent
Increases by m!,lltip!ication)
Beglnhlng tissue and physiological
changes
Secor:1darv prevention: alms to:
• Promptly diagoose and treat disease
• Prevent spread of disease to healthy
population
• Prevent complications aod sequefae
• Shorten period of disability
Early dfagnosls and prompt
treatment
• Screening
• Case-finding
• Selective examinatioo
Concept of Causality and Association
The concept of causality lay on two premises. First, it states that disease does
not occur at random ; and second, d isease has id entifiable cnusal and preventive faclors.
The Hen le-Koch Postulate asserts tbat a cau se of a d is ca5C is any eve nt, conditio n.
characteristic or a combinatio n of these factot·s thut play an important role in produci,ng
the disease. fu rther, a c:mse m ust precede a d isease irnd lhe cm1se o f a d isease must
be necess ary :md sufficient for the occurrence of disease. Ne cessary cn u s c refers
Lo the fact t hnt the factor ffillfil be present fo r t he disensc to occur. S u ffi cicn t caus e
indicates that if a factor is prese nt, the discn.sc c..m occur, hu t the fo clor's prese nce
ru:,es not ahD1YS result in th e disea8e's occurrence. T hus, whe n Lhc spnt um from a
person s uspe<:ted of tuberculos is demonstratc.s the bacilli in the s mea r exam ina tion,
it confirms lhe p resence of tuberculosis. The tubercle bncillus is a 11cccss,1ry cause
for TB to occur. The presence of d iabetes mellitus in n person d ues nut .ii ways lcm.1 to
occurren ce of tuberculosis; but studies have shown that il is a sufiicient cau se for Til to
occur. The condi ti on of reduced blood glucose seems to lower the perso n's im m unity
and make him susceptible to communicable diseases like tuberculosis.
Thenurse is not only responsible for ma king sur e U1at thcsick in the commnn ity r ecover
from th eir illness a nd injury. In caringfor the pop ulnli c111, the moreim po1·tant d imcns ion
is for the healthy to rema in in Uieir optim um level of wellness whilst preven ting them
from developing d isec1se co nditions. Th ere a rc segm en ts of the pOJ')1Jl.1Lio n who have
certain risks of acqufring certai n diseases. Ris k is th e probabi lity of an w1fnvurablc
even t- disease, disability, defect or even death. It is imporwn t fo r the nu rse ,rnd the
people to have knowledge ab out these risk fact ors associated with disen.-,c cond itions .
Disease can only be p revented if tbe risk factors a re iclen1ified and dealt with. The
concept of as s o cia tion does not necessarily imply a c.iusal rela tionship. It on ly states
that if there is concurrence of two variables more often lhan wo uld be ex-peeled by
chan ce, then the two variables under in ves tigation are said lo be associated . The
following a re the differen t facto rs associated with increased rii:;k of disease:
•
P.redisposing factor - any characteristic ofan Individual, a community or an
environment that predisposes behavior or other conditions related to health;
Includes knowledge, belief arid attitude but may include other factors such as
•
Enabllng factor - any characteristic of an lndlvldual, aroup or the environment
that facilitates or make po»ible a certain health behavtor or other conditions
affectina health; inc:ludes any skill or resource required to attain that condition
Relnforcfr,g factor- any reward or punishment or any feedback followlns or
anticipat~ as a consequence of health behavior
soeio-economk: stat1JS
•
The relat ionship between a risk factor and a certain disease can be described in terms
of the following types of association :
L
Sp urious or artifactual association - association when none actually exists
2 . In direct - presence of a known or unknown factor common to both a
characteristic a11d a disease may wholly or partly e., 1>lain a statistical
association
3 . Direct or causal - presence of a factor wh ich wholly and directly explain t he
cause of disease; no intervening variables
• One to one causal - suggests that when one factor is prese nt, disease
res ults ; conversely, when the disease is present, the factor must also be
pres ent
191
test. It measures the probability o f the test correctly identifying a posi tive case o f a
disease (tnie-positive). S pecificity is the proportion of person:; wilhoul a disease who
have negative results on a screeni ng lcsl. II n 1cns11res th e prr>habili ty of correctly
identifyi ng non-cases (true-nega tive) (Ander.son a n<l Mcfo',irlane, :wn7). ·111e nurse
must be aware o f th e sensitivity ,incl spccifici ty rn tes of screening measu res that are
used to detect a disease. In co mmunity situ:i tions when there is ;m imm!!diate n eed to
as<.-crtain d isease sta tus, the nu rse sel!!cts scrr:ening measures thal wi ll yield I he highest
probability of tr ue-positive for the pu rpose of providing appropriate trea tm ent an d
consequ ently preve nt the transmission of cfo;.casc to t he rest of the health y ropulation.
On the othe.r lw ncl, if reso urc es are limi tcd to the extent th:il scrcc!ning ca n not he done
to all people suspected of the disem,c, the nurs c will have to cQrnpromisc with screening
tests with high specificity, ident i(ying only those who "do not have the d isease". TI1e
choice of h aving a specific or a sensitive scrc.-enini.: test is not an easy one fnr the nuri,e.
If she chooses on e tha l h ns high se nsitivity, there is Lhut probability of some people
having the disci1sc that will not be detected hy th e screening test. This is referred
to as false negative. 'J11is impli cs thri t these? r eople may not be g ive n ;ippro p riate
treatment having tested neg;itive rn the test. If th e nurse decides o n tests lh al have
high specificity, there is probability that some people wh o do not actually have tl1e
disease wi ll be diagn osed !L'l "diseased"'. This is rcfo rrccl to as fa lse positi ve. Peorle who
arc false positives may be refe rred lo hospi tals for trc,1Lmcnt when in fact, th ey a re not
ill. Table 7.5 shows the r clnlion~hip of sensi t ivity a11d specificity of a screening test :
TABLE 7.5 SENSITIVITY AND SPECIFICITY OF A SCREENING TEST
Disease Status
Wlttiout
With Disease
Scre ening Test
Results-
.
'
Total
Positive
True Positive
False Posftfve
True Positive
+False Positive
'
, Negative
'
False Negative
True Negative
False Negative
+True Negative
' Total
Total Wlth Disease
Total Without
Disease
\
.
'
'
.
'
' ..
True poslt1Ve5
Se'nsltll,:lty, or True -Positive Rate =
------------ KlOO
Tot al with disease
'
'
True negatives
Speclficit-y: or True, Ne~ tive Rate.=
I
;. '
·- xlOO
I;
Total w ithout.clsease
''
'
---
False negatives
False-N'e gatlve Rate =
I
..
'
' '
' Rare
'
False-Positive
=
'
'
'
'
.'
-------·
--- IC 100
Total with disea se
.
'
False p ositives
-·-------------- xlOO
Total without d isease
'
0
MacMahon & Pugh,(1'9"70). Epidemldlogy: Pr/help/es and Methods. Boston, MA: Little,
'
,
'
· Brown and Co.
193
After the nurse ascertains the diagnosis of disease, she n1akes observations of
the disease frequency and recorded as disease rates. The attack rate (Valanis,
1992) is used to calculate an identifiable p opulation ex p osed t o an infectious
agent. It represents the incidence of the illness amon g the exposed population.
They are frequently used in surveillance and control of communicable
diseases.
2 . Describing disease as to person, p lace and ti m e characteristics
After the disease or condition has been identified with reasonable certainty,
the number of persons who possess the disease a re recorded n oting down the
characteristics of the afflicted persons, the time the disease was initially recognized
and the characteristics of the place w h ere the cases came from .
To a certain extent, the nurse can derive associations between the risk of acquiring a
disease and characteristics of persons. Some variables provide cl ues as to the probable
cause of the disease. These variables include age, sex, marital conditions, occupation
or socio-economic status.
In viewing the susceptibility of the community as host, the n urse determ i nes th e
characteristics of the community and its population in terms of the following:
1 .
Herd immunity is tbe basis for determining the community's reaction
against disease invasion since it re presents the immunity and susceptibility
levels of individuals comprising the population . T be immunity level is
inversely proportional to the s o scepbbili ty level.
When the proportion ofthesusceptible are high compared to the proportio n
of tbe immunes, then the community is experien cing an epidemic. An
epidemic is a s ituation when there is a marked upward fluctuation in
disease incidence.
An cnd.emic occurrence of disease implies the habitual presence of
diseas,,> in a given geographic location accounting for the low number of
both immunes and susceptible.
Wb.en disease occurs every now and then affecting only a small n umber of
people relative to the total population, then we have a sporadic type of
disease oceurrence.
2.
Exposure or Contact Rate represents o p portunities for p rogressive
opportunities for p rogressive transfer o r transmission of an infectious
agent to a susceptible host and d epends on the frequency of contact. and
facility of transmis s ion.
3. Chance is the probability of contact between the sour ce of infection and
the susceptible host and depends upon the num ber of sources of infection,
the number of immunes and location o f the source of infection.
1.94
The nm·se characterizes the pattern of disease occurrence in terms of date or time
onset. This is indicated by the epidemic or attaek curve. Disease occ urrence can be
described by the following:
1.
Short time fluctuations common in epidemics:
a. Common source epidemic is cliaracterized by simultaneous
exposure of a large num ber of susceptible to a common infectious
agent;
b . Propagated epidemic is caused by a person-to-person transn1ission
of disease agent;
2.
Cyclic variation refers to recurrent fluchlations of disease that may ex.hibit
cycles la,;ting for certai o 1>eriods;
Secular variation refers to changes in disease freque11cy over a perio.d of
many years.
3.
The demonstration of association of a disease with place implies either tJ1at tJ1e people
living in a certain geographical location have certain traits or a re un i([nely different
from those residing in other places. The differences in terms of trai ts may have been
influenced by certain environ.mental factors present in tlle biologic, chemicaJ, physical
or social environments of the people inhabiting that place.
3. Analysis of the general pattern of occurrence of the disease or condition
After establishing the disease frequency and distribution in a population and d efining
th e characteristics of the d.isease 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 shldy an·d the probable factors surrounding it. It focuses on
clinical observations using case reports or case series. This stage is called hypothesis
testing. The exp osure factors and the disease wi.U be tested or proven in the next phase
of the epidemiological process.
Analytical Epidemiology
More than just describing the disease in terms of person, place and ti me, Analytical
Epidemiology attempts to identify the possible factors as&oc;iated with d isease
oc.currence. Using the concepts of causality and association, it seeks to establish the
risk of developing specific disease or condition among people exposed to k nown factors
or situal'ions. It consists of hypothesis-testing of causal association using different
epidemiological study designs. Case-control and cohort studies are em ployed in
investigating patterns of disease and cause in individuals. Correlational or ecologic
studies are utilized in analyzing patterns of dis-ease and cat1se in populations. Analytic
studies employ meas ures that show strength of association between a purported health
condition or factor to increase risk of disease. These measures, a.lso called risk estimates
a.re relative r isk ratio (RRR), odds ratio (OR) and attributable risk (AR).
Risk Estimates
The relative risk to an individual developing a disease due to a pa rticular exposu re
is derived by com paring the occu rrence of a disease in a population exposed to the
suspected factor to u,e occurrence of disease in a population not exposed to the
suspected factor. It is a direct measu re of the strength of associatio n between a
suspected cause and effect (Lilienfeld et al, 1994) The relative risk ratio only implies
an in creased probitbility of developing a disease as a result of exposure to a risk factor.
A relative r isk ratio of 1.0 means that the ris.k is the same for botl1 exposed and nonexposed pop ulations. A risk greater than 1.0 indicates excess risk in the exposed group.
(Valaois, 1992)
195
l
lnddenat Rate amcng those exposed
Relaaw Risk Ratio
=
Incidence Rate among those not exposed
An e.-.:ample cited in MacMahon and Pugh (1970) d escr ibes the relationship of heavy
smoking (defined as smoking of 25 or more cigarettes per day) and incidence of lung
cancer am ong British m:1le physicians from 1951 to 1961. The in cidence r ate of lung
=~among heavy smokers was 2 . 27/ 1000 populatio n . .Among the n on- smokers, the
incidence rate was only 0.07/ 1.000 population . Using the above formuJa, the RRR is
32. 4. It means that 1he risk of lung cancer among heavy smokers is 3 2 t.imes great er
compared to non-smokers.
The odds ratio is similar to relatiYe risk in a way that it estab lishes tl1e probabili ty of
disease development as a result o fbeinge..,q:, osed to a suspected factor. In epidem iologic
studies where incidence rate.s or prevalence rates are not available, t he o d di:; ratio is
used to estimate tlw risk or probability of disease de,·elopmeut. ff the odds ra ti o is
equal to 1.0. it suggests that the factor is not a risk factor to the dise~'lse o r condit:-ion
being inv·estigatt>d. (.:-\ .nderson and l\1cFarlane, ::1007) T o compute for th e odds ratio, a
cross tabulatio n sho wing the proportion of persons exposed to a susp ected factor with
or without cilseca.se a.ad proportiou o f person s ·who were not exposed to a suspected
facto r that deYe]opt'd or did not develop disease.
Exposure to a Rlsk
With Disease
d toafactor
A
Not e ,:po,ed to a facto r
C
E•p1
Taal
Tota l
Health Status
Factor
Without Disease
8
D
b +d
a +c
a+b
c+ d
a+b+c+d
The odds of having the disease when exposed to a suspected factor is represented
by a(b in table 7.6 wb.ile the odds of having the disease when the fact o r is absent is
represented by c / d. The odds ratio is com puted:
TA8LE 7.6 ODDS RATIO FORMULA
8/b
Oclds..a.tro - - c/d
ad
w. be
The use of odds ratio is dem onstrated in a case-control study on the association of
meat consumption ·w ith enteritis necrotic.ans in Papua New Guinea (Millar et aJ, 1985
cite d by Beaglehole, e t a l, 1993) En teritis necrotica n s is infla mma tion of the small
bowel, u sually the jejunum and ileum leading to ulceration a nd p erfor a tion of the
s m al l int estine. rt is a fatal type of food poisoning caused by 13-toxin of Clostridium
perfri ngens.
196
.
Exposure to a Risk
Factor
Recent meat Ingestion
No recent meat
lmrestfon
Total
Total
Health Status
With Enteritis
Without Enteritb
necrotlcan1
necrotlcans
50
16
66
11
41
S2
61
57
118
Usihg the formula for the odds ratio:
OR= ad/ bc
= so (41)/ 16 (11)
= 11 ,6
The OR inclicates that the people who were diagnosed to have Enteritis necroticans
were u.6 times more likely to have ingested meat compared to those who were not
diagnosed to have the disease.
Attributable Risk provides information about absolute effect of the e;,,.l)osure or the
e.xcess risk of the di$ease to a causal agent. It gives a better idea tban the RRR of
the impact of successfi_1J preventive or public h ea]th program might have in reducing
the problem. It is computed by taki ng the difference in the incidence rates of disease
between e;,,.'J)osed and non-exposed population.
Attributable Risk = Incidence Rate among e11posed - Incidence Rate amon1 the nonexposed
The concept of attributable risk can be shown by looking into lbe relationship of
mothers' atlendnnce to reg1.1h1r pre-natal clinic visits to maternal complications. The
incidence rate of maternal complications among those who regularly attend pre-natal
clinic was 53/10,000 live hirtbs compared to those who do not attend pre-natal clinic
at 798/10.000 live births. The AR was computed at 745 which means that 745 excess
cases of maternal complications can be attributed lo non-attendance of pregnant
women to regular pre-natal clinics.
.
Analytic Stu dy Designs: Cohort and Case-Control
Analytic studies employ cohort and case-control study designs to systematically
detem1 ine whether or not the risk of disease is different for individuals e.xposed or not
exposed to a factor of inleresL Cohort studies arc also called follow-up or incidence
studies stru·t with the determi nation of the suspected exposure factor among the study
population and asce rtaining their disease status late r in the study. Coho.r t can be
prospective or retrospective. If the prospective eohort will be employed, the measure
of clisease frequency lo be used will be the in cidence rate. 111e retrospective cohort
uses the prevalence rate as measure of disease frequency. The relative risk, odds ratio
and attributable risk are used to measure stTength of association between disease and
•suspected factor. The figure 7.3 (Beaglehole, et al, 1993) shows how the cohort study
design is carried out:
197
In case-control study des ign (Fig. 7.4), the study population 's dise ase status will b e
ascertain ed first . Those w i th the disease are considered as coses and those who do not
have the disease are considered in the control group. The p1·esence of the suspected
el\.l)Osurc factor for both groups will t h en be d etermined. The inciden ce or p revalence
rate ca n not be comp u ted in case-contro l study design; hence, t he odds ratio wi ll b e the
m easure of disease association.
lnterventional or Exp erimental Epidemiology
Iot erventional Epidemiology aims to test effectiveness o r ""r eason a bleness" of
interven tio n progr ams d esigned to p reven t and control d iseases utiliz ing randomjzed
controlled or clinical trials, field or com m u nity trials.
Eval uation Ep idemiology
Evaluation Epide miology attempts t o measure the effectivene ss of differen t
health services a n d int e rvention p rograms. The a p pJication of epiclemio]ogical
methods in evaluati n g programs to contr ol and p revent epidem ics of
com m unicable diseases led to g lobal efforts in erad ica ti ng cliseases like polio
or thwart transmission of d ise ases to pand emic p roportion . (Beagleh ole et a l,
1993)
198
CONCLUSION
The nurse uses Community Diagnosis as a tool in the assessment of the community's
health status. A,; a pTofile, it d escribes the different factors that relate to existing
health and illness patterns of the community and its people. These factors include Lhe
demographic variables, socio-economic and cultural factors, environmental factors,
health resou rces, political and leadership patterns found in the community. As a
pro\;ess, comm un ity diagnosis involves the co]lcctio_n , collation, synthesis, analysis and
interpretation of health data in order to d efine the diffe.r ent community health nursing
problems. Figure 4 illustrates this process. It is carried out with the active participation
of community members with the specific purpose of bringing about change i11 order to
improve the quality of life of the people.
The three clisciplines of p ublic health - demo grnpl1y, vital statistics and epidemiology
_ are u tilized by the nurse in analyzing the factors that bring about ill health in the
community. Demography helps the nurse understand the characteristics of the
population in terms of its size, composition and distribution in space. It also makes it
easy for her to define the focus of ca rein tcnns o(specific population groups.
Vital statistics are indices of the h ealth and illness status of the community. They serve
as bases for planning, implementing, monitoring and evaluating community healtl1
nursing programs and services. The epidemiological approach is used by the nurse to
explain probable ca uses ofhea Ith conditions as they occur in the comm unity. It consists
of four phases d escriptive, analytical, intervention 1md evaluation epidemiology.
Descriptive epidemiology aims to descrioe the occurrence of health conditions in the
community in terms of the atni butes of the people (genetic make-up, demographic
characteristics and lifestyles), the pattern of time Lhe disease emerges and the
ch aracteristic of the place where the disease appeared. 11te nurse will then fommlate
a hypothesis regarding the relationsl1ip hetween the exposure factors and the health or
disease conditions u nder study. To prove the association between a suspected factor
and disease, the hypothesis will undergo a systematic process of testing to prove that
the risk of disc;.1se is different for individuals whu are exposed or not exposed lo a
factor. This is the seco nd phase of the epidemiological approach caUed analytical
epidemiology where the nurse establishes a causal association between a dis~e and
suspected risk factors present in the communi ty. Analytic studies that are commonly
used a.re cohort and c:ise-control sllldy designs. To test the strength of this association,
risk estimates arc computed.
The health problems and the factors that conLTibuted to these problems can now be
presented using the PRECEDE-PROCEED Model that will be discussed in the ne)((:
chapter.
REFERENCES
Anderson, ET and McFarlane, J. (2004). Community as Partner: Theory and
Practice in Nursing. Lippincott Williams and Wilkins. Philadelphia
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2,
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·neaglchole R, Bo11ita Rand Kjellstrorn T. (l993j Basic Epidemiology. World
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. • Bennett FJ (Ed.). (1979). Community Diagnosis and Health Actio11. A Manual
for 1}•opical and Rural Areas. London and Basingstoke: The Macmillan Press
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.1
C' ""~l. ,I(' ( 1003l Crnnmu nil-y l"li:ii-:.nt>'-i!". 1 n ,\ R Omrttn ( Ed). C o1H1111111 it JI Modrl~
m t>rt-.·i<•pho n,ur:tric-.o: I.Pl' :\ lS-~t{-.2l. N ..w York : S pringe r.
!-•
Cl4 rk. ,1.1. \100::). , ·un-111!} i,i chr C1•mmrmir.11. No rwnlk. Co11m:cl ic ut: J\pplctc,n
und I ..anp•
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C'J nr"k. ;-.1.1 l.:Pt,3l. c ...w,· 11111iry hr-uitlr 1111n; in9: curing .fc)I' pop11lat ions. 4 '" eel
l"(-ar-so ;:; Cduc;,ll(>· i. lnc. l'ppcr ~addk R.h·l·r. N.1 0 74 ~8.
-;
l'\c:',"'C'" er.. {1o~l'•' l",,,.n.ru,:tlt_v flN::lth , \n nlµsls: ..A
G r □ant.,wn. "la.p l.::1ud: .\ s~'<·n Systems.
Holis tic
A.pproac'1.
rmnrµn. 1 Jrn.l l::,...._"ln. ~ ltOSo) .\.n Epidemiologic.,l App r oad1 to Commun ity
A~ <c-.cnt r t.-i..t.,· Ht'tl.!~h S 11rsing 0(3): 147 - 15 1.Se ptembc r 1989. Cop yright
10"4 Bu,d,"-11 ,·
ec"'.11i& Publkations.
o.
Flon-ndo•. PF t!'t al ~::coo$) Communitv IJiagno!'i!' of Zone 3 . Barangay Sro.
1-., ~J.. a~Jurc.r.. Fi; a-;vs.
-
10
l ·::-• bl ,;hed Co- ..r::urut) Di.i.lroosi"' CP M anila College o f Nursing.
·- F~;,c RB ar-d l:i('"'..a.--ich. J (1981).Com munity Health ,Yursi11g P ractice (2""
«-i M:,~d~..,i~ v.·e: u..ode.s.
l~
l'
F~~=. ''T 1cS-6l P'aHmT5
.
in evaluation: et:aluating dcL·clapmcnt a nd
o.......-wrr{¥ ,:J '!:, cv.r-.c.s 1.dth partiapants. :.t a.cm.ilia a Publi.shen- Lld. L<lndo n
.c;c. Ba..'<i::.;:.r..;o e.
H.wdoc:C"TlSa:!kO, Prio-i-iy &tting OfCommunity Hcalili ~V un:ing Prob fr:=.
tJ P Cna7-e$:!e (X ~ ursin1;. CHX Specialty Group.
, •._;.So
1.5 iidv-.r. C.O. {.1-c-<:<c)• •'Vivar.coo practice numng in th e communit y. Thou.c;.;md
~CA:"-i=
t!i. Hunt. R 1~51
fo r.r 'Xluct ion to oommtrnity-bo.scd numng. 3 "' cd Lfppinco11
·...-.aa~ t. v.-,.n~<
:-.
Kuss,•~ f'ruol.ir-Gir.a.d. L.. L,:r.in.. S .. ~17.. C., and Kennplly, P. (1997). J-\ p ublic
l:irahh cur-.ir;;; rnod,cj. PJJbu:; Health Suning, 14 , 8 1-91..
1.8. Lil~ ' 1 D. LJ II!""' Id .-\ af'd ~1oftl"'}-, P. 11994) Fnurula1 i o ns ofE rndcmiology,
: ~ "Ja-< .. o~.r ~ I ·.._,,,,<"T"",t)"P-r.,.. ~
Jc;. Ln:xf) <.i, .!a~ S ( Ed'<} (2091) Community Jlealth Nursing: Carin g fo r th e
Pur.x's Hrai:'1.. ;.:..,...-buSIi!~:,<.. ~ and Ba rtJ!.-t t PubliCiltions.
20 ;.ac. 1A~~ D and P~. TT f1,r,-~J. Epidrmwlogy: Princ iples and McrluxL...
Bo-'on. MA.. J....-<le, Rn,wn _.nd C-0.
21. M.a.••:e:saci. P!>-. ' 2f.lOl1, PTcrarir-2; ~ for t he future. In P.S. M a llc:-on (F.,d.).
v--r.mun- ·y-1,cso:J rr.u:rrrz~ rdurat 0 ri <pp.1-7} :,_,_ York: S pri ngc-r.
200
22. Mcrcndo It. ( 199a). Read ings in Uealth Sys tem .~ Manauement. UP Manila:
Coll cy,c of l' uhlic Hea lt h.
23. Me nd mr.1-1 O M 11 nd r11he rs . ( 1997). Fm mdatirms of S tatisti cal Analys is for the
Jlea lth Sr.fences (Volume 1). UI' M:ini l:i: College of Puhlic Health.
24. Mo ral R, el al. (2007). Community Diagnosis of Masagan a. Brgy. Sta. A na,
Pateros, Met1·0 Ma nila . Unpublished Co mmu ni ty Diagnosis, University of the
Philipp ines, Man ila .
25. Muecke. M . (1989). Com m unity Hca Ith Diagn osis in Nursfng. Public Health
Nursing 1(1): 23 -25, March 1984 Keprinted hy Blackw cU Scien tific Publicatfons
In c.
The enviro nm ent in human e.cology: General
conside rat ions. In Pan-America n Health Organ ization: En vironmen tal
Determina n rs of Com m unity Well-Being. Washington, D.C. 1965 p .3.
26. Pay ne,
A MM
(L965)
27. Sanders . I T (l958). Theories of commun ity de velopment, Rural Sociology. 23,
1- .12 .
2 8 . Spradley BW. (t990). Community Health Nursing: Concepts and Practices.
Glenvie w. Ill inois: Scott, Foresman and Co.
29. Stnn hopc M and La ncaster J. (Eds.) (t996). Community Health Nursing:
Prom oting Health of Aggregates, Familfrs , and Tndividuals (4 th Ed ition ). St.
Lou is: M osby YeaT Book.
30 . Ta n. ML :md Dalisay. GY Man ual on Operations Ri:search. H ealth Action
Information Network. Que?.on City.
31. 1\iazoo. JA. , Do nes. LBJ>. and Bonito . SR (2003). A Training ;i,Janualf or Health
\Yorkers , m Prom oting HM/thy Lifestyle..~ l JP :Manila College of Nu rsingDe pa rtme nt of He:ilt h-Wo rld Health O rga ni7.atio n.
32. \ 'nl:rnis 13. (1992). Epidemiology in Nur·sing and H ealth Care. No rwalk.
ConnccL;cul: Appleton a nd Lange.
33. Women's Healt h an d Safe Motherhooa Project-Partnerships Component (2003).
" '/11 e P.R .A. - A Participatory Plan n ing Process". De partment of Health and
E.u rope nn Comm is sio n in the Philippines.
201
Ch ptc r 8
PLANNING FOR
COMMUNITY HEALTH
NURSING PROGRAMS
AND SERVICES
1
1
ru
...
JNTR OO-"" CTIO
""'~--.r~ ~ -i r,,~, r.,~mc ' - p'l'T.lT"i< r-'l'P 1l~• 1,
"'I",
,,, ~-. ' •.._.
",.
,;;.
L • ..,.,.. - •~ - :: ;"- ~~ • •uc:"'l ,,.., t-<t? .. -, ,,;-,.-: • n
' 1 ; ,,, ~ r.: 4 h(' r-1.-:,-:-r."1 r-:'1\,. •·••!l-.r•1 • nr~.. J
• , ... -c. -c. 7"'"-.4:r:- "'; ,d "-=': • ..,..., er r-~
:.••~""' • 1 .r j
,-n- n,-_ -,i..- r 1 , • ._
• ',r .;,, r•·\;io ,._ ..
Chapter 8
PLANNING FOR
COMMUNITY HEALTH
NURSING PROGRAMS ·
AND SERVICES
Luz Barbara P . Dones
INTRODUCTION
Planniogandimplementationofhea]t.hse1vicesandprogramsforgroups,populations
and communities involve the application of the nursing process based on participatory
community de,·elopment model. Since a lot of factors in the e xternal environment need
to be considered by the nurse, planning for nursing programs and ser vices generally
becomes more complex. Factors that may affect the planning process include existing
health policies and legislation, level of technology in the area, econom ic r esources
and pres ence of p rograms and institutions tlrnt a re s upportive .o r that may conf1ict
with proposed programs. la addition, the nurse ,vill find herse lf ,vorking with other
members of the h ealth team or ,,ith o the r sectors that may have different orientation
or strate.g ies in terms o f ,ie"ing solutions to coJUJJ1unity J3ealth problems. The most
important challenge to the nurse however, remains that of generating and sust aining
the community's sense of ownership and commitment to health programs and services
that address their needs and problems .
WHAT IS PLANNING?
Planning h as b een defin ed in many ways by maoy authors. What is common about
these definitions is that p lann ing is a process, normally, future steps to be undertaken
in orde r to achieve a desired end. This implies that the planner assesses the nature a nd
ex1:eot of the problems as well as constraints and limitations tJ3at may affect planning
decisi on.s . In general, pl anni ng.i s done in our desire to source o ut and allocate resoa rces
to improve t he present state of affairs. Mercado (1993) s ummarizes the concepts of
planning as follows :
Planning is futu ristic.
Plan ning is change-oriented.
3 . Planning is a continuous and dynamic p r ocess.
4. Planning is flexible.
5 . Plann.ing is a systematic process.
1.
2.
In community h ealth nursing, ilie nurse pursues the objective of enhancing wellness
and improving the h eal th status and quality of life of the p eople. She does this by
applying th e n ursing process in providing solutions to identified cornn1lmity health
problems and needs.
202
rlaoning in com munity health nursing involves the orderly process of assessing
1.he health problems and needs of the comm unity. Communily health problems are
conditi ons or situations that intervene with the communit)'S capability lo achieve
wellness. Th ey a re generally ca tegorized as hea lth s tatus problems, healtJ1 resources
and healtl1-related problems.
Priority goals are set accorcling to which (lroblems or needs are being add ressed
in relation to the ava ilability of resources. Interventiqns arc carefully thought of
consideri ng constraints or limitations as tl1ey may hamper the reali.rnlion of set goals.
In order to keep the commun ity healthy, the muse develops " i tb the community heal th
programs a11d Sel""\ices as well as organizational structure and resou rces to maintain
tliem.
APPROACHES TO PLANNING HEALTH PROGRAMS
Participatory Planning for Community Health
For commun ity and health developmen t programs and .scr,ices lo become rele\·anl,
responsive and susta inable, plan ning should involve people"s parlici-pation. People's
participation enables the community to become an integral pirrt of1hc dedsio11-making
and action process (\VHO 1995) a.nd guarantees the integration of their indigenous
knowledge a nd serves as social preparaLion for the program plan·s implemcnli'ttion
(WHSMP- PC 2003). The whole process of e ngaging th e co mmunity in the planninl?
process starts by analyzing how tbe nurse looks at the people or the community in
the sche me of d evelopment work. The Primary Health Care /\pproach (WHO, 1978)
emphasizes the need to w o rk w i th p e ople as equal partners towa rds th e goals of
incrcasecl individual and community control, political efficacy, improved quality of
comm unity life and social justice. (Wallerstein 1992)
Planning for a sustainable com munity health development grounded on healU1
promotion and wellness can 011ly be achieved when programs and projects utilize three
importan t ap proaches: (Tuazon et a! 2003)
•
•
•
Community-bMed approach which empowers the people to address
their health needs and problems
Integrated approach which considers various dimensions of health
and developme nt such as changing lifestyle, changing envi ronment and
reorienting healtl1 care systems
Comprehe ns ive approach which strikes at the root of t he problem and
addresses the social determinants of health
PRECEDE-PROCEED Model in Community Health Planning
The PRECEDE-PROCEED Model (Green and Kreuter 1999) is one of the extensivelyused models to guide nursing practice in health promotion planning, implementation
and evaluation. There a re two phases of the mod el. PRECEOE stands for prC>disposing,
r einforcing, and enabling const ructs in educational/ecological d iagnosis and
e valualfon. lt corresponds to the assessment phase of the model itwoh; ng social,
epidemiological, behavioral/ environmental, educational/ecological a11d administrative
and policy assess ments. Since the model examines th e different dimensions, it
guarantees a more comprehensive perspective of acldrcssi11g u he..1\th problem. The
PROCEED e mbodies the implementation and evaluation phases and stands for policy,
r egulatory and o rganizational<--onstructs in educational and e nvironmental d iagnosis.
203
For the nurs e and the communily, using the l'RECEDE-PROCEED Model clarifies the
possible roles of the stakehol.ders as welU as the s trategies/approaches in addressing
the health problems.
PhMl!S
Phase 2
Administrative
EduJ;atfona
Phase 1
EpldemlolagJcal , Social
and Polley
Ecoloa1c.i,
Msassmeni
Assessment
Assessmf!fl1:
) r
(
')
HEALTH
PROMOTION
Predisposing
factors
Health
education
Reinforcing
f actors
. '
Health
Po licy
regulation
organization
Enabling
factors
Quality
of
life
PNase 9
hppl9mentation
Outcome
Evaluation
Planning for Health Promotion
I n Gr een's original PRECEDE Model (1980), the framework analyzes the social
concerns, the h ealth problems and the b ehavioral and non-behavioral factors that
contribute to the h ealth problems. Unhealthy b ehavior s are further evaluated by
looking into contributing factors identified as predisposing, enabling and reinforcing
factors. These con t ributi ng factors become th e focus of a hea lth education intervention
aimed at vol untary adopt ion of h eal thy behaviors_ lfthe adoption of a healthy behavior
entails organi7..atiomtl, en vironmenta l, logislati-ve or economic change, then the change
204
process needs more than just heallh edu cation. W11en factors other than behaviors are
adcfressed, the p rocess becomes o ne of heal U1 promotion. Hawe, Degeling an d Hall
(1990) employed the PRECEDE framework in needs assessment but expanded it to
assess not only the health education needs bu t also th e be,,lth promotfon n eeds of a
community. Thus, r isk factors do not onlv look at behavio rs. Socia l, organizational
economic, legislative ,md environmentat' factors (non -behavioral factors) are als~
considered as 1isk factors. Risk factors are analyzed for their pred isposing, enabli ng
a.nd reinforcing factors.
The origina l PRECEDE model, thus, was extended lo encompass . the , ~ider
environ mental, policy and organi.zationa l foctors that Green a nd Kreuter had found
important in launching natio nal programs o f community health promotion. The goals
of the model a re lo explain healtl1-reJated behado rs and enviro nments, a nd tu design
and evaluate th e interventions needed to influe nce holh Lhe behaviors and the living
conditions that in:f:luence them and thei r con~cqueL1ces. (Green and Kreuter 1999)
As you c.an see, the issues raised by Hawe, Degeling and Hall were addressed in ilie
PRECEDE-PROCEF.O Framework. This model has been npplictl, tested, studied,
extend ed, and verified in over 960 published studies nnd thousands of unpublished
projects in commu nity, school, clinical, und workplace settings over the last d ecade.
(http://www.Igreen.net/precede.htm) 111e figure below shows the relationship of
health education and liealU1 promotion:
HEALTH PROMOTION
Environ- mental - -
egulato
\
,
.
Enviro.ri-
.nviron-
. mel)(al
mei:)tal
Policy
t no
Env(ronrriental
Socia
Environ-
mentat·-
HEALTH PROMOTION
R elationship of Health Education a nd Health Prom otion
Source: Green LWand Kreuter MW (1991)
205
'iH t: PLANNING CYCLE
\\,'" ' \':t11 tlw nur,;<' 11111k1• the 1>lanning process s imple an<l uncomplicn t cd so p eople
nbk h• 1',u-l k ip11tl· in it ? Oft e n, p eopl e Jose in terest in p la nnin g because of the
t\, ·hni,·:1l la11g11:11.~l- :111ll p r 11cc,;s th a t nurses and o lbc r p1·orc:ss i o 11:1 l s u se. This n eed not
"-' th,, <":1,;,•: 1wopll' 1,110w h e lte r abo ut their co mmunity; they ,il::;c> ;;ire :wticula le a bout
1h,•i1· m·,·d,- :111d lhl·i r pn1hlL·ms. Whal the nun;e or o lhe 1· h ealth p rofessio nals nc:e tl to
\\,, is t., t:wilital,• p,•oph• to express 1.hc:m sc:lvc:s. A common 1cehniq 11c for pl;111 n ing Lo
lw p:11·1i,·ip:11ory is In ask k:ncl qu1:stions for people lo tl iscuss about . The n1 11·sc and
tlw l'lll1lt111111ity can go abou t lh e pla nning c ycle guided b y the followin ~ questio n s
( Mt•n:11clo 199:{):
:\\"<'
Situational Analysis
•
Gather hea lt h data
• Tabulate, anal yze and i nter p ret d ata
Identify health pr oblems
• Set p ri ori ties
•
Evaluatio n
•
Determine outcomes
Specify cri t eria and standard
-·
•
Goal and Objective
Setting
• Define p r ogram goal s and
obj ectives
Assign prior ities among o bj ec tives
Strategy/Activity
Setting
• Design Intervention p rogra ms and
srrategies
•
•
Ascertain resources
Analyze constraints and limitations
How do we get there?
Situational Analysis
.Auswe ring Lh c ques tion " \-Vhere are we now?" involves the process o f collecting,
synthes i7.ing, nn olyzi ng a nd i n tcrpreting in form otion inn munn e r l'hnt provides a clear
pict11rn of the healt h s tlll"us of the commun ity. It brings out the h ealth problems o f tl1e
community. In th is phase of the planning cycle, the nurse, togcth er wi tJ1 the co mm u nity
idcn1ify Hnd provide expla n ation 10 th e proble m s. After t he nurs e :ind t h e p eo p le have
g:itlie rcd data abont the: h eHlth status of l he community , they ide ntify and proceed
206
to explain th e problems leading the m to project what s ituatfon needs to be cha nged,
d eveloped or mainta ine d.
The common be lier among hea Ith p rofess ionals is thut si tuatio na l a n;ilys is is us ually
driven by a need to immed intcJy ad(li-ess an aclm1l o r ;i po lenlial health problem or
conditio n. The refore, lhe goa l n f 1111y h c allh inte rvention is m ni nl.y lo mi tiga te the
effects of the he allh p roble m o r he a lth risks. ln this ccm tcxl, p(!(iplc le nd to d e velop
;1 <:ri s is-o ric n l1'!fi b e h a vior, res ponding o nly lo situutio ns if l hcy pen:civc the he alth
th rc nts. The health i-;i tua tio n is cons ide red solved if it nu lun ger poses ri lh rc:H lo the
populatio n . The I lc;il lh Promo tio n pe rs pecti ve goes hcyc>nd merely p roviding he alth
servi ces . The O 1t;1wa Chart e r o n Mcallh Promotion ( 198 6) highli~hts the need to
address the fund am e nt a l co nditio ns a nd resources for health c11re - pe11ce, s helter,
educatio n, food , i11co111<;, a s t11hlc eco-syste rn , sustain:i hlr: reso urces , socia l j us tice
nntl e quity.
Fo llo wing the PR ECEDE framewo rk, the .~itualio na l ana lys is in voln-s
"conscious ly d e te rmi ning soc ia l, physic.i i, c ultu ral a nd pol itica l f.1ctors tha t a ffe ct
behaviors" ( WHO 2003 ). Enguging tl11.: people lo analyze human be havio r .is a product
o f complex fa cto rs will .e nable them lo he mo re pro-active in m o difying be haviors and
creating e n vi ron ments to prevent hea lth prnbl l) ms and protect the m from hcallh ris ks.
Stages in Conducting Situational Analysis
Using th e PRECEDE-PROCEED Model (Green and Kre u ter J999 ; WHO 2003), tJ1e
situ:itional a nalys is \,~11 proceed as follows:
se ~ SOtlal Diagnosis
~rmlne how tl:ie sitUatibn affects the qua llty of 11fe of the population In Its socral
s. Does the sltuatlori result in the breakdown otfemi!Yrelationships? Ool!S it
to econom ic catastrophe? Does lt,lead to shorter life spansi' Does It lead to
· v1otence and conflict?
ea~
iehase 2•Epldemlological Diagnosis
·
~ t,rmlne how-the situatfon .iffects1he health of the population In
Ttlemtologloal,terms., 00@$ ~~ §ltuatfon leads to high rates of morta lity and
i,rbldltyi'-l!>oes 1he situation cau&eS diseases to 5pread it undesirable ar:id
co nJro lled rates/
han a Bef,tavlora l and Environmental Diagnosis
.
~ aspepts of the pmb1-m can be solved by ~e.adopting ne,w behaviors or
ler'natfve lifestVles? What11$pkts can tie a ltered by changes In the environment
eluding new pcllldes, pra1ra.ms and more responsive health c,re ~ms?
207
Phase 4 Educational and Organlutlonal Diagnosis
Which of the behaviors are due to predisposing factors (beliefs, attitudes and
knowledge)?
·
Which are due to enab1Jn1 factors (influences of the Immediate environment,
accessibility to reso\Jrces and services)? Which are due to reinforclngfacttrrs
{social pressures, media m essages, religious and lnstltutlonal dogmas)?
Phase 5 Administrative and PaUcy Olaposl s
Which of the fact.ors can be modified throush education? Which can be modified
through advocacy? Which can be modified throush social moblll,atfon?
Fig. L2 Steps In Analyzing theSJtuation (Social Mobilization for Healtfl Promotion,
World Health Organlultlon, 2003)
.
Socla l D iagnosis
Tdentifying the priority problem requires stating the specific population affected by
the proble m , its magnitude or the extent that it affects the quality of life of the said
population. Thi s comprises the fu:st phase o f the s ituational analysis - the social
diagnosis. Social diagnosis conveys the impact of the health problem in terms of the
overall quality of life of the people in the community. Green and Kreuter (1980), look
at quality 9flife as a subjectively defined problem o f i ndividuals or communities.
The following a re examples of indicators of extent of social problems present i n a
community or a population group:
Illegitimacy
Absenteersm
Hostlllty
Alienation
Population
Drscrlmln~on
VC!>teS
esr,nies
W-elfal'e
Unemployment
crowding
Riots
e sodal dlasnMJs. must M described in terms of the. followi ng:
» M ~gnltudeofthe problem- ls the pioblem widely e,cperlenced
· by the pe(!ple?
.
.
• Population ·~ffected by the problem - rs the problem •conffn.ed
to a speclflc population group? Does It lnv:olva a p_articular
vulnerable or risk sroup?'
» Severity or gravity oftlu! prablem- ls ~a debilitating problem?
1$ It causing premature "llilths In tire popuiatjon? ·
» What are Its lmpflcaUons to potentfal years of life lost, quality oii
llfe, econcmlc ar,d h~lth Cilte c;osts?
208
.....
Epidemiological Diagnosis
Epidemiological diagnosis eiq>resses the beal lh problems in tcm1s of "ital heahh
indicators of mortality, morbidity, fertility, disability or deformity. The extent of
these problems is described in rela tion to:
>>
Distribution of the condition in terms of person, place nnd
» time char.icteristics
}>
Intensity of the condition in terms of incidence and pre\lalence ; and
» Doraliou of the condition
Behavioral and Environmental Diagnosis
Tbe th ird stage of the silualional analysis involves exn minalio n of the health problem
by providing additional data about the factors thnl are contributing to the health
problem . It is concerned wilh detem1ining the behaviurnl and envi ronmental factors
that account for the health problems.
Explain why the problem is occurring and being maintained. This is done by
looking for risk mm·kcrs. Risk markers poi nt or :snggcst where the problem ·
might be occurring. For example. if th e probh.! 111 it- intestin nl parasitis m
among young children, the risk markers wotd d inclmle children, aged 2 to
7 years, low socio-economic status nml belonging to u rban and rural poor
origi ns. Al though risk markers are associated with occurrence of problem,
they are not necessarily contributing to it.
Iden lify the risk factors that directly a ccou nt for the problem. Risk factor
refers to a ny attribute, characteristic or exposure of an individual which
increases the likelihood of developing a disease or ill ness condition (WHO
2001). rusk factors ca n either be behavioral or environmental. Behavioral
indicators cited by Green and Kreuter (1980) can be expressed in terms of the
following:
,. Utilization of a specific service
» Carrying out of a particular action
,. Consumption of certain commodity, product
» Com pliance to a prescribed regimen
,. Ability to perform self-care
An example of a risk factor for intestinal parasitism among young children is increased
hand-soil contact b rought about by play activities witl1 and on the soil.
Other th an b ehavior and lifestyle, the environment of the population can also ex'Plain
the problem. Environment does not only refer to the physical environment . U also
encompasses policy, social, cnltural, economic and physical fac tors p resent in the
community that determine behavior. Enviromnent,11 r isk factors for the problem
of intestinal parasitism among young children include unsanitary excreta disposal
system, lack of water sllpply necessary for hygienic practices and use of freslt hwn an
feces for fertilizer in vegetable gardens and 1ice fields.
Ed4cational and Organizational Diagnosis ·
Educational and organizational diagnosis looks into the contributing factors of a
problem that rn.ay become the focus of subsequent intervention . Contributing risk
factors (Green et al 1986) a re those U1at co ntribute to or account for the risk factor.
These a re sot1:ed into:
,. Pl'edisposing - any characteristic of the client that motivates behavior related
to health; t hey can be described in terms of the client's lu1owledge, attitudes,
209
»
,,
values and perceptions
Enabling - any character istic of the environment that facilital'es health
behavio,., and any skill or resource required to attain the belwvio1·
Reinforcing - rewardorpu11ishme11t followingoranticip atedasa conseque nce
of a h ea lth b eh avior
The factors are s011ed out into logical o rder t h at will help tease o u t the causal
pathways leading t o the p roblem. The following framework wilJ help the nurse and
the people assess factors associated wit h or contributing to the health problem under
investiga tion.
me Examples
lues, beliefs, self-esJ;eem, health locus
port, soc:fal deslrablllty, cultural norms
onutron, h~stng, 't ransport routes,
tlty, sensttlvlty·o r acceptability to·target
ventlve care, fl~anclal-lncentfves for
ortunttles for participation in
on health and equity
nmental pr,otection laws,
SJ.Ire
.
tohazardous materials, school
.
.
d With·o'r Contributing t o the
· 1ellna,.r~ Hall, 1990) . ,
Administrative and Policy Diag nos is
The a dministrative and p olicy diagnosis de6nesthepossible points of action where th e
hea lth problem can b e addressed. Tn a way, the last phase suggests the activit ies that
will lead to the resolution of the health problem. Adminisb·ative and policy diagnosis is
not lilnited to assessing health education needs oftbe population group or community.
It must also highlight issues necessary to create a s uppor.tive environment to e nable
individuals to adopt and maintain healthy lifestyles such as need for healthy pubHc
policies, community action, more responsive health care system and healt hy p h ysical
environment.
Problem identification and explanation are facilitated with tb e use ofa .. tool" known as
"problem tree." Th e "problem tree" visually maps out t he p robable causes of the health
statu s problem. An exa mple is given on the ne.xt page.
210
Poor Qu 1•
a •ty of llf
Years o ld in
e o f child ren 2-12
8
a rangay Sta. Cruz
High incidence a
intestinal
. nd Prevalence of
Paras1tis
m among children
aged 2 -12 Years
F:- --r==~~~---:'rf-_
-:----__-l_--.----_:~.:1;ypoor personal
t,abits
unsanitary waste
disposal system
poor child care
__ ___
["'-"
LoW level of
education
poor utili
healths
_,,
lack of basic health
facilities
Preoccupation
with econom ic
of
rtit'-'de
negative a viders
health pro
activities
. factio1'1
job dl ssat1 5
governmen t
negl ec t
health 1s least
prior ity in t erms of
budget
t
~-----1--------_;._....,
l
One notices that the rools of th e h e alth status problem (high inciden ce a n d p r evalence
of parasitism) are related to health resources and liealtb-celated problems like
educational status, grinding poverty, govern ment n eglect and quality of health care
providers. By explaining and analy.iing the p r oblems using a problem tree, the people
will recognize what situation needs to be ch a n ged or what can be done in order to effect
a desired change.
211
Goal and Objective Setting
"V{h ere do we want to go?~ r efers to the process o f for11111lal'ing the goals and
objectives of the hc,1 lth proJ.>;rnm a n d nurs i t1g services in order to change th e sta t us
quo. Goals nncl objectiw s will serve ns ~uide l o the efforts o f the nu rse and the people
to ntldrC'.ss the health problems.
A goal iJ:; a d esired e nd. The des ired end may be a tota l c hange, improvement or
m a intenance o f it :-ii ua tion. II is d irected towards solving the hen ILb status problems that
were identified in lhc commu n ity di ag nosis. It is gcn cr.illy b road and not co n str a ined
by ti m e o r rcsnnrces. It s 1:1tcs th e ultimate desired s t a te. Objectives ;ire more precise.
TI1ey· are com;ide red as pl::inned end point of all .ictivitics. Objectives a re concerned
with U1e resolution of t he he.:iltb problcrn itself. They h ave to b e s tated in s p ecific and
measurablt: tc m1s.
,.
,,
Goal
'
.
~
what you ultlmohtly want to achieve by running the program;
ducrlbes tht! ch•nge In the hl!Olth probl~m or condition that
motivated you to design an Intervention
'
Objeecive
describes what changes Vou want to bring about in the target group In
terms of their behallfoe; d escribes what the program achieves~ has to
be stated $pedfically
.sub-obfectfve
change In afactorwhfch Is a prerequTslte for the change in b ehavior
.
The example b elow shows the relationship of Goal, Objective and Sub-objective to
analysis ofhe.'llth problem:
ti
ld,Pnlblem
.,.,..._
a·••·
..........•c
Excessive l!XpGSUre
of school chffdntn to
ultravtolet li8ht
Goal
Nor enou,I\ shade In
Objecdve
,.....,
Oep(d._no~
on pt utliidfolt
·••rtsttel
ewposmw10w...(l. .,'9r~
Increase the amount o f shade
In school playgrounds
,.,..,ts and teachers Sub-
lnsuffldentfonds
tobwlld . . . .
2U
chlldrento ultraviolet light
Khuol~nds
not sufflden1fy
awar.oftbltof
sunnposute
(p~
-
Reduce exposure to of school
Obf■ctlu•
Increase the teachers' and
parents' knowledge of risk of
exposure to UV exposure
Acquire Php 60,000 for
shade/shelters
Have UV exposure protection
1'1lClH'pOiaCt:d Into DepEd
polk;y
The goal of a program is directed at addressing: the health problem whi le the ohjectives
address U1e risk factors. The sub-objectives address t he contrihuli11g risks.
Goal
Health problem
Objective
corr~sponds to
corresponds to
Sub-objective corresponds to
Risk factor
r
Conrrlbutlng risk actor
Strategy and Activity Setting
"How do we get there?•· defi nes the strategies and the activities that the nurse and
the community set to achieve in order to realize the goals and objectives. It implies
the identification of resources- manpower, mon ey, materials, tech nology, time and
institutions - needed to implement a p rognun. The nurse facilitates the community
define the. st rategy or ap11ronch in a h c11lth program. A program is defined as a timed
series of act ivities to be ca rried out in order to correct the 11ealth proble m. Resources
needed for the implemcntution of the activities are esti mated. Constraints or limitations
that affect p lanning decisions are alsc> assessed. This particular phase of the planning
cycle involve..c; three activities:
• Designing lhe health programs o,. seruices involves d efining the strategy
objectives and the strategy activities. Strate1,,y olljectivcs describe what
you .O..Q in the program. They state what your progra m is going to provide
and deliver. They bring about the achieve men t of multiple objectives or subobjectives.
---- ----~---------------------Example of multipl e sub-objectives rinked to a single strategy ob~c.tive
(Haw e, Doge/Ing and Holl 1990)
improve
teen-agers'
self-esteem
Improve and practice
skills on how tousay no"
In difficult s it.u ations
Increase peer
support among
teen-agers
Strategy Objective:
Conduct assertiveness
train ing workshops
for teen-agers
Strategy activities a re what you actual1y do to meet your strategy objective. They
make up the component parts of the strategy objective. They are categorized as
service, developmental and s upport activities. Ser.-ice acth;ties provide direct
health care services to the populat ion such as immunizations, family planning services,
213
nutrition s upplement a tio n a nd the like. Develo pmen tal a ctivit ies a r e d irected towaJ·ds
transferrin g kn owle dge and s kills to sp ecific gr oup o f p eople like Lh c co mmun ity
volunte e r h ealth workers o r m others. Suppo1·t act ivities ~encrntc rnntcri a l, t echn ical
nn d ma npower resources l o SU$tain the service and devclopmc nlaJ nclivi l ics.
Ac•e:twll• Df scr.tqy obJudlM• and activities In. ,
_.l'CIIN promotion pro1ram
.,
~
Strc11egy Objective:
Strategy Objective:
Run a 3-week local media
campaign regarding
exerc:ise f acilitie s and
activities In Brgy Sta Ana
Involve local commun ity
est.iblish ments in Brgy Sta Ana in
lobbying for additional exercise
faci l ities forthe community
Strategy Activities:
Strategy Activities :
•
Coordinate w ith local
paper t o have sp ecial
feature on exercise an d
healt h in th e community
•
Ru n ads and news
releases In lo ca l
paper listing ava ilabl e
exercise facil ities in the
commu nity
•
Hold a press conference
with expert in
card iovascular disease
and exercise, loca l
officla Is, p r ominent
p e r sonalities and
p eople w i t h CVD in the
com m u n ity
•
O rganize an open day
at the gym t o t ry out
f aci lities and r ai se
f unds; give talks on
benefits o f exe r cise
Bud.geting invok es specifyi n g Lhe re quirements o f eac h program in re latio n
to the n ecessary resources and considering con s traints th a t may luim p e r
i mplemeI 1tation of p rogr a m s a nd act hities.
l\fal..i ng a time plan or sc h edule hel ps the comm uni ty o rga ni ze tJ,e activ ities i11
such a v.:ay that time, mon ey :rnd effons ar e not wasted. Sin ce th e progrnms a re
con strained b,· time. the nurse sees to it that wh a t is intended lo be <lone a1·e
carried out ac~ording to the specification o f a p l an b ut a llowing for fl exibility
Developing an Evaluation Plan
In o rderto find o ut if the p rogram.s and services achieved lhe purpos e for which they
w ere fon:n ulated. th e nurse .ind the commu nity pose the question ~u ow do we know
,,·e a r e therer. Thls is the pha.5e o ( the planning cycle that detennines whether the
program is rele,·ant. effectiYe. effici,mt and adequate. r1is conce rned ,vi t.h finding out
tbe specific in_put, process an d ou tput / o ut com e indicators of th e pro.gram s tating t he
crite ria and standards o f each. This c.-..ercise is caJled CWJJu at io n.
Evaluatio n is th e p r ocess b y-which w e j u dge the worth o r vaJue o f somet hing (Suchma.n
214
1 967). Evalua tio n involves two processes, nan1ely, observation and me;:isurement The
nurse observes , lhen compares the ohserved data with some criterion s lamfard or
indicators of good performance.
There are two approaches of evaluating a program. Qualitative methods of evaluation
determine t he meaning and experience of the program for the people involved; and
in terprets the e ffects that may be obs1:rved. Quanlilalivc methods measure and 'score'
changes occurring as a result of the program. S uch measu rements are systematically
made using pm-selected inslrurneots to detect cxpecti;:d changes.
An evaluation may look into three <•spects of a p rogram, namely: its processes, im pact
and ou tcomes.
• Process evaluation measnres tl1e acrivitias of rhe program, its quality and who
it is reaching out.
• Impact evaluation measures the immediate effect's of lhe program and
determines wht:)U1er the objectives oflhe program were met
•
Outcome evnl uu ti on measu res t he lorrg-term effects of lhe program and
determines if it meets lhe goal of the program
How program components relate to evaluatfon
(Hawe, .Dageling and Hali, 1990)
Goal
Outcome Evaluation
is measured In
Objective and sub-objective is measured In
Strategy objective
is measured in
Impact Evaluation
Process- Evaluation
Andersoi1 and McFurlane (2004 ) use a three-p,rrt model for program evaluation that
they h ave adapted from Green and Lewis (1986):
Information to
colled
'
PROCESS EVALUATION
IMPACTWALU~ON
Pro,:ram imprementallon
inctudlng:
LJ
Siu:, re sponse
Ll
Recipient response
r: Pra«tdoner repoose
0
Competencies of
lm'IJledlir~ affecu of
prou.mon·
ICnoWledge
Altitudes
'
pe r:sonne.l
I•
1.-~
~-...·•
1
-=
:,:,
to.
lnltlal Implementation of n
program or when changes are
ma de, In a delrelopctl program
lnclden~ anti
prl'VollE-ncr. of ri•d::
flleton, morbidity and
mortality
Percepao11$
r
-
(:
'"'.
-
When to apply
OUTCOME
EVALUATION
51tlils
Bellef5"
Ac.UH lo
resourus
Soma! .. ,..,,,,,,
l'o determine If faqon
that affect health
(behavior •nd Ufestyle
and l!flVlronment) have
IIN!llllle!IQ! ~ s " -
chllnpd
been alterttl
Ta me~~lfvltal
and health lndlcatofS
$ucl, n tncidcnc,e and
Ta meaoure if people's
quality-of life has
lmpro,,ed
How do nun;e and the nrnrnnmity know that the program has achieved what it has set
to d o? This is th e purpose of using indicators. Indicators a re considered as "markers".
·n,ey show p rog r,~s1: :ind help to mensure change. Indi ca tors consi.<;t of measurem ents
and are often expressed in numbers such as percentages , rates and ratios.
215
Indicators m:iy be c:itegori7.ed :1s to availability, relevance, accessibility, utilization ,
coverage, quality. effort. efficiency, and impact (J,euerslei n 1986).
Indicat or
AvailabUlty
Example
Purpose
Sho w whether something
exists a n d if i t Is avallab le
.
Whether there is one available
trained local h e alth w0rk,er for every
." ·--'-- ·
Relevance
Sl'low how relevant or
approprlat~ something Is.
Accessibility
Oeterrnlne w h ether what
exists is actually Withi n reach
of those who n eed t h em.
Whether a health center may be out
of reach by the people because of
mou ntains, flooded rive rs, lack of
transport or people's povert y
Utilrzation
Show to what extent
something that h as been
m ad e availab le is a ctually
being used for that purpose.
Number of non- literate who ar e
attendi ng llteraay cl asses r eg ularly
Coverage
Show what proportion of
t hose who n eed something
ar~ a c tually re cei vi ng It
Number of people estimated or
known to have tube rculosis that are
ac t ually rece iving reglllartreatment
Show the Q.uality o r standard
o f somethin g
Water quality Is free-from harm f ul ,
d isease-causing su bstance s o r
Quality
Effort
Show how much.and what
is being Invested In o r der to
__... ,_ .._.......... .
~
..
Whether the newly acquired
p rogram vehicle can access hilly
project srtes than the o ld one.
, ___ N'1"P-nn-r<:
-----:... _..
How long It takes how many n u m ber
o f health w ·o r kers t o construct what
-••-L..-.r - ~
.. -:1 .......... ;~ :a
- -•·
Efficiency
Show whether resourc~ and
actfvltles ar e being .put to use
to achi eve the o bjectives.
Number, frequency and q uality of
supervisory visi t s a~er attending a
training p rogram on su pervisi on
Impact
Show If what you are doin g Is
really making an y d i fference
Reduction In the lncloence
of measles after a 6-month
i mmunization campaign
.
Using th e d ~1t:1 and information gencrn te d frnm the above indicators offer s the nurse,
community and Lhe people provic.l i og the funds to make recommendations o n the
future and directions of the hea lt h programs being evaluat ed.
Evaluating Community Competence Utilizing the Participatory Approach
Conventionally, the way lo evaluate t he outcomes of health and d evelopment
intervention programs is to look a t the changes tlrnt occur in t h e population, t he health
care syst em with in Lhe co mmuni ty 1.1r the community environment it·self. The ulti mate
meas ure o f effec tivenessofintervcntion program s and services is th e health s t atus ofthe
popula1inr1. IL can be described in terms of epidemiologic s tudi es. B nt whfle m ortality
and m orhiciiry cl:.1La are ohjccLi\'C measu r es, lhc nurse i s nlso conc-.crn c d ii, m easurin g
change;; in people's knowledge. b chavior. skills and atti t udes and their e m o t ional
,vell-being. The PRECEDE-PROCEED Model clearly demonstrates this framework.
There are several paradigms in e v.iluation (Anderson and McFarlane 2004), however,
216
c1
participatory evaluation hcst describes the fra mework that pursue capacity-builcling
in an empowering appro,1ch. (Minkler 1.997; Kellogg Foundntion 1998 in Anderson
and McFarlane 2004) Bartle (2000) emphasized that Lh t: task of cv;1l11ating the
community's strength or competence is nut the research er's sole responsibility . It i.s
as much as th e community's responsibility lo ev.iluatc its m,11 s trength with in its own
cultural and contexl.
But how do w e operationalize the parti cipatory approach iu evalua ti ng the level of
community competence? There are two important iss ues a nurse ls faced wi th in
planning eval uat ion_ of commu.ni ty competence_
• What arc th e outcomes to look for in measuring community cha nges and
com munity comp etence?
What are tJie m ethods and tools to employ to maximize partici pation of the
commu11ity in evaluating community ch anges and competence?
Measuring Change Outcomes
The ultimate goal of community l1ealth nursing interventions is commu nity
competence. \l'lhile achievement of program goa ls, objectives 11ml strategics ca n easily
be quantified, measuring community strengtl1 or com petence is s till an unfamiliar
ground for t he m1rsc. The concept of commu 1Jity competence is firmly Jj nked lo
empowerme nt where people ach ieve a consensus on their health needs and problems,
possible solution s and unified actions to address these needs and problems. (Co ttrell
1976; Minkler 1991: Wass 2000). Cott rell (19 76 ) nnd Eng and Parker ( 1994) tlefine
comrnunit-y competence iu te1111s uf eight di111ensiu11s. 111ese dimensions are used
to qu alitntivcly describe the extent the community has ac;hieved competence. In the
succeeding chapter, the eigh t dimensions are described exhaustively in the context
of community h ealth an<l d evelopment interven lio ni;. Similarly, Bartle (2007) in
his model of community empowerment includes the sixteen clements tbat define
community strength. Cottrcll's eight dimensio ns and Bartie's sixteen clements provide
inclicato rs thul wi ll help the people themselves un<lcrstau<l their status as u community
and their ca pacity for self-reliance in terms of managing their own health problems.
Furthermore, us ing tl.lcse indicators ,vill enahle the nurse to measure the response of
the commun.ity to th e programs t)1at are being implemented in lhe comm un ity as well
as the efncieney of various sectors of the community to achieve a common goal.
Cottreu-s Dimensions of Community
Competence (1976)
Bartie's Ele ments to M easure Commu.ilty
Strength or Empow erment (2007)
•
seir-otner awareness and clarltlf of
si tuational definition
•
Altruism
Common values
•
•
articulateness
comm itment
•
Communal services
•
•
Communications
•
machiner y forfacilltating participant
lnteraotion and decision-making
•
Confidence
•
Context
•
Information
.
217
Stren,th or Empowe rment {2007)
gement of r-elatlons w Ttll wl der
· ty
n
•
lnterven
•
Leadership
•
Networking,
•
Organization
•
Pollttcal power
•
Skills
•
Trust
•
Unlty
•
Wealth .
Bartle (::woo) admits t h at t·hese eleme nts ca n not e.a s ily be meas ured using a checklist
to q uantify community strength. Wass (2000) agree s that there are limitations to
q uan titative approacl1es aJooe hence, evaluating any activity needs t o be built around
methods appropriate to the program a n d where the participation of the people can
b.e maximized. Qualitative meth ods sucl1 as conununity observations, interviews
i1nd discussions with the people ca n generate a n abundance of data and information
necessary to measure community change. T hese methods have been disc ussed in the
previous chapter. If th e nurse expects the community members t o tak e part in the
evaluation, tools to measure change ioitiat;ve o u tcomes must b e uscr.:frien dly, easy
to admini.ster, and written in a language that is clear or compreh ensible. Aside from
ensuring reliability and validity of tools or instruments, the nurse should also make
certaia that community member s assigned t o partake in the evaluatio n are well- trained
in the use o f th e tools.
·
Participatory Evaluation: The Nagcarlan-U P Manila College of Nu rsing
Experience
Tcrmlnadon
Phas~
Ma11111n1•t wlln_ _ ~ --'I
wlll9rsoc!«J
COMMUNITY
Moblllz,e
218
On the seventh year ofNagcarlan-UP Manila Co1lege of Nursing p artnership, students
assigned in Nagcarlan, Laguna decided to conduct a study to dete rmine the level of
communi ty competence of selected barangays. The faculty and students developed a
framework for evaluating community compelence built o n Cottrell's eight d ime nsions
using p a rticipalory a pproach. The framework reflected the different dimensio ns in
the con tex-t of the comnnmity organfaing p r ocess. This was discussed in a mee ting with
tJ1e barangay officials. [t was emphasized t h at unlike in past program evaluations, the
fo1thcoming a ctivity will seek the involvement of th e people in m easuring the extent
of community competence related to specific programs that were implemented in the
barangay.
The people themselves were interested to know if there were concrete evidences of
cbange as a result of t he programs. Fo,· the community volunteer h ealth workers, their
concern isto dev elop a tool or a re port form t h attl1eycan use to regularly monitor change
outcomes in the community. Ha ving real iz:ed that, tJ1e community's involvemen t in the
evaluation of community competence began. The first stage was to develop evaluation
tools t h at the community members, th e commu nity leaders or barangay offkiaJs, and
the health workers of tbe community can u se to evaluate community competence
on specific programs. Altho ugh th ere were existing tools or instruments that can be
adapte d based on studies and researches do ne in other countries, the students realized
tl1at the indicators for each of the community competence d im e nsions do nol capture
the community's own realities and experiences. 111Us, it was necessary to generate
defmitions o r indicators from the people's conte:1.1:. In o rder to operationalize th is, the
students together ,-.rith the selected barangay o(1icials; commu nity volunteer health
workers and com.mu nity representatives (they we re composed mostly of the students'
foster parents) did the following:
1.
Operationalize the definition of each dimens ion of community competence in
terms of knowledge, attitude and skills indicators;
2.
Construct an evaluation tool that qu antifies community responses to
i ndicators of community competence; and
3.
Detennine the validity and reliability of the evaluation tool as it meas ures the
dimensions of community compet~mce.
While the students did a literature search on the community competence indicators,
a series of focus group discussions were condu cted in the community to identify
process indicators in each cotnmunity competence dimens ion i.n relation to the
diffe1·ent community p rograms th at were implemented. These p rograms include waste
management, nutrition, healthy lifestyle, hypertension and livelihood projects. The
process indicators were then translated into questionnaires and observation checklists.
Knowledge and attitude domains will be eva luated with a questionnaire atthe household
level. Thus, community members are the intended respondents. The skill componen t
will be m easured with a n observation checklist and utilized a l t he ~purok" level. This
is so beca use the program implementation was at the purok level. Evaluation using the
observation checklist will be done by the community volunteer health workers and the
barangay officials. The instruments were pre-tested in a paralJel community. Vague,
unclear and ambiguous statements in the instruments we re restat ed and / or modified.
All the instruments on the five l1ealth and health -relat ed programs were sent to content
specialis ts (the M unic"ipal Heal th Officer, a public health nurse, facu.lty from College
of N u rsing and faculty from Cone.g e of Public Health) for content validation. Content
validjty indices were calculated while interrater reliability was t ested for observation
checklists. The progra m evaluation tools w ere r ated valid in terms of content. Using the
219
SPSS (Statistical Package for Social Sciences), the phi correlation coefficient (<I>) was
determined to establish the degree of inter.Tater agreement. Jf there is high in terrater
agreement, the instrument is said to be reliable (Abaca e t al 2006).
After the instruments were proven to have very good and acceptable content validity
and reliability, the instruments were employed for th e actual evaluation of community
competence on varied programs. The process of developing the evaJuation tools for
other health progrruns was replicated in other barangays.
ln one barangay where commu nity competence in addi:essing the problems on waste
management, d iabetes mellitus, hypertension, parasitism and unheaJthy lifestyle was
evaluated, the community and tbe students agret:d on the following findi ngs: (Abad et,
al, 2007)
1.
Community membe rs possess the knowledge and attitudes to dea l '1-\'ltb
tl1e problems but there is a gi-eat n eed t o develop the skills because of the
inadequate competence in the psychomotor domain. T his is consistent
with t he iindings in the d imension of self-other awareness and clarity of
situation
2.
Conflict containment is an asset of the community because of the presence
ofleaderswho act as mediators. People remain tohavepeaceful relationship
despite d ifferences in ideas and opinjons about the problems.
3.
The articulateness dimension n eeds improvement to enable them to
communicate with authoritative bodies and other community mem,bers to
address the problems.
4.
People have to work on their commitment and participation in order to
sustain the programs.
5.
There is much to improve in relation to creating mechan isms for facilitating
participant interaction and decision-making and allo~" people to identify
cour.ses of action, put up organizational structures and formulate a plan of
implementation for identified areas of action to address probl ems.
6.
Socia] support and management with ,-vider society must b e strengthened
to promote un ity in solving health problems and to establish outside
linkages.
The people realized tha t it was not enough having the nursing students drift in and
out of the community to implement programs. More than anything else, they have
the respons ibility to sus tain t h ese programs. They also recognized which dimensions
of community competence th ey have to work on. An in1portant realiza tion is the
fact that the people consider their communjty leade rs or bnrangay officials as solely
responsible to address comm unity health problems. The evaluation results highlighted
the important areas for competency-buHding towards community development.
CONCLUSION
T he planning stage of the community health nursing process begins with the
identification and analysis of problems. Once the health problems are defined, the
nurse together with the community identifies what conditions they. want the commnnity
to ach ieve. This will bring her to the next phase of setting the goal and objectives
of the plan. Strategies and activities are developed specifying the needed r esources
220
and mechanisms in order to reach the desired end. Finally, the nurse identifies what
parameters to use in measuring whether tl1c goals and objectives were attained.
REFERENCES
1.
Abaca, MJM et al. (2006) Developing Measures of Community Competence
in Barangay Talangan, Nagca,·/an, Laguna. UP Manila College of Nursing
(unpublished).
2.
Abad, YKG et al. (2007). Evaluating Community Competence of Barcmgay
Balinacon, Nagcai·lan, Laguna. UP Manila Cllege of Nursing (u npublished).
3. Anderson, ET and McFarlane, J. (2004). Community as Partner: Theory and
Practice in Nursing. Lippincott 'Williams and Wilkins. Philadelphia
4.
Bartle, P. (1967, 1987 1 2007, :wo9). Participatory Methods of Measuring
Empowerment. Retrieved July 9, 2009. bttp://ww1,v.scn.org/comp.modu1es/
mea-parl1tml
5.
Clark, M,J. (1992). Nursing in the CommunittJ.
Appleton and Lange.
Norwalk, Conn ecticut:
6 . Feuerstein, MT. (1986). .Port:11e1-s in Evaluation: Eva.luating Development
and Community Programmes with Participants. Macmillan Publishers Ltd.
London and Basingstoke
7.
Green, LW and Kreuter, MW. (1999). Healtlt Promotion Planning: An
Educational Ecological App1'oach. 3 rd edition. Mountain View, California:
Mayfield Publishing Company.
8. Green, LW and Lewis, FM. (1986). 1'\,feasurement and Evaluation in Health
Promotion and Health Education. Pruo Alto, California: Mayfield Publishing
Company.
·
9,
Green, LW, Kreuter, MW, Deeds, SG and Partridge KB. (1980}. Health
Education Pla11ning: A Diagnostic Approach. Palo Alto: Mayfield Publishing.
10 . Hawe, P ., Dageling, D., and Hall, J ..(1990). Evaluating Health Promotion:
A Health Workers Guide. MacLeman and Petty Py Limited, Sydney.
11.
Mercado R. (1993). Readings in Health StJstems-Managemen t. UP Manila:
College of Public Health.
12. Spradley BW. {1990). Community Health Nursing: Concepts and Practices.
Glenview, Illinois: Scott, Foresman and Co.
13. Stanhope M and Lancaster J . {2002). Foundations of CommunihJ Health
Nursing; CommunihJ-Oriented Practice. St. Louis: Mosby.
14. Suchman E. (1967). Evaluative Research. Principles and Practice in Public
Ser uice and Social Action Programs. New York: Russell Sage Foundation.
15. Tuazon , JA. , Dones, LBP. an d Bonito, SR. (2003). A Training Ma nual
for Health Workers on .Promoting· Healthy Lifestyles U.P Manila College of
221
--
Nursing-Dep a rtment o f H ealt h-World Hcnlth Organiza tion.
16. Women's Health a n d Safe Motherhood Project-Purlnersh ips Comp
(2 003).
Tli e P.R.A . - A ParticipatonJ Plan ning Process ... Departtnoneru.
Heal th and Tiuropc:m Commission in the Philippines.
ent of
0
17. World H ealth Orgunizatio o . (August-September 1978) . The Declorati
Alma /\ ta. World Ifeal1h Organizatio n .
on of
18. Worl d Health Organizatio n . (1995). District- H ealth S ystems: Glob
1 011
Regional Re1Jictu Based on Experiences in Various Cou.nh·ies. Geneva ~
d
Heal th Organi 7,ation World H e a lth Organization (2003). Social l\1ob;i· 0 _i-lct
for Health Prornotio n . Regi onal Office fo r th e W este rn P acific. Manila.V.Oho11
222
Chapter 9
NURSING INTERVENTIONS
FOR COMMUNITY
HEALTH AND
DEVELOPMENT
Luz Barbara P. Dones
INTRODUCTION
The World Health Ocganization's (1978) definition of heal th emphasizes not only
the prevailing pl1ysical a nd m ental conditions of the people and th e com munity. It
also considers the political, economic, social anrl cuJ tu cal dim ensions that affect their
living conditions and q uality o f life. In Lhis context, the interventions of the nurse
cannot be limited to acti ons gea red towards the reduction of mortality and morbidity.
Community h ealth nu rsi ng interventions necessa rily caJI for improvements in the
standards of living and quality of life of the people and Lhe comm unity. The WHO
definition of health, therefore, clearly makes a stand on the link between health and
development. It implies that a healthy population is a moving force for economic growth
of the community. Consequently, marked improvement in the economic conditions of
the people will e nable them to enjoy a sustained level of health and wellness.
In the health development process, the Alm.a Ata Declaration (1978) stresses two
important concerns in addressing he.al th issues in the community. The fast concern is
the 11eedfo1· u n integmced approach in solving health problems. Comm unily health
needs and problem s are not solved by simply inducing changes in personal and group
attitudes a nd b ehavior. lf one eKpects lasti ng and sustainable solu tion, reforms have to
be can ied oul wiU1in U1e health care delivery system and the larger socio-economic and
political system . T he second important concern is the needfor enhanced capabi/ityfor
greater parlicipalfor1 cmd inuolucmcnt ofthe people in hca/rh efforts includi11g policy
making and influencing dec isions. Often, U1e people most affected by the problem
feel h elpless si mply beca use tl1ey do not believe they have the power to change their
situation. In other words, community health nursing interventions must focus on
provid ing health-related interventions to improve the health status of the population
and enhancing the capability of the community to manage its own health.
COMMUNITY COMPETENCE AS OUTCOME OF COMMUNITY
HEALTH NURSING INTERVENTIONS
Community competence is defined as tl1e ability of tb e communi1y to (a) collaborate
effectively in identifying its problems a_n d nee ds; (b) achieve a working consensus on
goals and priorities; (3) agree on ways and means to implement the agreed. upon goals;
and (4) collaborate effectively in the required actions to achieve goals and priorities.
(Cotb·ell, 1976; Hawe, Degeling and Harl, 1990; Wass, 2000) It is very much linked
to the concept of community empowerment (Minkler, 1991; Wass 2.000) wh ere
223
tht· cummunity is nblc l o rccogni7.C. solve: o nd ca r ry ou t a c t ions to address its ov.rn
problems.
AL"COrd in g to Cotl re -11 ( l 976). \h e! community con b e described as having incr e a sed
oornpdence by e., a mininf! the ch <1ngcs i n tl1 c commu n ity itse lf, its ne tworks . its
slnlcturcs. the w ay in wh icb p t-oplc p e rc-civc the com m u nity, o ,.,-n ersh ip o f issues, and
perceive d nc: wel l as acl'Unl ; empo w e rment in h e11 lth n.nd social issu es".
Co rnmlln ity compet l"nce was co ncc ptunlizcd by Cottre ll :-ind various stu dies iden tified
its d irn en<:inn s, h m_.c, ·cr. o nly a few s.Lmlic." looked in to th e e n tirety o f its eight
dim ~ns io ns On<" o f l hc ,;t ud ic:- was c n ndurtc d h_v En g .1 n cl Parker i n 1994. They
evaluntL"Ci !l h e;i lth promotion pro~r.im i n ~lis$is ;;ippi De lt,1 ;ind describ ed t he co n cept
of community t•n1 pow,•n11e n l 11<sing the folllo " ; ng dim e n sio ns:
J.
~· lf-otlir:r au '1rcnrs." am/ d a rity <!f c1 situatinnal definition, d e fin ed ns how
well ca..:h parl o r th e commu nity p erceives its identity and position o n issues
r!!lnted lc, ntlw r partS n f I he community. ·111e community m e mbe rs a r c seen to
perceive the p roble m. accept its existence and att empt to articu lat e thi s with
neig hbors o r to n s m a ll pnrt of t h e community .
0
2.
A rticulatc11es.-:. defined as Lh e ability to articulate in volveme nt in the collective
,;cws. ::illitud.:s. n eeds. nnd int e nt ions of Lh e co m munity; Lhe process or
e.xcbaa,zi n g info rm::ition ; :i11d how well tJ1c co mn1 u n ity deri ves a common
rn c-ani ng fro m th<.• ot he r pa rts of th e c ommunity. TI,e community is seen wil h
a 1':TTlll(1 n f indi,;d ual, who s h are th e p rohle m and nrticu la1 e 1hi s with o th e r
m e m l><·rs of th e com muni ty csp eciaJly to the a uthori ties.
3.
Cnmmitmem. de fin ed :is a relations h ip worthy o f enha n ci n g a n d m:iinta in ing.
'I11is defin itio n i-; basically v ngue bu t th e guide q u estions identifie d by r;ng
a nd Pn r ker su~e.st identification of individual roles and the community ·s
contin11 otL<; acth·c pnnidpn li on in effort.s l<> solve th e problem. The c ommu nity
is ,-C>en ns grou p o fi ndi,;du a l,. "'ho a r c faced w ith a proble m . h.ive ta lked abou l
l11e proble m a nd h nve id e ntifi ed w h :Jt o nc·s r oles :ire in solvin g th e problem.
Commitment is co1tsidc rcd the nr>cfal paint for shifti ng into t he n e ~:t phase o f
organi7Jng. havi11g identifi ed in div idual!; who wouJd be part o f tlit! core group,
orgnni7,atio nal stn,H.:turc, ::ind po~<;;nJJe implemente rs of program p la ns.
4.
J\1uc-liinC!r!J fnr faC"ilit a 1in.9 participant inter a ction and d ecisitm m aking,
which refers to th e Ability of th e comm unity l o es tablish fo n na l m ec ha n is m s
for- n.•prns e nt:Hh. e input int o d ecis ion-mald ni:r.. The p rognu11 plnn is s een a s t he
1a 11~ibJ,, ou Lp u l u f t hi,- dim rJ m, io n Jerivcd Crom pro blem n nd ro le icl c nLif-icH t io n
a nd cum munity-wid.: disc:ui.sions on th e p robl e m. It p resents I h e co,,rsc-" of
:ict.io n .
.,;.
Ccm{lirt eo ntn inmC!nl curd accomrnodation , which re lates to ll1e estab lis hmen ts
o f prt)(·••d11n-s to :ic:<:t,mmodate o p en conflict and continued interac tio n
lwtwt>..,11 d,ff,..n., rlt part:< of tho com m1111 i1y. T his d im(' n:-ion is to ke n as pnrt o f
the mac hint·r y , os in 1.•vc-ry orga ni7...-i tio n. ther e s h o u ld b e a u nit respon si ble for
m1u1agi 11g c,inflicH.
o.
Parririparion. de.fi ned a.s th e p rocc.- ss o f co mmitti11~ t o the com m un il)' a n d
c,ont.ribut in~ w se1, in1?. goa ls 1rnd pla nning Int e rve ntio ns. ln t hi s r cscn rch
st u<ly. Lhi..; d ime ns io n is ide ntified as t h e ac, o f atte n din g and co ntribu ting
t o the acu,; ti~s se1 by th e progra m plans. Crantinit th nt 1he probl e m s arc felt
nl!'Cd-- o f Ull' c.""Omn1unity: p:irt:ic:ipation is ex-pected Lo be hjgh.
1
7.
Socia f :mppar·t. which involves knmvi ngn nd cari ng for oth e rs in a n eighborhood
a nd th e \'l>'i ll in g ncss n f people to assist hy provid ing su pport. It i.q fu rther
define d as the set of be haviors indic;1tive of the a cceptan ce o f the commun ity
o n th e p r ovisio n s of t he progrn m p lans and con tributing r esources, political,
fin anc ial and olher forms o f support that promote pro6'Ta m e ffi ciency.
8.
M·a nagement of ,·elal ions with w ider society, which involves us ing resources
a nd s upport o ffered by lh1: la rger society and reducing th e threa ts of la r ger
social pressure on comm unity life. In th is dimension, th e commu ni ty is seen
to be c.,1pable o f estab lishin g exlerna.J li nkages and its members assu min g
Hdvocacy ro les in e ffo rts to solve tJie problem orto furth er develop t he existi n g
p r ogr ams.
co mmunity c ompetence is a product of an itera tive p rocess of m e ntori n g t he people
in a p artn e rs hi p context. Co m p etency-building does not merely con sist of giving
informa ti o n a.n d leaching sk ills whic h the nu rse expects the people to d e m o nstrate
if and ,vhcn s h e asks th em to. Competcn.C),·-building is all about a chievin g ch ange in
person.ti a nd group att it u des and behavior and deciding to adopt a nd s us tain h ealthy
practices a nd lifesty les that eventually im p rove the people"s qua lity of life.
COMMUNITY HEALTH DEVELOPMENT STRATEGIES
The framewor k of com m unity hen.Ith d evelopment is best captured in th e
train ing package d evelor>ed by th e Wo m en"s H ealth and Safe Motherh ood Project
( 2 003). It huilds on the co nce pts of Prima ry Health Care. mai.nst reami n g gen der
in hea lth , strengt.l1c ni ng partne rs hi p building and the use o f com m u nity organizin g
and develop m e n t approaches. Th e CHD fram ework evolved fro m tbe long years
of gover nme nt and non -governm ent organi wtin ns· col laborative experiences in
attempting to c reate a mo re respon s ive a nd relevant health care system in t.l1e local
and global sphe r es.
Gender ;and Health
Primary H ealth Care
Approa ch
Promotio n
+
Strengthened
• Philosoph y
• Structu re
• Ser vices
f.
Partn erslhi p B u ilding
and Community
Organi zi ng Strateeies
Com m unity Health
Development
• Integrated
• Comprehensive
• Sustaina bl e
T o a dd ress 1'11c two importa nt concer ns i.n addressing the h ealth issues of the people.
n amely 1) need fo r ;111 integrated approach in solving h t•alth prob lems , an d 2 ) need for
en ha nced cn pabilil'y for itrcatcr participat ion nnd invo lvem enl of the people in health
efforts in cluding pol icy mak;ng and influ1:ncing dt!cis ions . this ch apter highJjgh ts the
d iffo rc 111 appr oac hes a n d stn1tegies that th e nurse can e mpl oy to help tl1e people a nd
the comm un ity to b rin g out Lhcir potential and achieve the h ighest level of h ealth.
Primary H ealt h Car e and the concept and ele m en ts of p articipatory approoch h ave
225
1~1..·n di<:('US!tc-d in previ!"u.« ch:ipt c r-s. Co n:i:equcnl ly. iU11sl rntion t~f a p p lien t ion nr I h c.!lc
:<Lrnl1..~it--s 1111d :i.~~pm:ich f.'" fn,111 p roject - b ased nm] t"e-"t' nn.:h - bu:<c.:d cxp c: ri c n cc"
~\ld('n\ s .lOd mu·H· p nic-til iunt'rs \,i ll tw c-itC(l.
,,r
HEA LTH PROMOTION
R>llowi n i:, th<- H e:11Lh fc-r ,\ti proj.1.rnm. t h,, \\'orld I lcalth Orµ11 ni wli o n clircc tc cl its
d f<>rt,; 1\) \\-;u-tl:, dcn•lopini th <.· l'On<'t' J'l of lwult h pn,mol io n 1ts inr. lh c Primary l·lc nllh
Care ,\pprNl <'h . ·11ir Ol'taw.1 C harU.'T for MNtlth P r o m oli(>n wm,; the result of the
Fir:I l ntt> maln•nal C:t1nt• t"\: ncc- c•n I h-:11111 l' n,1111,tion nn d wn:< built on t h e values o f
the Dr.-lnr.11io n ,,f .\.lmn .-\I n II :-tn k :< th .1 1 he:1lth pn,m o t ion m11 s1 occ ur o n five fron ts
0
namely: ( 1 o~o)
Ruildini; hc;1lthy puhl k p"l,lky
Cr<!nlhl!? c nvimn m cnt$ " "hid, s uppo rt h ealthy li vi ng
$tn?n)!tli.-ni ni c,,m munit y nction
Hel p-in~ pt'<•r'k develop t heir s kills
R<'On,·nlm~ hc·.ilth ~-;:tcm
•
•
•
•
C'('Qrdinis tn \\710 C1986) . IV ensure c ffc-cth·cn css of th ese five a r eas. heal th w o rke r s
m u"l 1-.e eff<'(:'t in• in crdt·o-e•oc:tJ a nd media tion in o rd e r 10 e nab l e p eop le to 1,sai n
("(>ll!TT>I o,.:r the ir lh·c;; T o n ,!;-. Tilford a nd R o binso n ( 1990) agr ee t11111 th e O ttawa
Cha.nn ,._" ·nt'" puhlit'. h<'-11th appm:1d1 in h<:':ihh pro motio n" and t ha1 it diffe rs fru m
u-adi11nnal puhh..- health .ipprr\;lcb 111 thn.-e impo rrnut wnys:
•
Jt re<."<..> :;Jllh.... the bro-ad n a tu re vf h ealth p ro m o tio n a nd th e need to
wu rl-. ,,, th ,, tbe r q_-ctor:: •J r i n!'litu t io n :- wh ose wo r ks im pact o n lw.1hh
•
IL n..~",:m1e- the ,-;i]ue of p:i rtn er.;hip ,,;11i ro mmun iti c..; c nahlinp,
th.cm to i;ain c<\ntrol o, ·c r i~"u e..; affec ti ng t he rr health
•
11 ['Pt"t:,,:1111.._,... 1h.: primacy o f p eopl c·s c 11,-i ro nrn c n1 (hath l)h y:;i caJ
and :-QCJ'l-f-'¢l n<, mic) in de1 e m 1ining h eal tl1 and the need to w o rk for
ch:uur"' 111 th,J e n,iron m e nL rather th a n focusi n g solely at the level o f
irnh , idual beh~,; o r change
1n the ~lar.11ion of Alm.a AL1 . the Ottm ..a Cha rte r for H ealth
Prcnnm ion
ackno,,·1,--d,:<"' 1h,· nL"n-<"il}' for poli tic.11 a ction :rnd a llo " -i n ~ health prohl c rm, to be
deal! ,,, tit 1\1 th,:,1r root <',.,use__
As
Th!' S<-<'Ond l ott.•rnntio n a l Co nferen c e of H e:1J 1h Pro mc,tion in A dcluidc
{19Ff-lJ m..,de d1ar 1hc 1mport.nnce ">f h !!-"lhhy public polky u rni nJ; in d 1rntriall7.c<l
coontrie-- t tJ dcH·l•)l) 1'>Qlk1e<: 1h;it 1....,v,n ,he J;."ll) flf rich a nd p u1Jr co untric:,,-. l' rlorhy
areas for ;.rlion " " rr 1d••n11fied a c. fqllo,, -,:
•
Suppc,n f,,r ,-·nm ~n ·., hNt h h
•
E.l tn11n1111, ,n ()fh u n11;,·r :,nd ma lmll ri tio n
•
R<.-<lucti<m oi wh:1e("(, wn,,-i nn .:i nd alcohol p-rod ucii o n
•
CN3 lHHl o f -.upprlrtl\·,. Pm:i rrmm <'n :-. 10 r rn m o tin1t h c;ilth
Th<" TI1i rd Jnterna ti o n nJ C <J n fere. n c e on H C? nlth P romot ion in S unds"a ll ,
S '4e<fen ( 1~1) m a dt• n"<",mmf'ndnu <m for ac11nn 10 C"'r C'I\IC.- li UJ)f)Orti v · c n vironr n en l'~.
Tiw ~
, mm,·nd..,11,m'- ,n, hid•--<l ·
•
•
•
•
216
~trt'lll!thc•n1n1t ,uln><".ac,,• 1tlrm1~1 communltr nctio n
E.r..1ltl1 11;.: c ,mmun 11' ,int.I indwi,lual.; to u1lcc con t rol over t h e ir h c t1lt h
o.1nd ,..,,_, , .,r,n,,,m throu~h v.-Ju,.,-:, 11,m and cmpowc rm c nl
~tt, nS(th,•nm~ c-M,p- ra11•m tl1r,,u1,!), allian ,·c building; ond
l-.ncurin~ •-•q u 1u,hlt· .11 ·, .- ... 11> ,, • u r>r>o rthc- t>nvirun m e nt 1h ro uglt
mKi1.o11on o f ronlhctinJ!. 111t.-r!.!.~rn amr,ntr, members o f !!OCicty
Fiu:1lly, in 1997. tlu- .Jak:.1r-ta Decla ra ti o n o n Leading Hc:1lt h Pro m o ti o n i n to lltc
2 1• ' Ccnlu ry was .i tui-ni n/.\ point a s it w;:1s th e fi rst he.:i lth promotion conference he ld
in a develop in).\ <:'>11 ntry nnd act ive ly participa ted in hy the p rivate sector in d eveloping
hcnll h promnl ion s lralcKics . I t ide nt ifie d the im portance o r health p romotion as a n
invest rm;n t ::ind reitera te d th e need to address social determinants o r health, w hic h
arc: (1997)
•
•
•
•
•
•
Pc.ice. s h eller. educatio n
Suc:ia l security, social relat ions, em powerment of wom en
Fnod , im:om c
A :;table ecosystem, s ustai nable resou rce use
!:incialju..,1.ice, respect for h uman ri ghts and equity
Pover ty wh ich is th e greatest threat to health
What were Lh e lesson s learned fro m the intern a t ional conferences o n health from 1986
to 1997?
• ·.111.,t health a nd health p romolion will never be the sole responsi bility
o f th e li t.!al th prrJfessionn ls and th e h eal th professio n aJone;
•
Health progra m s should address the social c.let:e.nnfoants to health in
o rder to be e ffective and su!>"tainable; and
• Commitment to hea lth is a commitment to social justice, equity,
com munity participation and sustainable de,·eJopmenL
The Philippine c.xpe ri ence in advancing health pro m o tjoo programs were initially tied
u p wit h control a ml pre,·en t ion of non-communicable dis-eases(~CDJ like h ypertension ,
cancer. d in he t es m ellitus . as thma and chron i c o bs tru ctive pulmonary d isease (COPDJ.
The Filipi n os. kno"·n to he more cris is-orie nted tha n health conscious •.vould usually
n eed to have -"C ri , ,u_._ l1e11 lt h reasons for institu ting ,m <l maintai ni ng healthy lifest yle. The
fra•n~·work fnr a 11 i11tegrn1t.;J co mllluniL~·- based NCD pn:,·ention a nd control p rogram
in th e· <:nunt ry tT11:izon el a l, 2003) took o ff fro m the \NHO's gen e r al frame --·ork o n
intc,:?.r:11l-d NC:!) r1r,•q•11Lio11 ;,ml r.:ontru l i n the \ vestem Paci fi c Region ( Wl!O-'..VPRO,
1998). \\"ltil..- 1111t.·gr.1t cd NCO pre \'cn tion reco!{ni7.ei; t he impo rt;im;e o f insti tu tions and
com1111111it r i 11 t, ~·a ltlt promotio n , delive ry ;1 nd mri inte na ncc. much o f the interve ntio ns
s h crn lJ put pnr1in1br rrnpha;; is • 111 imlivi ch 1nl con trol tluo u?,b chan~i n?, beha vior and
lifo,-.t}'k s. I low,•v~-r. <,: 011:;;i~krab l1.: prnl!,ro::-s in ?iCD pre'-'eQlion a nd control cnn be
nchi cvcd b y c n : at i11~ ti health protective c1wiro11me□ t through healthy public policies
11,a: well a s h ca ll lt -"Ccto r l·cfon11s a nd cos t-cffectfre interventions.
22 7
"lb•' fr.un;,,w c1r k l'h o ~,,1 nho,-c• w;1i, u1ill1c-Ll in dc, ·dopinµ n t rni nini; ·11111 1111111 for he-, 11
workt>f'l' 1,n pn."n<.>I in i:, lw:i ll hv ti fc,$1~·h •:,.. The 11111 ni c ipnlity of P :1 lt·r?l' n nd l h e fJrovj~ h
l•f G11im:1rno: " ' Crt· lhL· pi\N ll TC'lll' fo r tl w 1rnini 11g prOF.r11 111 wh i(·h rocu scu " " ti~~
following key inlcrvc nt i,,11 ,1 r:11,,,:.ic-:<: (Tlll17t'l1 ,·t nl. :..:oo~i)
c
1. Din.'<:tio n tlnd 111fr:1:s ln1l'111r~
•
l::nh,111<-i n i.; ancl :::t r,•11Al h l·ni11.1; lo<'n l govc~n.mcn1 11nil ( l.G U)
c;:i p:,hility t o d t•v ,•l op :ind i1npll' rn e11 t poh c1 cx a n d pro~nirn
:1imc·d n t NC ll pn·,·,• nti t> n .111,I c·ont r o l.
•
S t r<'n'1-"lh ,·ni n~ rcs(.'nr<"h t·:1p:ibilit y. 11tili 7J1 l io11 :i n d
infominlion c..;ch:in1s,• o n NCD in o~dcr t o incren:c:c c fficic.ncy
a n d dfo,:t h "t' n t'R' of he a ll h c a r e de liv e r:-,· to co n t rol t h e..<:e
d ise:1.scs..
:.t. Changing. cn,irunme nls
•
.
.
E..c:tahlL,.hin~ partne r.::h1p:-; and 111le r~e~loral coor dinaLin g
cn~h:111i.:<ms in nrdcr t_o d e velop poh c1cs a n d p ro~ r a rns l hat
e n.$ure h,:a ll h a nti c n,,ronmc n t are not compro1n1 s ed by
=oomi c p m,:.n:.-:..-.. l'olkie!:' tn\J S l he deve loped t o
•
P ro,;d,· h e .1lthy choic~ of food. r educe prod ucLin 11
of :in im:i l fat s a nd e ncou rage prod u ction "nu
co n:o:umplioo o f vegeta b les a n d fruiL"- as well a iconsumptjon of m oderate amou n t s o f unsaturat e d
fats
■
•
•
•
Encourage food indus try t o dev elop. prod u ce and
m arket h e:;ilthy foo ds p:irticula rly !'hose ";t11 10\v
sat11nil t>d f:1t :rnd s alt con te n1
l..e,cii-lat,~ for p r ope r food labeling
Ad opt a nd suppo rt a nti-sm oking Jegisl;1t ion t,,
pr<Jtecm nrm .smokers· ri g h l lo d ea n a ir: c rc a t~•
mecha11i-..111:. !<l discoura ge toba c.co use and 1,.;:1rl\·
smr.iking initiation
·
Enrour.ige rhrs i<-~,111cth;ty and exerciAf! b y n wk ini;:
facilitie." av::iilablc. a ccessible and attrncl i,·<• 10
p,-<>pl e
•
•
•
Support iniliativcs of p riw1tc secto r and
non~m,emmen tal n rgnni7.:H inns '" develop
community he.~llh -.,•r.·icc.'i and in t c;,ratc NCI>
pn'lerHi'>n ;incl co ntrol m c:, ~u r c,5 into thc.:-.c 1,cr.·iec....
-.
Rrimhur-;e hf':c't lth promr, tive prncticc•-; lien Ith co,L~
for rro-,,-n t ion and control o f nuncom 1n urak:1i,h.:
di<,c."~
En-.urin~ f1tll 1•,immu ni1y pnrti c- ipa tion in t h e
implrm,·nu11,,n 11( XCTJ pn:v't•ntio n and control
J nteg.ra t mz hc,, lth, l1f,:,.t,·lcs a nd bch;:i,·iors in to oth er
health promr,t1n~ ;n1 t rnt1~'"" , u c h ao; f-JcaJ1hy C ities, Hea lthy
School" and H , ·-,lth~ W r,rk,;it~
3 . Chan ,:!,in,; lif~rvle
•
•
228
~ising public- a"'·:i rencs."' I~ · µrod u c.in~ ;u,d dis!:cmi n a Li n~
~nrmation t h:rnuJth m;,~o; m•'<iio. h ,.n hh c:1mpn ign.s. public
1nfnnn:u10n ~-,,.1, m., -ind <.(·h1>ol i'<.111CI1 t ion
At the L'<lmmunit~ "-"'el, mtJtb,-'"' d;.1.,....,_, h::im n ~oy
a.'-!.C'mbl1es. p,o«;t:ing in <'Ommunitv h ullc-t in ho:1rd <= or in
places '"'here m.oc-1 pt.,.oopl<> frequc;,r or conve1"1;C such a s sa ri-
4.
s i,ri ll lo rcs or ma rketplaces are example:; of activities that
can be c,1si ly carried out
Rcur·i c nlinl!, h ea lth services
•
Reorienti ng focus n f h eal th del ivery from cu re to health
p romot ion or welln ess. ·n1is can be achieved by enhancing
the s kills of hcalt h wnrk e rs in
"
scrc:ening, c:isc findin g as well as prevention and
manageme nt of NCO
,.
preventio n o f ris k factors that contribute to
deve l(Jpment of major NCO
•
Developing skill5 o f heaJ th workers for prevention and
control of NCO in the aieas of
»
Epidemiology
»
p rcvcn lion s trategies and intervention practices
»
health promo t1on
»
p rogram ma nagem ent and evaluati on
"
com m un ity organi1jng and mobilization
COMM UNITY ORGANIZING TOWARDS COMMUNITY
PARTICIPATION IN HEALTH
Communi ty participation r ecognizes people as Lh e cen te r of any development
effort. Jt is a process by which members of Lhe comm unity:
Develop t h e capability to assume greater responsibility for assessing
th eir h ealth need s .:md pro blems;
Plan a n d act to implement their solutio ns ;
Create a nd m a intain o rgnniz.ation in sup port of these efforts; and
Eva luat e th e effec ts a nd bring about necess ary adjustments in goaJs
,ind collective action.
·n,c \ Vl!O ( 1995) furt her nffirrns that ~,c om munity partic.i pation is a fundamental
rcq11iremc nl to nc.h ieve h ealth und s us tainable d evelopm ent. ..e aahling citize nship
lo h<'c-omc nn in t ci.:rnl p,1r1 o f th e d ccis ion- m,iking and act ion process ... a nd reflects
the cwcJ fur d evelo pment of more ncth•c com munilics in their rights- . To achieve
thii;, Comn1u.nity O r ~nnizing (CO). n socinl dcvelopmenr m ethodology is utilized
lo fn ci li t:all: t h e process of form ing nnd s us tnining self-reliant an d self-determining
co m 1111111 it h.-s.
Effcct in).I ch:111~c t hrou gh (·om mun ity p.:irticipatinn m eans changing the conditions
\\; thin lhe co n1m u 11ity and ul t imately, p eop le·s beha";ors. This means introducing
or i n s1i1111 i 11g n L• w pro).lram s and policies that ";II positively impact on the ir health.
T he luv,, I , if com muni ly·s pa1·Lici palio11 reUects I.he lt:!vel of power a community
orisan i:1.:.1t io ll h :'ls am! th ei r c apability l o lap resou rces in orde r to respond to their
net,•tls. Pa rt icipa t ion in h <.! a ll h ,·:m ra n!?,e dramati ca lly from passive invo lve ment in prelleh'rmincd a clivi t ius 10 full conlro l or health organizations and h ealtJ1-relatcd affairs.
lnc n: as,•d part i,;ipu lion addresse s the issu e o f sust ainabili ty of health. Wny is there a
nL-ctl lo s11st :1i11 health prn~T:11rn;'? T he answer is : simply. because we need to sustain
hc:1lth or I. he p co pll'. ,\ sus1aina hlc commu n ity health developmerlt grounded
on hc,i lt h 1ir·<rnwlio11 an d w<'ilrwss can o nly be achieved whe n programs an d projects
Ulili:r.c three impo n:1111 :.tpproache.-<:
•
C nrnmunit·y- ha.sed approach which empowers the people to
a d dre.ss th c:>i r health needs a nd problems
•
Loteg-ratc<I approach which conside rs various dimensions of heaJth
and develop m en t s uch as changing Lifestyle, changing, en vironment
229
•
nud r eo ri e n ting h en Ith c.-1 r 1a: sysle m s
Comprc h c nsivl' RJlproAch w h ich s t rike)' 11t t he root o f t h e p robl e m
nnd a dd resses the sociu I dct c n nin a n ts r,f hea lth
C<'rnn1ui1ily or)!nniz in~ w ork is c., rricJ out by t he nurSl' with th e ~oa t of moti vating,
, J,:,m•in):\ 11 nd srckin i widl·•· 1·om 1111111ity p <1rti<·ipali cm in ucc:is ion- ma k in g i,, acl ivilicR
~;n t h nn' 1hc _11;>: "n ti ul to im pact p osi~ively 0~1 com1111111ity h ea lth . U nli ~c in t_, c al l h
cducal inn ;Kt,,,tu·:< whl'rl..' t h~ n ur~,• .nm::: to 111f111c 11~·c . d rn n gc .ind •~1 v cl1fy n1t1t ud cs
J t,ch iwior of p,•npll· as 111d1v1Cl11n lt:. t he n u r.,;c• s efforts n r c dll"cc.:Lcd towo rds
:Hl
I ·1· .
I
I
. . .
·'
.
1
01117 ; 11 )'. and mn '1 111r1~ t H' pcop c to 111111;:itc nnu s us tnm c rn n g cs ns ;_1 g r o u p or ns
n[1?:o"''ani 7.~1tir-n. Tlw pL'o plc .1 rt 1101 :L~ individ11nl:s h 11l n:; members of th c,w g ro ups o r
-' 11 .,_
·
• •
. 1s
. more o n stre n~t I1c n1n
. g t11c
rg;inizn lions. ! 11 n •mm11t11ty
,)r~n 111z
111g.. t I H.' cmpI 1:1s 1s
0
e m ber,-· capahili!:)· in prohll:'m-sold n ~ and decis ion-makin g skills n ece..c;s:, ry for scl r111
. . . .
rdi :rnl d e,-dop1rnmt 1111Untl\"l'l',
Conununity 011!.llliTing i, a pn)ce~ wh ereby th e com m u nity m c mhe r s de,·c lop th e
abilit, · to ns~cs.s 1h .. 1r health tlL'e tls a.n d proble ms. pl.1 n .ind im p le m e n t ne t-ion s to
~i--e tb~ prnblem,;. pul ~p ~md s u;;tain_ o~an_iza tio n al s tructure..-. whic h ,,ii! !<u pport
a n d m o nitor implemen ta tio n o f health lllJba ti~·es by th e people. 1n o rgoni7.ing lhe
c:o rtimun it:-·. the nurse $toes th rough the foUo,-,og phases (Anda m o , J986; Manalili,
1985):
A. Prepanito~· Pl~ase. T!1e acth.iti~ in t he prep~a tory _ph ase i~1clmJ~ area
selection. commuruty pro-filing. entry in th e com111uruty and mteg,-at, o n with the
p('OPle.
1.
A ro•a sclec:n'ort
To ~uide rh e nurse in c h oosini:1 .a.nd p ri o riti7.ing area s for co mm u ni ty h c,1lt h
development. th e follo"i n g q u est.iun.s must b e answered:
•
•
•
•
L,; rhe comm un i~ in n,ei:<l ofassistam.:e?
Do the r::urn muni~- rno.,111110.,n. fol.'! the need to w o rk l ogcl h c r to
o ver come o .,pccific h c:alth pncJ l,lc m?
Art> t here cv ncc rn ed groups and 1Jrgan iz;1tions that th e n u rse c.111
pos~ihl y h'nrk "it h ?
\-\'hat ,,;II be th e coun t erpa r1 o f th e co mmuni ty in terms of
c'1mmunity -;-uppo rt, commi l'men t ;md h um.in resources':'
230
2.
Community pr-ofili119
O n ce th,• a,,.,. h:i$ been scl<:cte.<l. ;t Cl)m munily membe r who ii- known r111<l
;icc('Jltl'cl b, tl1t' r><·npl,~ ";II h<: c hosen to a c l ns th e c ontact perso n. TIie
c 11 ntac-t per-.nn r:111 id,·ntify o tlwr pcr.;;nns wh o C."1.11 b1· d e p e nded 11po n to
in11101t.- ,wt" 11 1,--. in the r-nm nrnnit y. ·111,·s<• p eople wi ll co m ros e th e c«irc
~rnufl "h<1" ill .~,-.,~t t h e· nur<:1.: 111 dning n <:t> n11nu n ity pro file. A <: <J11111111 11 it y
prnhlc pr11,1dt•,- :tn n,cr v1e-,,· r)f d e rn<\,:rn ph ir· chnr:1t·1 c r is li c,-. c o 111111u 11 il)'
an d 1i~•11lth-rdat l'd ,-..-r.·in.-,;; a nd fac-di t, c, . II wi ll ,-cr"c a.s ,111 ini t i,d d11 t a h asc
o ( t he ron1r1 11111it:,. :,nd pnn·id<· the b as i,- for pla11ni11K ;i nd p ro~r;,mmi n µ of
Orj1.:Jl117.llli?, :l<' ll\llll"'-. It c.,n nl'--'J he lp dL'te rmin(· llw :ippr·opriall· 11pp nmc.il
and me-t h n<l o l or)?.an i7Jn)?. ,;p,. :cific to th e popula1io n g r o u p o r sct:lor.s thn t
,-.;11 he- or:i:,a ni Ted.
3.
Rn rry in thf' <'om mu11iry and imc:grat ion u-itl1 th e p eople .
l:iefon· :'H'tu ,J cn1.ry in to Iht" com mu 11ity. ha.sic in form ,r tion abou t th e II rca in
n •fa tin n tll tla· (·uhural pract ice:. and lifM tyle o f th e p<'oplc· m11 ~ t lw k n o "'11.
F.~ ahh,h rns,: r .. r,,xi rt ,md i111.c.i:,rn t in,I! '"1t h Lh c m will hr m u ch c-11sic- r if o n e
Is at-)1.- I {, und e~-ia nd. accep t or imbibe t heir l.'Ommunity life. Lh·ing wi th
th e peop le, unde rgoing th e ir hardships nnd p roble ms and s haring th eir
h opes a nd ,1spiration s he lp build rn11 t11al trn st and cooperation.
H e rc arc som e g 11irlclincs in cnndu ct ing integ rati on wor k:
Rccogn i?.c: t he role and position of lncal autho rities.
•
Adapt a lifestyle in keeping wiLh tha t of the commun ity.
•
C h oose a m odest dwelling which the people, especially t h e
economically <.l isadva ntaged v.ill n ot h esitate to e a ter.
•
Avoid raising ex pectatio ns of th e people. Be clear with your
objectives and li mitatio ns.
Partidpate d iree1 ly in production pTocess.
Make house cal.ls and seek ou t people where they usu ally gath er.
Pa rti ci p ate in som e social activities.
. to the formatio n of a people's organization.
Phase. T h e organ i:;,.ational phase consists of activities leading
. .,
B o...,.anizalional
i.
Sociul preparation
The in tegr a tion work paves the way for the nurse to be introduced into
t h e co mmun ity and signals t he begi nning o f t he social prepa ration p hase.
W h ile co ntinuously learnin g more about th e conditions of the commuJJ.ity,
th e n urse d eepe,ns a n d stre ngth ens h er ties with the people.
2.
Spotting and deueloping potential leaders
As a result of living and IJeing wi th tJ, e people, the nurse comes to know
w ho ,i m0ng th e m have deep concem and imderstancli.ng of the conditions
of the co mm u ni ty. However, it is necessary t hat they should also b e able
t o g;:ii n t h e tnist and respect of the com munity members. Pro"iding
opp ort uni ties t hat will demonstrate their po tentiaJ as leaders can test their
com mi tme nt to the com munity"s well-being. The nurse must consciously
pro,·ide learning experi en ces t hat will prepare them as future leaders of the
co m munity.
ll is not necess.iry tha t t he r>otenti al leader is h ighly educated or one
!,dongin g to n ffluent family in the community. What is more important
is fo ,· tha t p erso n lo be a ble to iden tify ,vith, un dersta nd and articulate
e ffedively th e p ro blems that b eset the community. lt is to his advantage if
he hm; a relatively wide influence not only a mong t he p oor but also among
the e li te. Perh aps, one im porta nt consideration in selecting p oten tial
leaders will be t h eir wiUi ngness to work for the d esired ch ange.
3.
Co,·e g ,-oupfo,•matio n
T h e co re gr oup consists of t he iden tified potential leaders who ,,.;11 be tasked
with layi n g down the fo1111cfati o n of a s trong people's organization. Ideally,
the c-or c gro11p re p resen ts the differen t sectors of t he community - women ,
yo11th . fn rm e rs m· workers - depe ndin g on the type of Lhe community.
T h e nurse :1ssists th e sector a l r ep resen tatives in fo rmilil!, co re groups in
their r espective sec tors. She a lso facilit<1tcs in skills de velop ment of core
group me m b ers 1·el;ited In lh1: tasks t hey ""ill assum e in the o rganization.
See Ch<1pte rs 14 an d 15 for s p ecific interventions to develop partnership
compe te ncies and worki roup tas k and maintenance functions. The core
group serves as training gTound for develop ing the pote ntial leaders in:
democratic and collective leadership
p la nning a nd assuruing tasks for the forma tion of a
commu nity-wide organization
231
h nnd lin$', n nd rc:s olvinA group c<.m flic:- ts
criticnl lhinki n~ nnd tlccisio11- 11inki11 ii proce!cls
-1 - Sctti11q 1111 the co n11111111itu cJ1'(1C111i7n tio11
Wh e n all 1-,•ctural o rw11~ i ✓11 Li<Jn :- huvc l ll'L'II put up , th e p e op le .tr c
rcndy to f11n11 a c u11111111 11ity - wid L· t> r )).:1 11i ,.:itk111.
This u q .;nni:r.ation
will f:H.:i lit:tl l.! wid1•r part idp:~ti,111 ;u 1tl C'lllh•ttivc a c tion 011 c-0111111u11ity
pruhl,•111s. \\' h ,·11 tht·11r1tnni;;1li!>11 is rornwd. t h L• n 11 rs~· n1nkcs su r e Llrnl
tlu.:n ' is 111.a:--inn11n p ;1rti.-ip:11io11 111' 11ml con trol 1,y the rn e 111 hc1·s i11 nll
its nt· t h;tit", Thl' o r~a11i ,.i1t1u1111l 1<tn1t·tt1rc 111usl bL' s imple to facili t ate
con s 11l1n1io 11 nml d,•L'i,: itm -11,11ki 11g a11rn11g it:-; 111t·111ln: rs. l'ar·t uf th e
o rµ.:111i1.lH101111 l ::: t nll'I u r t· will hl' wo rking co111111itt ccs s p ec ifi c.i lly c rcntcd
to 10<:>I.. in to th,· tl,ffL·n:n t n >n <·•·rns of th v 1J1·g:111izatio11 and con1munity.
O ne ,-11c h ,·,1111111it1,~ i~ tlw h L·:ilth n,mrnitl L'C:. T h e nurse ,,s s ists in l.iying
out p l1 111, of tl1 .:: ln: al l h l"•m1miltt' C' thn l initially includes idcn tifi cntion o f
i>ro,,p,·.:t iw 1:on111n111it~· h,·n llh w11rk<·rs (C HWs). The com m ittee m ny
d,>c1dc to in,ol\·.:: th.::m in th e n c" t phns e.
•
c.
Edu ca ti o n l.l.Jld Tr:,inin~ Ph:isc. TI1c purpose of t he ed11c:1tion n n d trni ning
ph:1..<:c i~ to s tre ngt hen the o~ani7.ation :rnd deve lop its capability t o a t tend to the
cornn1111ii1y·,- h., ,-j,· h,•alt h -1.·:i r,· rwt•d-<. "l11is c:in be ncl1i c v c cl hy cnnd11ct i n g the
rorn m1t n1t~· Lh:i~nn ,i~. tTaining o f r ,11111111.mi ty h e al t h worke rs . 11nde rtR ld n g h ea l th
,:cn-iet::." :iml rn11bili, Jt1on nnd leade rs hip s kills t raining.
1.
Cuml11cri11f1 c,) m1111111ify d iny 11osis
The cnmm u 11 1tvt.litt ~110,:1,- t>' <.l c111c lo co m e up wi th a pn,lilc of loc.-11 hc.1llh
"iltl:ttinn th :11 ";11 ,cn-c as h ~1si--; o f h c alth fll'OAnim ~ ant.I se rvi ce:-, to be
cldiH•n.'<.1 tu th e ,-.1111m1mity. The nurse a !>si~s th e.: p eople i n dcvc lDping
11 p lan :ind in the ,1c.:t-u:i l ccm<lucl of community diagn osis. S h e a lso helps
t1,.:: community tu id en tify. an t1 l)~.1.e u.11<..I u nders ta nd the impli c:..1l ions o f
th<! dat:1 t hat th ey ha,·<: cul lectcd .
2.
Traimng nfrmn muniJy h colrh workers
Afl,: r the rt'<.ults o f the co mmunity diagn osis h a.5 been prcscmtcd. t h e
c(7111111unity d, -ritl cs on tJ11.! r~)lcs th e co m mun it y h C'l llh workers a rc
cxJ>t.'(;ted to pcrfom, a nd th e c omr>ct c ncics and p crson nl qnnlit i•~ th ey
sh ould pos,e.ss. Ba!<ed on a n 11 14recd upon c.r ih: ria , Lh c pe<.1r,l1.: " •ill d t•cidc
,,·ho will be tra ined a ,; co m mun ity hcallh worker:- bns cd on th e exp ected
roles o f tlw Cl-!Ws.
After t h e community h ealth wo rke r s hnvc h ccn nam e d, t lic 11 ur:-ic
facili ta t e..,; th e C'(lntlu ct o f n r raining n eeds assc.,;o;mc 11I (TNA) w dctcrm i n c
t11~ level uf h e alth , kill, and kno,...-lcdgc th e trriinc•c.c; p osse ss. T h e r csu l L-.
o f thi"' a ......c_-.i:ment ";11 s.cn ·c ~, ... the bnsis for th e h e a lt h skills t r a in ing
currin1lum which " 'ill focus on the rcquirc·d co rnpc.:t c m .:.ies.
3.
232
Health scruice.s 011d m o hili,.<1/ io n
TI1c orga ni.r)tr ion ta ke-. th e le:id in 11nde nak.in14 net ivi I ics that w ill solve l h e
pru blc:m ,- Lht• c:,1mm unitv,, , -,,nfr()llf r·d wi th . l:'. nl!,a J.t i n)t th e m in c·oUcctive
w o rk j!h ,.,., tlw P'-'' ,pl•• ,,ppon un i t i, --. tn 1,•,1 and "' t rt· nJ:I hvn c nl'J c cti\'C s pi r it
and .i i 1h~· ,-.~1111.: t 111 w . build an J c 11 h ,111n .- th eir 1;c,11lidt.:11n;. O ftentim es.
JW<>pl,• nre ve ry ,•n1.wr t " Jl'l \,,1 hou1 con-:1JL•rn t inn I" rc•:,.,,u recs ncc clcd t o
c;i ~
ott l t h,• f!L' tion. I t \,-ill dn w e ll for 1lw 111 1r ,-.e tn t 1·r1d1 the people how
t n fll1Llnll7!'- th,· pr11bl ,·111.-. 1h0 1 n €'t.•d 1n be .idclrP<;<-ed o t a ~ivc n ti m e. T his
will p r...-vent fru:-tral i1m on th ,: pan of th e p ("<l µlc w h e n they do n o t see m
to a chic-v,• th eir goah righ t ,jW.«y.
4. Leade1·s hi p- ror rnati o n acti vi ties
The p r o cess of dcw:l,,pingcomm unilylenders is n con ti nur)lls :ind s us tainc<.l
proccsi:;. Lc,Jdcrs learn a lot hy r, ng11g ing in actuol o ri;anb:ationa l act ivi ties
:=:11ch ns conduct of nw,· tings , :,51,,!~c;mc•nt, plannin~. im plc m c nh1Lion ,
m o ni lorin g and cv,ilua tion ,,f;1c ti vi tics. T hey ca n ut ili:,,c t hcscoppo rtunit ies
in m as tc rill )!,<Jrg;,nizini; .~ki lls , h uma n n.:1;,t ionsdevcloprncnt or ~u pervisory
s kins. How1j ver, th ey an• not e nough . Thei r expr.:ri e nccs can very well
serve as bases fo r th eory l1;arning when th ey undergo fonnal le,1ders h ip
s kills Lrainin g whi ch ca n inc.Jud(: s ki lls in financi;il a ncJ prr,j cct/prngram
mnnngc rn c nt . l\.s th e nurse works w ith th e nrgan iu, rion and the comm u nity,
s h e w ill be ahlc l ei nsscs~ the s pecific t r:iini ng a nd oth er prncti ca l needs o f
th e leaden; :ind p lan for a conlrnuing education pmgr.:im for t hem. See
Chapters 14 nn d If> for inh:rven ti ons o n leadership formation.
D.
Jnte rsect oral Coll ahor;,i l 'ion Phase£ As the orga ni7.ation grows, its needs
will :i lfio g ro w. ·r111.: n eed for resource.<;-m atc rial. hum a n, fin a ncial- w ill have to be
so urced externally. Assistan ce a nd s uppo rt in any form can he funne led into the
orga ni;,.;iri,1 11 through c-nl111bnrn1 in n with other nrgani7.a ti rms a nd co mmun itie.5.
The nu r:-c is in l hc he.s t position tn foci litalc and coordi nate with institutions,
ugcncics and oth e r k ey p cnplc to ;irticnla te the communi ty's n eed for support a nd
assistance.
E. P h ase- O u t. ~\s th e o rganizatio n an d the co mmuni ty assume grea1 er respo ns ibility
in m .rnagin?, Lheir hcall h-c.irc needs, the nurse gradually prepares for turn- over
of wo r k a nd d evelop s a pla n fc;, r mo nitori ng and subsequent follow-up of tbe
organiza tion's .act ivities u ntil the co mmunity is rcatly fo r fuJJ d ise ngagem en t and
phase-out.
CAPACITY- BUILDING THROUGH COMPETENCY- BASED
TRAINING
l11e efficien cy and e ffectiveness of the health care system to address the h ealth
conce n li- of the commun ity depe nds o n th e level of competence of t he people who a r e
ex pected t.o delive r t he servi ces and m;m ngc the available resou rce.". In a sett ing where
the nurse c:rn only rely on vo lunteer workc·rs wilh little or no form al trnin ing o n heaJth
services p ro,·is in n. s h e n eeds to equip these workers with knowledge and skills as b as ic
health servi ce providers. health tench ers and commu n ity he~lth leaders to the r est of
tl.1c populntion in the community.
·
The compete n cy-based fra mework involves the mastery of a cluster of r elated
knowle dge, s kills . and nttituclc.s critical to performance of one's ro le or r espon s ibilities
mcm; urcd agnins t we ll- acce pted standard s. (Sullivan, 1995) ll is n syst ematic
approach to developing and e nhan ci n'1, the competence of a n individual being trained
to p e rform a certain ro le in a practice setti ng. Usin~ a competency-based framework
(Ma~layn, 20 0 6 ) in trn inin/'.\ o f community volu nteer h eal th worke rs makes certain
that the n ecessary compe te 11cics ;ire ac4u ircd anu perfo rma ncc o f U1e ro les and
responsibi lities can b e cerl ificd 11<)t o nly as competen t but proficient. The following
describes I h e process or co111petency-ba,-;cc.l trainin!!, from the experiences urU P Manila
Collq:;e o f Nurs ing s tudents' application o f co mpetency-based framework in training
of community volunteer healt h workers a.nd pa rt ne rs in Nagcarla n, Laguna a nd San
,Tuan, [bta ngas. (Abad et ,11, 2007; King et al, 2008; Mascarenas, et al,2 008)
1.
Analysis of work serting. The initial phase in developing a competencybased t raining progra m for conununity volun teer health workers is to
233
l'Olt..,idc-r thE' pres e nt h ealth issu es :in d t-on ccxns Clf tJ1 e co mmunity nn d its
pop,1\ati<'n. An nw;,i,·~n,.•s,.<; of I lw h ,cal lh silm1l ion provide~ direct- ion to t h e
rolel'. T'\'!<J'l•11:-:ibilitks nnd task;, th a t th e henlth w o rkers will be p rnparcd
a nd train~ l for. The folln";ni:. !\C-t h-itic..-. will h elp lhc nu rse com prnJ1e nd the
hcnl th ronditinns 111 tlw wo rk s L'tt-i~:
•
revie"· o f thl' Ct.'>111111un it)· d in_1-;11osis rcpor1
• in ten; t''' l>f \..,:,y l'l.111inm11ity lc (1<kn- pnrti cnla rly t h e local c hie f
•
•
•
e.xe<:utini nnd tlw t'l>11nd lo r for h ea lth
inteniew of the municip~B h cnltJ1 o fficer 01· s taff o f.tJ1e Rura l H ea]t}1
Unit
ocular sun"€y of the com m u n ity
random int..-n;l!w of resid en t s in th e com n.m1l.ity
SJX"C[f.uin9 the- roll'$ of th£? community L•olu11teer h ealth worke r s. T he nu rse
aoaly«~" tltlc' critknl roles th at the health worke r s will need t o car ~ · o ut t o
addl"CS$ UH.' heallh i~-u.-.. aod con cerns o f th e comm u n ity. ln a dditio n , the
munkipaJlty may ha,·"' special heaJtl1 programs being im ple m e nt ed in w h ich
C.1.."'fc'. t11e roles and ~p<>n,;ibiliti.:-s may have to be re defin ed. G c n crn lly , t he
roles of LUI! health workers include healt h care p ro ,;dcr , h ealth ed u cat o r/
tcach.:r nn d rommuni~ · h<c'altb lead e r . l n so m e of the barangnys in Na~ca rl an .
La.pm.;.. I :\ ood ct al. 200 - ) the..--c three roles especially t h e las t two were d eem ed
cruc1al in Ute m1.plemeo latJoo o f a health~· lifestyle pro~ram t ha t is working on
pl'C!'-ention ;i.ad control of majo r risk factors t o non communicable d iseasessmokin~. akohul drin.ki.n~. unhealthy diet and ::-edentary lifestyle . l n Sa n
J 1um. 8 ,11.ang:as ( King et al. 2008) " -here the nursi ng s tudents imple m e n ted
a comix>t-enc.-:,-t".Lx'CI training. Ut e role o f health care p ro,;der w as g.ive.n focus
in the hi:ht ;h.-.: the barang:iy h ealth wo r kers are actively in,·olved in tbc
implernent.:tiio n o f 1he Integrat ed :>- tanagement of Childhood llJnc.'-1' (T M C ]).
l o othe:r baranirny,; of San ,Ju a n. Batangru;. ( :,Ol ascarcn as. 2008) l11 c moth ers
'-"t're the recipients of a training progr am on hom e m anagement o f 11,,-I CIrelalfil conrutians. ln this train ing program, the mothe r 's role as h ealth care
p~,der for her cb.J1d v.-as also the focus.
3. Specifying the responsibilin·es or rasks related to tf,e rol.e. \ \fhen d escri b ing
ui~ ~nsihilities znd U1.Sl:s. take into accou nt v.-hal the Pc:partm1;n1 o f H eallh
only ex-pect.s the h~tu, ,-:o rkers ro perform i n t h eir respec·l.iv c communities.
Tite :,lunicipal Health Office as well as t h e local govern m e nt unit will he hrdd
accoun t;;ble for "-hate,.·er ill coru.equc ncc tJ1e h ealth wo r ker':, nction rnay
brinit. no not erp,.!ct the healt h w o rker to perfo nn Las ks which n r c d<·:1rl y l11 e
mid..,i(e·s rc:5'ponsibility. Another consideration ,,..,;IJ b e 1J1c level o f cduc..,tion
of the heaJth wo rken;. One can n oL expect the h ea Ith wo r kers tn fun c tio n wit h
lhe same competence and proficienc:-· as professional hcal(h wor ke rs.
S~fyfng the skills, lmmvledge and altitudes needed to perform the tasks.
Each "pecinc task will be ana l}7..ed in tcnn_s o f th e follo wing:
•
Skill - what !<;/ are the ~ ha,ior/s nc.-ed<--<l to p e rform th e task
•
Knov.led~e - "'· hi\ t is/an? th e co nt ent n eeded to b e oblc t o p erform
the ,.,kil,J
•
Anirud!! -wha t are th e feelings, beliefs , a p proach or va lues t owards
othe rs, one self or one's work which facilita te t h e execu tion of a
'>lo1] or a pa.rticolar task
S.
0'nductinQ rhc rra ining needs ~
<>nl (TNA). ·n1e TNA is c ruci:1I as i i
lnve$the nu.r-s.e who is de,..eloping the training p r ogram an csLirn.1te o f the en t ry
competency of th e participant-; to th e t raining progrnm. This is done by givi n g
them n pre - tes t to cvnhrntc t hc i.r level of know ledge and atti t ud e nnd readin ess
in term ~; of t h e n ew ma teria l th at they wi ll go throu gh in th e t rain ing. Skills
test can ;ils o be don e lo eval u a te pe rfo rma nce hnsecl o n s tanda rds. In the TNA
cond11 c led by th e n ursing st udents , t hev we re a b le to det ecl wrong informa t ion
abo ut vit.,d si).\ns Laki11g from th e pre-t~s t. Erro rs were o bserved in vi ta l s igns
ta king <.luring Lhc ski lls les t. T hese obse rvat ions were u sed as bases to make
sure t hn t t he m isi n for mation arc co rrected and the e rrors avoided. The TNA
res u lts ca n actual ly he lp in d evelopi ng th e instructional design or th e lesson
pla n for th e tra ining and in provid in g details in the SKA a nalys is of each task.
6.
Developing t h e in s tructional desig n. After the TNA. the nurse is no w ready
to d evelop the instructional d esign. The instru ction al design is s imilar to the
lesson p la n. lt specifics t he content. the instructional activities or the te acbingleitming me th o d s ,me.I h ow the competencies are going to be evaluated. The
S KA analysis ,..;I] be the basis for making the ins tructi,mal plan.
•
Al l behaviors listed under SKJLLS a re th e competencies that s hould
be b o n ed in actu al clinical setti ng wi th act ua l patien ts.
•
Al l items or co ntent Listed und e r KNOWLEDGE will h ave to b e
learn ed during didactics or in a classroom settin g or practice
s essions.
•
All items un der ATITruDE should be ta ught both in classroom
and prac tice sessions and actua l clinical setting•
Al l ite m s lis ted under skills , know ledg.e and attitudes are the
COM PETENClES that the bealth workers n eed to learn_
When p lanning for tl1e instructional activities, be guided by the followi n g
principles:
•
Lea m ing activities must be purposeful, planned and organized.
They s h ould e ngage the learner s to listen and interact with one
a n o th e r. make observa tions. th ink or a nalyze critically, perform
s ki lls o r d e monstrate behaviors that approximate the expecte d or
inte nd ed training o utcom es (BilJings 1.958).
•
Lea min~ acti vit ies sbou.ld be d esigned in s u ch a way that they
pro~res.siv<;?ly contribute lo the achievement of competencies of a
•
train ing course whil e preparing the learners for ·mor e complicated
cogn itive , psychomotor and cogni tive competencies . Ke m p (197 1)
s ta t es tha t con tent sho uld he m eaningfully aJ1d systematicall y
o r~an izcd in a way that there is a grad uated sequencing of content
from s imple to co mplex st arting \,ith fact learn ing, moving o n to
co n cept forma ti o n. pri n ciple s a nd t he n to higher inte llectual levels
of p r oble m soh,i n g. predict ion an d in fe ren ce_
Consider principles of learning in m eeting learners' needs and
abi lities. The teache r m ust recognize lhe m any variables in a given
s ituation t h at can affect indj vid ual's desire to learn a nd a bility to
m aster the needed skills (Schweer l976).
"
»
Recogn ize th e student a s on Individual; respect individual
stud e n t's wo rth and dignity regardless of teacher 's
expectati ons and goals
Motiv:oition pa tterns are highly individualized. Studen ts
tend t o be h ig hly motivated when they can see a direct
relationship b etween the learning activity a n d their
learning needs.
235
•
•
•
7.
Provide flelcibility in selecting available resources for clinical/ p r actical
experienc.e assignments_ (Schweer, 1976)
There mus t h e freedo m to select clinical /practicnl exper ience from
a wide w,riety of settings within t he t o tal community to increase
opportu nities for providing all lear n er!. with desired exp e ri e n ces at
the time n eeded.
Maintain an .e nviron ment of acceptnnce by personnel in the RHU.
Developing the evaluation p(an. The final phase of developing a com pet encybased training p rogram is designing. the evaluation tools to detem1i ne achie vement
of lea.ming ou tcomes. The follo·wing are guidelines in developing an evaluation
plan (Maglaya 2006).
•
•
•
•
•
Specifythe learning ou tcom cs/ competcnciesand the testing condition
u nder which the learners are to be evaluate d
D et e m1ine the performance s ta ndards and specific criteria/in.dicators
to meas ure the achievement of the standards
Id en tify evalua ti on methods appropriate t o the learning o u tcomes.
S pecify th e soLJices of evaluation data.
Use a ppropriate eval uati o n tools t o measure a chievement of the
learning outcomes
PARTNERSHIP AND COLLABORAT ION
Health a nd heaJth-related p roblems i.n the community are varied. Most often
the problems are complicated a nd too many for the nurse and th e people or tliei;
organization to band.le. They cannot solve the problems a lone. They mus t work with
otber people or groups to inc rease the probability o f accomplish in g the goals tl1at they
have set. A,; tbe sayi ng goes, th e re is s tre ngth in numbers. The n urse must plan t o
establish a nd m aintain valuable working r elationships with people such as p eoples'
organizations, h eal th o rgani za tions, edu<:atio n al institutions, the local government
uni ts, fi nanci al ins titutions, religiou s g roups, socio-civic organizations, sectoral groups
and the Like.
The ai m of pa rtnership and collaboration is to get _people to work t ogether in o rde r
to addr ess problems or concerns that affect th e m. It gives people tlrn opp o rtuni ty to
learn skills in group r elations hip, interpers onal r elations, critical analys is and most
important of all, decision- m ak ing process in the context of de.m ocratic leadership.
Working togetJ1er enables organi:1..ations to accomplis h their goa1s much q ui cker
because resources, skills and views are poo,Jed together. Organizations can com.mit and
wo r k togethe r in different w ays (ICHSP 2000).
236
1.
Networking is a relationship among organi zations that con sists of
exchanging information about each othe r 's goals a nd objectives, services or
facilities . Th.is results in th e o rgan izations ' becoming awar e of each o ther's
worth and capabilities and how e.ach can contribute to the accomplish m ent
o f th e n etwork's goals a.ad objectives. Net...vo r ki n g r e quires s m all amount
of time, yet it h as great potentia l in t erms of joint actions.
2.
Coordinatiorz is a r e lationship where organizations mocjjfy t h eir activities
in order to provide better service to the tar get ben eficia ry. To a certoin
e>..--tent, this level of organizational r elation ship becomes tirne-conswning
as it requires more involvem ent and trust on t he part of t h e committed
organization. Modification of activities that are more responsive to
comm unity's needs may significantly improve people's lives.
3.
Cooperation is a relationship where organizations share information and
resou.-ces and make adjustments in one's own agenda to accommodate the
other organization's agenda. I n this type of.relationship, organizations share
ownership of th e success, rewards as well as p.roblems and h assles that go with
working together.
4.
Collaboration is t he level of organizational relationship where organizations
help each other e nh ance their capacities in performing their tasks as well as
in the provision of services. At this point, people become partners rather than
competitors. Collaboration entails a lot of-work but the potential for change
can be great.
5.
Coalition or Multi-sector Collaboration is t h e level of relationship where
organizations and citizens form a partnership. All parties give priority to
the good of the community. It requires great investment in terms of effort,
time, trust and the will to make a change.
The following are general ideas for the mrrs e on how to get started in partnership and
collaboration work:
1.
It is imperative for t h e n urse to involve a ll the stakeholders in the process
of forging partnership and collaboration with the community.
2.
In working togeth er, the nurse and the co mmunity face risks together. It
is important therefore, t hat they need to know and t rust eacb other.
3. Determine how each organization views the problem, h ow it proposes to
solve the problem and how it perceives an organizational relationship can
help s olve the problem_
4. Organizations should agree on t he kind or level of relationship that will
help best accom plish the group goals considering needs and available
resou r ces_
5. When organizations have agreed on the type of organizational r elations hip,
formulate grnund rules that will become tl:te bases for decision-making.
The following are the most important points:
•
Listen to what each has to say. Points of agreement can only be
reached if there is an excl1ange of information.
•
Take t ime to listen to people who voice different opinions or
concerns. Keep an open mind. Try to identify points of unity from
diverse op inions.
•
Don't force organizations to give up their ide n.tities. Remember,
organizations work together for a comm on good. They do · not
work together just so they can out do each other.
ADVOCACY
Advocacy work is one way the n urse can promote active community participation.
The nurse helps the people attain optimal degree of indepe ndence in decision-making
in asserting their rights to a safe and better community. Advocacy work in nursing has
gone a long way from one who just acts on be]1alf or intercedes fo r the client to one who
assists parties to understand eacb other so that agreement is reached (Sta nhope and
Lancaster, 1992). Today, tl1 e nurse as an advocate places the client's rights as priority.
She is respon sible for providing mechanisms for people to participate in activities
237
tbot a im to improve the cond itions of the community. The n urse os an ndvocatc helps
empower the people to mnke decis ions and carry out action s t hat bave th e poten t ial lo
better t h eir lives. Advocacy work involves (Kohnke, .1982):
1.
In.forming the people a bout the rightness o.f clie cause. The n u 1·se conveys
the problem to t h e people, shows h ow it affects them and describes what
possible net.ions they can take.
2.
Tl101·ou9'1ly discussing with tlae people t'lw nalure ofthe alt'er11atiues, tlicir
co11l'e 111 a rid possible consequences. While discussing the a l tern atives, the
community's needs and problems are amplified and eventually becom e
t he bas is for decision- making,. It is through this pr ocess that t h e nu1\5e
and th e people co m e to agree on th e relevance and appropriat eness of th e
action s to be taken to solve the problem.
3.
Suppo,·ting peopJe'.s riglrt to make a clroiceand to act on t h ei1·choice. The
nurse puts e mphnsis on t he p eople's r ight to deci d e on action s that t h ey
thi nk should benefit the community. It is also the nu rse's r esponsibility to
facilitate the process of weighing the benefits and losses of the a ltern a tives.
1N11ateve.r the ou tcome of the d ecisio 11-m akin g p roces s, Lh e n urse assures
the people that they do not have to change t h ei1· dec isions because of
others· objections or pressure.
4.
I11jlue11ci11g public opinfon. The nu rse affirms the decision made by the
people by getting powerful indjvidu als and grou ps t o listen , support and
make substa n tial changes to solve the problem.
SUPERVISION
Supervision is a developm ental an d enabli ng process whereby the nw-se supervisor
en sures tlrnl work is don e e ffectively and efficiently b y the person (Morrissey, 1970)
b eing s u pervised a nd at th e s a me time, keeps th e person s atisfied a n d motivated with
his work. Supe,vision is also seen as a foci litating process that con s ists of insp ecting
and evalua tin g the work of another in order to remedy r a ther than pu n ish poor
p erform:rnce (Gillias 1989).
If t he goal of comm u nity hea lth n ursing is commu n ity health and commm1ity
developmen t. it is n ecessary for the n u rse to invest in training m e m bers of the
community o rgan iza t ion not only in Ll1e p r ovision o f acl ual health services but also i.n
mnnnge mc nl fu n ction s. I n commun ity-man aged h ealth programs, it is the intention
tJrnt the nurse will eventually hand over the management of th e heallh p r ogram to the
people and the o rganization .
\-Vhat a re th e objectives o f supervision? Supervision is done in order to:
•
identify tJ1c superviso1y needs of th e worker
•
determine ways of meeting the need s of th e worker
develop th e capability of the worker to solve own p r ob lem s and meet
own n eeds by providing continui ng personal guidance and professional
deve lopm ent
•
evaluate t·heperformanceoft he worker as it becomes the basis for providin g
help or guida n ce
In community health nursing, supervision is s ee n more as a coaching (Gillies 1989)
function ra therth a n a function of control. This isso because tl1e intensity ofsupervision
238
-
can not be like n ed to institutio ns where th e environme nt can b e readily controlled
and where the supervisor can expect a cert'ai n a level of compe ten ce from th e worke rs
}laving more or less passed certain qualifying criteria for th e positions. Tbis is quite
different in the commu n ity whe r e the wo rkers ha ve varying levels of cognitive and
psycl1omot o r capabili t ies not to mention the ir a ttitudes towards health work. In tJ1 e
commun ity, most of t h e s upervisory funct ions of the nurse are dfrected towards lower
Jevel health worke rs, t h us, they will re qufre closer supervi&ion than d o professional
health workers. In additio n , supervis ion ·is not based on set ru]es or form u la but 011
each supervisory situation.
The n urse as a coach to health workers uses persuasion, exhortation and judicious
mixture of r ewar d and punishme nt to motivate the players toward hlgher levels of
p erform ance. She emphasizes group goals rather than fulfilling th e needs an.d desires
of individual grou p members.
.A n u rsing supervisory plaa is a written document on how to organize and systematize
supervisory activities. It includes objectives, strategies, resources and timetable
of activities to m eet the identified n eeds o f the p erson being sup ervised. Generally,
supervisory n eeds arise from:
inadequate s kil ls, knowled ge and attitude
•
conflict between organizational and individual goals
•
work and personal s ituation
•
Jack of motivation
Makin g a Supervisory Pion
The following a r e t b e steps in making a supervisory plan (Public Health Nurse
· Manual on Su pervision, DOH):
1.
The nurse conducts a situational analysis focusing on s upervisory needs
assessment. lnformaliou regarding supervisory needs of the workers can be
taken from the following;
•
Review of r ecords and reports
Observation of the person at work
Interview of the wo-rker
Interview of co-work ers and clients of the worker in th e
com munity
2.
Supervisory needs and problems may be p rioriti;,:ed based on the following
crit eria:
•
Degree of importance or urgency of th e proble m /need
•
Activities/strategies needed to meet iden tified needs
•
Availability of resources needed to meet identified need
•
Magnitude and e:-.'tent of the pr oblem/need
•
Time frame to carry out actions
3 . Set objectives.
4 . Select activities, strategies and resources needed to meet identified objectives.
5.
Identify indicators for evaluation.
•
Met the needs
•
Perfo1·mance increased
•
Improved qu ality of service
239
Methods and Tools for Supervision
.·
......t11bd1
~ of rKOrds and reports
TOC111
~dfomal
s-nonal data sheet of the wo.-ker
1
•
-
•.. cGent records
•,. performance evakAtton
daily time record
ts 5t,jbm1tted
•,. 1epo,
~hshment reports
,.
.
Actual observatlo i, of worker's
perlormance in V1trio\.ts situations:
d inic
home visit
conduct o f lndlvldual or group
das~
nu rsins conference
•
..•
•
•
.. tMget cilent list
Observation 1ulde in the form of:
• quemonnalre
• checklist
o rgamzation/lmplementation o f
commu nltv p rojects and
activities
tndivlduaVsroup conferences and
mNtinp
Anecdotal report
Cfltfcal Inciden t report
Performance evaluatfon form,
M inute$ of meetings
M anuals/handbooks
Modules/ca$e studies
Nursing audit
Supenilsory logbook
Conducting a Supervisory Visit
240
1.
All s uper•: isory ,·isits must b e pla.nned. The nurse reviews the outcomes and
recommendatio ns of the previo us visit and hosed on these; formulnte u work
p la.ti for t h e ,;sit. If necessary, d iscuss the work plan with. other team members
fol" collaboration. Determine \\!hat m ate rials aI"e needed fol" the conduct of the
supervisory visit.
2.
The actual conduct of the visit is divided into three parts:
a . Opening - The nurse creates a wann, open and friendly atmosphere.
Discuss the objectives of the viisit, ell.-pected outcomes, the process and the
time frame.
b.
Body -The nurse discusses the following points with the woI"ker:
• Res ults and recommendations of t h e last vis it.
• Actions token by the worker a nd the o u tcom e of these actions
• New a re as of co ncern of th e health worker
• Actions to address concerns
• Review objectives and exlebt to which they were attained
c.
Closure - The nurse expresses a ppreciation and s upport extended during
the visit. Togetl1er v..ith the worker, she plans for the subsequent visit.
c ase Study Illus t rating th e Application of the Steps ;n Sup ervisory
p/onn;ng
Unda. a Pu blic HeaJlh Z--:u rsc of M unicipali ty o( Son .Ju:m. has fhe midwi.ve.< under her
sopen-ision. They a r e :S:ona . '.\lildred. Letty . Celia .-.nd .Jane.
\ \'hile Li nda w as doing h er a nnual e,:ahml ioo nf miJwhe-:. '<he fnund oul lha t th eir
targets , ...-ere not being met. She con du cted ~uper,.,..,_ory visit~ to a II midh-ivc;; and found
the foUo,~;ng :
•
Sometimes. logii:tics a nd sup p lies com e 1:He a nd in;idCQua le: reqtii~tion
n ot s u bmitted o n l im e
Target client lists. tallJ i:h~ts/ n.:portinJ< fonn-. ;ind I n •nlmrnt n-cord." w eru
n ol propedy filled up a n J updo le<l. Reasons i,ti,-.; n by the live mi d w1vcs nre
the follo,dng:
"
,,Tong com purn tion o f 1ar,tct": don·, know updalc<l )!11ldeline- in
ta rget -set1.ing
»
inadequa te re porting a nd n:cnrdin~ fonn s
1)
con fus ion in lhe use o f FH I S form
»
t.liffi cu lt t e rrain affect Lhe perform:mn· o f l"dia :ntll !So nn
»
inadc..'Qutl t c lv\S o f Jnn c who ii- new in 1hc :,;l'n·in·
Based o n the above situ atio n . l.i ndn makei- n plnn. Folln";ni lhc s lrp~ in plan nini. sht!
identified th e p rio rit y proble m tha t is poor recnrdini: anJ n·por1i11g whii-11 is cn mmo n
to the five mid"i ves u n der h er s u p ervi,-;io n. Poor n•cordi ni: and n ·1"1rtin~ an.· dt1L' to :
\~To n g computatio n of t;i rgets: they do n~,t h:w,· t lw u1xl a k(l r.uidclincs in
target-setting
•
confus ion in t h e n ew F l:11S form
•
in ade.qua t e recor din g a nd r eportin~ for ms
l\ sam ple supe rvisory p la n is s h own o n T a ble 9. 1.
·n,c s u pc n ·i~ory .-;t rn tei;tics/ nct h ; ti es
are di r ecte d at ac h ieving the identified learn ing objectives an d th e cvnlun tio n indico tors
as learning outcomes in s upervision.
CASELOAD MA N AG EME NT
An importan t functio n of Lh e nu rse in commu nity selling is tu providl.' h ealth care
services for groups o f in d ivid ua ls with sim ila r h cnlth prnhh.:ms u r comli t ions. A
caseloa d refe rs t o t h e num be r of c lients being served in a :::pcd tic pro~ram o r sen 'ice .
Caseload manage ment d iffe rs from ca se mnnagc m c nl hccn usc it fucLL-.cs on the
common p ro b le m s of aggregates or grou ps. Case mn n ai:;em cn t is di rcctl)d to t he
ind ivid ual client . It t akes in to account lhe clie n t":< ch aracteristics and s pecific responses
t o its h e a lth co nd iti o n from wh ich the n u r'<c hu ild-s he r nursinµ. cnrc plan for. Caseload
manageme n t however, is consistent with t he epidcmiolo~ic a pprv:Jch bcc.'luse olh t::r
than p e rs onal variab les, it considers envirvrunental variable.., as impo rtant in fl uences
in the agg r egate's vulne rability to certain disease co nd itions. The n u rse th e refore
highlights in her p lan of care variou.s in tervent ion slrategics that will di min is h lbe
population g r o u p 's vuln erab ilities and in1p rove tJ1cir competencies in health care
man agem en t .
Caselo a d ca n b e identifie d from th e differe nt hea lt h scn ;ce registries of the henlth
ce nte r . I n the P hHip pines, th e Dep a rtm en t of H en Ith pu t e m phnsL, on severa l programs
th at n eed t o be gi ven atte n ti o n to . Examples o f t hese proi;ram s t h at t h e n urse ca.n
obt a in a case lo a d from a r e th e Nation al Tube rc ul osis l' rogram -Dire<:t Observed
T reatment Short Course (NTP-D OTS), lategratcd Ma nage m e nt of Child hood lllaess
2 41
(!MCI) a nd Matc rnn l a n d Child Hea lth Programs. TD casc_s are in~portant fo cu
o f case lo ad m a nag em ent as w ell a s p regnant and nmlno~r1sl.1ed c h ildre n . Clien /
,,; t11 cardiov;iscular d i.seuses. dinbc tcs o r ca n ce r nre b ecoming import a n t cas e I
s
o f th e n urse beca use of t h e high m o rta lity it b rings in th e com m11 ~ities. M ore: :ds
the d isnbilitfos resulting from t hese con d ition s pu t II toll o n t h e social and econ o r:: •
1
conseq uen<.-es in t h e r,opuln tio n .
c
111e nurse us a casclood man age r assesses the h en llh s ta t us of _Lhe in d iv:idu a J cli
:tnd determines th eir risk fac to rs and variables -~:it lead to their vu lne r ab ility toe;;:s
d isease con ditions. As ide from hea lth r isks a r1s 111g ~ro m p e rso nal or d e mogr a _c
1
ch a rocte ris ti cs, vu lne rability issues a mong p opula t io n gro u p s con sist o f h a P_lie
limited contro l, powerlessness, disenfra nchisem e nt or alienation , victi mi zation VIng
o d isad van tag<.-d status. Mo re ofteI1, th e risks t hat vul nera ble p o pulati o n s r un _and
are gen l.!rnll y 11ot vol u n ta ry o r u nder th eir control. (Stru1hope a n d La n ca:;te r
into
1
Anderson and M cFa rla nc. :woo) Peoplc- or e made to feel and b elieve th a t t h e r e'c 992 ;
no h op e for Lbem and as s uch. le.irn to jus t accept Lhei r condition an d d epend o n ~n ~e
o ut from o t her peop le . rn th is ki nd of si tuntion. th e nu rse m us t facilit ate the P O e o f h aving people to tn1st themselves and gai n co nfid ence in t h eir a b ility to tranr~cess
5 0
t h cir p resen t sla te th rough communi ty p art:n e rship s . ( Freire, 19 97)
nn
r.
,,u leS of _.....blNty
1'2altfl r'illlcs
,._
L
../::
Umleed control
Cone.pt
Certain a s ~ of
physiology, environment
(lncludfng personal
habits, social anc:t physical .
environment) make It more
llkely to CMVelop particular
health problems
Based on the health-.fteld
concept that describes
the lndlvfduals as sharing
c:ontn:>I and responsll,ility
for their health status but
lfffll!ly affected by soc:fety,
bfolotw, environment and
~
,
I.
I,
r,.,
h,
•
02 l.lfranc:hrsement
!4
~
242
health care system
Umlted flnancl.al resources
puts Individuals to
dependent,-OS,ttonsand
l'llducas their ability to
millce dlolces about their
health
FNllna of HparatfC#I from
mainstream society anslna
from lade of social support·
may IMt.
of •
deviance diaplavec, by these
people ;w ,_■ty to fulfill
consecauence
IIQfpltlled aodaf rofes
Examples
Special populatio n sroups
as age groups, indigenous
people or low-inco me
sroups
Infants, young c hildre n
adolescents, elderly, '
the_ homeless, medically
Indigent, ethnic gro ups
Infants whos e h e a lt h st at us
depend on their mothers
health management and
health seeking behaviors;
people who can not access
specific h ealth services
because of poor financial
status
Poor ly educated, lowIn come people
Streetchlldren; run-away
adolescents
Vlctlm lz'atton
Blaming the victim for are.1s
Impoverished people
outside lndfVld ual control
leading to limited access t o
services
Disadvantaged status
Being 11'1 the rnlnorlt'( Hn,lts
the partrcipatl on of this
people in health planning
Indigenous groups; women
Source: Sta11hopt! and l!ancastu, 1992
Th e nurse develops and implements the plan of ca re in the conte.x-t of the above causes
or s ources of vulnerabilities of her caseloaa . In address ing th e specific need for health
care treatm ent, the nurse focuses on care coordination with other members of the
h ealth team depending on the actual or potential heal th and medical problems of the
caseload. [f sever al mem b ers of the healt h team w ill b e involved, care coordination
calls for a mechanism for systemat ic follow-up or mon itoring of the progr ess of cUents
under the caseload. R eferral an<l follow-up to va1;ous community resou rces will be a n
integral part o f cure coordination and allow the clients to access health services. In
this regard, th e nurse will be responsible for identifying resources tha t are available for
the clients. Co lla boration with oth er sectors or disciplines in ca.re provision addresses
the issues of vulnerability. As health advoca t es, n urses are ex-peeled to ad vance the
interest of her clients fo r bette r h ealth conditio ns by lobbying for healthy policies and
delivery of quality health service.
Although much · of the work to be don e by the nurse as n caseload manager involves
tl1e external environment , it is equally important to put emph asis on developing the
competency of th e clients in self-care and to facilitate behavior change. T h is can
be carried out as group intervention wbe:re clients under the nurse•s caseload come
together to learn specific skills related to their health care. The nurse can take this
opportunity for clients t o cultivate and foster a supportive system among them.
CO N CLUS I ON
Working with aggr egates of people for sustained participation in health d evelopment
work requires empowerment p rocesses a n d competencies. The nursing interventions
d escrib ed in this chapter are a.i med at developing these competencies ....,,;th the
communit-y. The Primary H ealt h Care Approach serves as the context of these
in terventions while community competence is seen as the ultimate goal of a ll these
interventions. Health pr omotion as an a pproach is importan t mainly because it
encompasses h ealth education. Health education mainly focuses on ind ividual
behaviora l change but h ealth promotion believes that behavioral changes can be
speeded \tp with environmental changei;; an d reorien tation of health care system.
Jndividual behavioral changes coupled ·w:ith community organizing and mobilization
facilitates Ll1c empowerment process. Bul nurses need lo ensure that the initial efforts
will be s ustai n able. Sustainability is guaran teed through capability-buildi ng activities
and proper s u pervision of l1calth workers who are ex7Jecte<l to monitor the different
h eal th activities in the com.munjty. From time t o time, th e commu1tity \vill need to
lobby for support from other p eople in their effort to address their healt h concerns.
Issues of vulnerabili ty limit certain grou ps of people to access health services. For
this reason, the nurse must teach them how the process of advocacy, partnership and
collaboration work to imp rove their h ealth status.
243
"'t
.
,,_,.,.,.,u,
Poo, rtpartlng/reco1dl~g
dutto·
..
TABLE9.~SAMPLE SUPfRVISORY-PlAN• .
"'......,.. .....
3,.,.,, ...,fE$]Ac: "'"'-
~
--
TA1111"
TIM£ fl!AMl
INOICATUll3
$Rur1I
tlt.alth
Ml~lvi'l
3 hou1s dutti,a
Mldwl'tfS compute targets
correctly le>r dlf~nt Pf01'3ffl$
~ on 1111dated gvld~lnM
S~ur.11 Health
3 hours
during SGI\Uday
~ rr,ldwl<leJ will I,,, able tCI.
a. compute tatl'ls
L wrona aimpum!on of
COrtec(IV based OIi
llflel,: don't h~ an
updo!td CUiatllllt for
updated auldtllnfl
evercne on compur~ilon of lllrccts b.i"d on
upaotcd gufdi!llnt5
Saturd.ly
mte.ting
follow up during supc,vlsory Ylslt
ia,aeuetvnc
b, confusion In the use of
ne,, FHISfOf'l!'I
b. we -lid l\ll,up the
FHIStorm pn,perly
011t111slon on the purpme~; objectives of the
IIIIW FHISform
Midwives
Mldwl'les l(tompllsh fHIS forms
aCt11rite!r
mtetlng
Eitercisn on the procedurelor fil\inR up FHIS
form
Follow-up durlng1upervlsory visit
c.
c. lnJdequ, te
r@qUt st loglstlcs/ supplle$
on time
Olstl/S.SIQn on the lrnportante of wbmit1ing
11!Q.Ulsltlon ol l01isflts/ ~uppll~ifn lime
SRttral Health
Midwives
logistics/11Jpplie,
3 hours during
satunlay
Midwlve5 deroo11Stfite proper
filllng-up of rtqulsltlon fortnS
meeting
berciseson howto fll\-up requ1$1tlon forn\5
FaDow•LIP duringsupervlsof'/ Visit
it
.
g_
S°·
d. keep inventory of
stotks up 10 <late
&>
ij,
~
"~
Demonstratlon and exercises Qnhow Ii>
sel ui,,an·updated monitoring system for
inventorv of stotks
S Rural Health
Midwives
3 hours during
Saturday
Midwives submit requisition or
logistics andsupplles on ttmc.
meeting
Mldwlves show updated
I
.
follow-up during wpervisoryvisil
inventorv ofstocks .
~Adapted from the Department of Health. (199.4). Resource Manualfor the Public Health Ifurse on Supervision.
'
REFERENCES
1.
Abad, Y. et al (2007). Community Diagnosis and Program Plan of Barangay
Balinacon, Nagcal"lan , Laguna. (Un published Community Diagnosis.)
University of the Philippines College of Nu rsing
2.
Andamo, GP. (March , 1986). Community Organizing in Health. Paper
presented in ACHAN Conference on Social Mobilization.
3.
Billings, D (1998) Teaching in Nursing: A Guide for Faculi:IJ, Philadelphia.
Saunders
4.
Department o f Health. (1994). Resource Manual for the Public Health Nu,-se
on Supervision . Manila, Philippines: DOH.
5.
Gale.a, G. (200 1) . Integrated NCD Preuentio11 and Control:De monstration
P,·ojects. World Health Organization-Western Pacific Regional Ofnce. Manila.
Philippines
6.
Gillies, DA. (1989). Nursing Management: A SystenwApproach. 2 nd edition.
P ltila delphia: W.B. Saunders Co. Harcourt Brace Jova novich, I nc.
7.
In tegrated Community Health Services Project-AusAid Assiste d (ICHSP- AA)
(2000). Community Health Development: A Resource Handbook. 4•h Floor
Philippin e Tuberculosis Society Bldg., Tayuman cor. Rizal Avenue, Sta. Cruz,
Manila.
·
8.
Kemp, .TE (1971) lnslructional Design: A Planfor Unit and Cour·se
Development, Fearon Publishers, California.
9.
·
IGng, H. et al (2008) Competency-based Vital Signs, Height and Weight
T nki11g. (Unpu blished research). University of the Philippines Manila.
10. Kolmke MF. (1982). Advocacy Risk a!ld Realii'y. St. Louis: The CV Mosby
Co.
11. Maglaya, A., et.al (Eds). (2006). Competency-Based BSNCurriculum.Manila:
Un iversity of the Philippines Manila College of Nursing
12. Manalili,
AG.
(1985). Community Organizing: Towards People's
Development. Training and Enhancement Program Reader for Land Bank of
the Philippines.
13. Morrissey, G. (.1970). Management by Objectives and Results. Reading,
M assachusetts: Addison-Wesley, p. 105.
14. Schweer, J and Gebbie, K. (1976) Creative Teaching in Clinical Nursing. The
CV Mosby Company. St Louis .
15. Stanhope, M a nd Lancaster, J. (1992). Community Health Nttrsirig: Process
and Practice Jo,- Promoting H ealth. 3nl edition. St. Louis: Mosby Year Book.
16. Sullivan, R. (1995). The Competency-Based Approach to Trai ning. USA: U.S.
Agency for International D evelopment.
245
17. T 11aY.on, J., Dones, LRP., Bonito, SR. (2003) A Tl'ai11ing Ma!1ualfor He
Wor-kers on Promoting Healthy Lifestyles. UP CoJlcgo ofNursmg-Depnrtmalth
of HC31th-Wor1d Health Organization
ent
18. World Hcnlth Organization. (August-September 1978). The D eclarati o n
Almo Ala. W orld Health.
J9.
24 6
of
World He:ilth Organization (1998) . Regional Pla 11 for Integrated f',·eue 11 .0
1
and Cardiouascular Diseases a nd Diabetes fo r tire \ \/estem Pacific R ti_ n
1998-2003. \"1orld Health Organi7.ation. Regional Office for lhe w eg ion
Pacific Manila, Philippines
es tern
chapter 10
·LOGIC TREES FOR SAFE
MOTHERHOOD
AND WELL-BABY CARE
Ma. Corazon S. Maglaya and Araceli S . Maglaya
INTRODUCTION
Maternal and pediatric population grou ps comprise sixty percen t (60%) or more
of the total popul ation of m ost communities. With e mphas is o n safe m oth.e rhood
and well-child care, the rural health nurse or the nurse p ractitioner can be guided
in handling mothers a nd b abies as population groups usi ng logic trees OD prenatal
supervision, home delivery, postpartum care and well-baby care.
The use of assessm·e nt a nd management protocols on safe motherhood and wellbaby s upervision a re critical options for improving access to quality health service
and nursin g care specially on enhancing wellness and improving competencies for
handling p opulation aggregates.
THE USE OF LOGIC TREES
Assessment and management protocols for safe m otherh ood and well-baby care
have been developed by the authors based OD a long experience in general medical
and episodic nu1·sing practice in the community. Each protocol focuses on a specific
complaint, history or physical assessm ent data or a set of signs and symptoms.
The assessment protocol specifies the appropriate history, phys ical examination
findi ngs and other pertinent data. These heaJth assessment da ta are classified
under red, yellow o r green categories. The management protocol indicates el\-p]ic.it
interve ntions to handle t he case or situation, classified as Plan A, Plan B, Plan C
or Pla n D depending upon specific combination /s of red, yellow, or green health
assessm e n t data. The p i:otocol i ncludes branching logic so that the assessment
data obtained from a given patient or case and the appropriate ma nagement are
"individualized" according to the patient's s ign s, symptoms or experiences.
This chapter includes Logic Tree protocols on pregnancy, home delivery, postpartum,
newborn and well-baby care.
247
ASSESSMENT PROTOCOL
FOR INITIAL PRE- NATAL CHECK- UP
(Logic Tree No. 28)
DIRECTION: Determine/identify whlch of the fol1owing symptom s/signs (S/S) or
history d ata O-LxD) are present and follow t h e Oowchart for the appropriate pla n of
manageme nt.
RE D
YELLOW
GREEN
S/S or HxD
5/S or HxD
S/S or H xD
• Continuous p regnancy
(I.e., patient did
not have any
men stru ation from
t h e time o f t h e last
delivery until onset
of th is pregnancy)
• LMP or qui cken i ng is
n ot known
• Patient has b een
pregnant for at
least five times or is
p regnant for the first
tim e
• Complications during
the previ ous
pregnan cy (l ike
hyperten sion,
b leeding, excessive·
.
vomiting, etc.)
• Persisten t and/or
excessive nausea
and/ or vomiting
• Ch ills
• Cough and/or colds
• Diarrhea or
con stipa tion
• Pa inful u rin ation
• Itchiness of the vagina l
are a
• Foul smefling vaginal
discharge
• Patient has h eart
problem li'ke
r heumatic fever
• Pati ent h as other
.
m ed ica l prob lems
(like d iabetes.
h yper te nsion,
t ubercu losis,
• LMP or quicken ing is
known
• Slight nau sea and/or
vomiting
• Frequent but n o n pai nful urination
durins the first few
weeks of pregnancy
or during the later
part of it
• Difficu lty o f breathing
dur ing the last three
mon t hs o f pregnancy
• Leg cramP,s during t he
la t e r m o nths of
pregnancy
• Increase i n n on -foul
sme lling mucoi d
vagina l d ischarge
: Fe t al movement still
present (may even be
increasing in n u mber
and quality) in a
pregnancy w it h AOG
of at lea st 20 wee ks
• Patient's blo o d pressure
w ithin normal limits
based o n h er BP
b efor e she b ecame
pregnant
• Patient is not in pa in
• Weight w ith in n ormal
range based on h er
weight before she
• Vaginal bleeding (even
if minim al only)
especially if there
Is no associated
abdom inal pain
• Abdominal pa in,
especially If In the
lower part of the
abdomen
• Sudden release of fluid
from the vagina
• Bl urring of vision
• Persistent and/or severe
h eadache
• Difficulty o f breathing
during th e first six
months of pregnancy
or If it occurs in
patient with heart
p ro blem
• Blood pressure higher
than the prepregnant BP
• Nostr ils spreading out
with each breath
• Patient in pain
• Swelling of the hands
• Swelling of the face
especially around the
eyes
• Marked swelling of the
legs and feet specially
du ring the first six
m o nths of pregnancy
• Fetal h ea rt rate less than
120 beats per minute
or m o re t han 160
beats per minute
1
248
I
-
RED
YELLOW
~ s/S or HxD
i..-----:: regoancv w i th AOG of
.. it'I a
G REEN
S/S or HxD
.
S/S or HxD
. becam., pregnant and her
• go iter. etc.)
:i least 16 w e eks
f tal heart beat
• NO e
dI
-3ppreclate n "
pregnoncv with AOG of at
least 16 weeks
Fetal movement ha s stopped
AOG
• Fundlc h"lght wit hin the
ex pected limit based on
the AOG
• H ead of the fetus Is occupying
the lower portion o f the
womb while the buttocks
or has decr eased In
number and/or i n quality
• Weight is more than what
ls expected based on
her wei ght before she
became pr.,enant and
AOG
• Temper.iture o f 37.S •c and
above
Pale l ips, nai l beds and /
or inner aspect of the
eyelids
• Ear discharge
occupy the upper por tion
i n a pregn ancy with AOG
of at l ~ast 20 w eeks
• Only one fc tD I h eartb eat Is
appreciated in a pregn:,ncy
with AOG o l at l east 16
weeks
• Slight swellins of the feet
during the few weeks of
.
.
• Runny nos~
• BP higher than her u,uat
BP before ,he become
pregnant o·r BP o l 140/90
• W histling or noisy sound
when the patient
p regna ncy
breathes
• Anothe r ilbdominal mass
aside from the g.rowing
womb
• Fund lc hei ght lllgher t han
what Is expected based
onAOG
Head is occupylnQ t he
upper portion of
the womb w hite the
bu·ttocks occupies the
lower port1on (breech
.
or "suhi") o r head Is
occupyi ng either t he left
o r right side (baby is in
l he transverse position}
In a ~regnan, v with AOG
of at leart 24 weeks
• More than one fetal
heartbear·can be henrd In
a pregnacv wilh AOG of
.
.
.
at least 16 weeks:
.
.
.
.
.
.
L
24 9
at least one
RED
s/s or HxD
at leas t one
YELLOW
s/s or HxD
at least one
GREEN
s/s or HxD
2:50
Proceed with
Plan C
Pro ceed with
Plan B
Proceed wit h
Pl an A
MANAGEMENT PROTOCOL
FOR INITIAL PRE-NATAL CHECK- UP
(Flowchart No. 28)
PLANA:
1.o
Dcternune patient's knowledge on b ow to take care of herself during pregnancy.
2.0
Based on 1.0, teach the patient about proper nutrition.
2.1Importance of well-balanced, good and nutritious meals (e.g., food sou rces
o f iron and p.-otein for hemoglobin production).
2.2 Stress th e inclusion of proper nutrition in pregn am.-y (e.g., inci:eased intake
of food sources of m inerals like calcium for fetal bone development; avoid
high intake of sugar a n d s alt).
3.0
Based on 1.0, a d vise tl,e patient to have enough rest and s1eep and to perform
prenata l exe r cises to pr event or n1inimize discomforts like low back pain and to
learn the proper breathing and "bearing down" techniques (start at last trimester
fo r "beari ng dowu" exer~-:ises).
4.0
Advise the p atient to take a bath daily and t o have daily bowel movement.
5.0
Advise her to stop smol<ln g, drinking alcoholic beverage, and not to take j ust any
over-the-counter m e<licine or herbal medicine unless prescribed by the doctor.
6.o Advise th e patient to use proper clothing:
6.1
6.2
6.3
7.0
Use comfortable, loose titting clothes.
Avoid usin?;tig ht brassieres, garter belts or "bigkis".
Use l ow-hee1ed comfortable shoes.
Advise the pa t ient to do the followi ng to relieve minor discomforts in pregnancy.
7.1
Por nausen nnd vomiting (morning sickness):
7. 1. 1. 1 fave a light bre;,kfast (crackers , unbuttered toasted bread, etc.)
7._1.2. Eat s m:ill frequent meals (around five to s ix times a d ay) instead of
three full meals, if tl1e symptom occurs later in the day.
7.1.3. Avoid fatty o r oily foods.
7 .2 Fo r ''he:u·th um .. :
7.2.1. Hove small freq uent mca1s.
7 .2.2-.
no not lie do"''" immediately after eating.
7.3 For co11stipat io 11 :
7 .3.1 Increase fluid intake preferably in the form of milk, sou p or juice.
7 .:;.2 Eat ple n ty ofvcge tables and raw fruits especially ripe p:apaya.
7-4 For varicosit;ies and hemorrhoids:
7.4.-1. Raise o r e levate the legs a t least twice a d ay.
7.4 .2. When lying down. lie s ideways (either left o r right s ide) with the to p
leg forw;u·d thus p laci_n g the weight of the baby on the bed.
7. 4 .3.
Do leg raising exercises.
7.4-4. Do not stny in one pos ition for a long time.
7 .4.5 . Use su pport or eh1sHc stocking5, if necessa ry, for varicose veins.
7-4.6. Do knee-chest position i f there are hemorrhoids.
7 .5 For incre<1sed non-foU-1smelling mucoid vagi nal discharge:
7.5.1. Take a bath daily.
7 .5.2. Was h genital area frequently using mild soap and water o r with
251
7.6
7.7
7.S
one tablespoon Del ~Jonte vinegar mixed with ½ "tabo'' lukewarm
water.
For sho rtness of breath dw-ing the last t hree months of pregnancy (patient
lrns no history o r heart problem):
7. 6 .1.Advise patient to asswne a semi-sitting position with tbe back we.lJ
supported by pino·ws instead of lying flat.
7.6 .2. Discourage patien t from using "bigkis".
For crnmps:
7.7. 1. Rub or gently m iissage the affected part.
7.7.::!. .Elevatc the feet often.
7 .7.3. Keep the extremitjes warm.
7.7.4.Tnkc milk.
For swelling of th e lower extr e mi ties:
7.8.1.Rest frequently witl1 the legs e levated. l f an activity can he done while
sitting down. :,it down "md don·t do it w h ile s t a nding 01· squatting.
7.S.2. ,"'11eoever possible, e levate the legs.
8.o
If the patient asks about sexu a l inte rcottrse, ·inform her that it is pern1issible but
it is advi:,;ed to avoid such an activity daring the last two months o f pregnancy lo
reduce the chances of p r emature delivery.
9.0
Give/prescribe over-the-counter multivitamin a nd iron preparation especially if
lhe AOG is 1uore than 12 weeks.
9.i Give/prescribe iron preparation, specifying accurately the dose and
frequency of the intake.
9.1.1. Advise lhe patient to take the medicine after meals.
9.1.2.Givc nn iron preparation that has Folic Acid especially during the firstthree months of pregnancy.
9.2
Give/prescribe multivitamin preparation aside from the iron p r eparation.
Specify uc:c: urately the dose and frequency of intake.
10.0
Advise the patient to have a re.gu]arpre-natal check-up using the followin g
schedule:
o lo 28 weeks : once a m o nth
29 to 35 weeks : once every two weeks
36 t o 40 weeks : on ce a week
The patient can have a more frequent check-up if there are problems.
PLAN B:
1.0
Refor the patient to a doctor within 24 to 48 hours.
2.0
Determine patient's knowledge on supportive management of the problems
presented.
3 .0
Based on 2.0, do the following supportive management:
If there is fever:
3.1.1. Give/prescribe over-the-counter medicine for fever, preferably a
purely par acetamol preparation, specifying accw·ately the dose and
frequency of the intake.
a. lfthe pa.tient is allergic to the sub stance mentioned above, give/
p r esc1ibe a purely aspirin preparation.
b. Advise the patient to take the medicine on a full stomach.
3.1.
252
3.3.
3 .4.
3.5.
3.9.
3.1.2 .Advice patient to take a quick bath using lukewarm water.
If there is cou gh, colds, and/or runny nose, advise lhe patient to:
3.2.1.lncrease fluid intake (at least eight glasses a day) in lhe form of juice,
soup. milk, etc.
3.2.2. Have s team inh,1lation fo1· 15 minutes t,vo to three tim r_<; a cl.,y.
3.2.3. Gargle wa rm salt solution if she h as a sore throat.
Tf there is excessive vomitinp. n ud/ nr nausea:
3.3.1.Give/prescribe over-the-coun ter medicine for nausea or vomiti n g. o r
herh:1 1 m edicine for dizziness. specifying nccnrntcly the me thod
of prcparntion (specifa:ully fo1· herbal medicine), tlw dose nnd
frequency of intake. Advise patient that the m edicine co uld nrnke
her sleepy.
3.3.2. Ad,'ise th e patient to do th e following:
a. Eat 11 light breakfast only.
b . Tnke small frequ ent m eals instead of tlcree f-t, 11 o nc.c;.
c. Avoid fa tty or oily foods.
1f there is diarrhea:
3.4.1.Advis e p:1tie nt to drink ornl r ehydra tion solution.
3.4.2. Give/prescribe herbn l m ed icine for dinn·hea. s pecifying accta·alcly
the m ethod o f prepara.tion. th e dose and frequency of intake .
3-4.3. Advise t h e patient to avoid fatty foods.
3-4.4. Ad vise pati1.ml to eat b-ana na (latu ndan), a pple or star apple.
If there is corn,tipation. advise t o:
3 .5. 1. Drink plenty of fluids.
3 .5 .2. Eat p lenty oflenfyvegetobles,e.g., kangkong/sayotc tops, maluni:;g:1y
and alugbati.
3.5.3. Eat fresh fru.it like dpe papaya.
3.5-4. Avoid eating banana (especially the latundan varie ty) , a pple or sta r
apple.
If there is itchiness of the vagina l area and/or foul-smelling vaginal
discharge, advise the patient to take a batll daily and to wa~h her ge nital
area freque ntly, using one tablespoon Del Monte vinega r mixed "'ith ½
"tabo~ luk ewann ·water.
If there is p ai nful urination, advise patient to drink plenty of fluids (at l east
eight g lasses) especinlly buko j uice.
If there is ear discharg"l, adv:ise patient to cleru1 h er ears with hydroge n
peroxide daily an d to dry it well aften-vards.
Advise the patient to see the doctor as soon as possible and not to wait until
the following day if there are oth er medica l p roblems (like d iabetes, goi.tcr,
hypertension, h ea rt prohlem) , surgi.c:il problem (like another nbdominal
mass other tlrn n the gro.,;ng womb) or obsteb;cal problem (like the b<1by
has stopped moving or fundic height is higher than e.-xpected or weight is
greater than expected).
4.0
Based on 2.0, teach/advise the patient on the proper pre-natal care (see sections
2.0 to 6.o o f PLAN A of this Logic T ree):
4 .1. Proper nutrition ·
4.2. P roper clothing and personal cleanliness and bowel h abits.
4.3. Stop smoking a n d drinking alcoholic drinks.
4.4 . Consult a doctor before taking any medicine.
5.0
Based o n 2.0, give/prescribe over-the-countecmultivitamins and iron preparat ion
for pre g nan t wom en, specifying accurately the dose and frequency of in take.
253
6.o
P ro'-;de the doc tor to whom the pa~e~t is be!ng referred to :-vith a ppropna .
clinical record o r re ferral no te crmtammg a bnef history, p hysical examin • . tc
tinclings· · laboralo rv
•' results (if available ) and manag cm.en t started at the re~eut~on
,, rr111
leve l (See Figure 3 o f Chapter 3 for a s ample referral form).
g
PLAN C:
1.0
2.0
Refer the patient immediately to a hospita l (preferably t h e nearest one).
Keep th e patient calm.
M ake the patient lie do,,.,"Il qui e tly.
If the patient has djfficulty of breathing, place b e r in a semi-s itting position 1.
her b ack well s upported by pillows .
'v th
5.0
P~o~de the hos pital where the pati.~~t is b e ing r~ferred to with appro ri .
chmcal record or refenal note conta ming a bnef history, physical e.- ...:amJ tia00
te
findings, labora to ry resU-lts (if available) and management started at the refe~
level (See Figure 3.2 of Chapter 3 fo r a sample referral fonn ) .
.., tlg
•
254
ASSESSMENT !PROTOCOL FOR
FOLLOW-UP PRE-NATAL CHECK UP
(Logic Tree No. 29)
DIRECTION: Determine/identify whlch of the following symptoms/ s igns (S/S) or
hist ory data (HxD) a re present and follow the flowchart for the ap propriate p lan of
management.
RED
YELLOW
GREEN
S/S or HxD
S/S or HXO
S/S or HxD
• Vaginal b leeding even
if spotting only
spec ia lly i f ther e
is no associated
abdominal pain
• Abdomin a l pain
esp ecia lly if se vere
and/or in the lower
part o f t h e a bdomen
• Sudden r e lea se of flu id
from t h e vagina
• Blur ring of vision
• Perststent and/o r
severe headache
• Difficulty of breathing
during the fi r st
six months of
pregnancy or it
occurs in a patient
with a known h eart
probl em
• Swelling of the face
especially upon
waking up
• Swelling of the h an d s
• Systolic Pressure of 160
mm mercury and
above or Diastolic
Pressure of 100 mm
m ercury and above
• N o feta l heart rate in a
pregnancy with AOG
of at least 16 weeks
• Feta l hear t rate less
than 1 20 beats per
m inute or more
th an 160 beats per
minute
• Persistent and/or
excessive nausea
and/or vomiting
• Chills
• Ear d ischarge
• Cough and/or colds
• Diarrhea or
constipation
• Pain f u l urination
• It chi ness of the vagina l
area
• Foul smellin g vagin al
d ischarge
• Fetal movement has
stopped or has
decreased In
n umber and/or In
quality
• Fetal movement has
not been felt and
the AOG is at least
20 weeks
• Weight gain o f 5 l bs.
(or 2 .25 kilos) per
week o r higher o r
less than one pound
(400 gra m s) a wee k
in pregnan cy w i th
more than 12 weeks
AOG
• Fundlc height higher or
lower than w hat Is
e xpected based on
AOG
• Head, b ack o r arms
occupying the top
or upper part of t h e
fundus
• Slfght .n ausea and/or
vom iting
• Frequent but
non -painful urination
during the first few
w eeks of pregnancy
or during the last
few weeks of the
pregnancy
• Difficulty of breathing
d uring the last three
months of pregnancy
• Leg cramps dur ing the
later months of
pregnancy
• Increased non-foul
smelling mucoid
vaginal d ischarge
• Regular fetal
movements if AOG is
at least 20 weeks
• Weight gain of 75 grams
(0 .1 lbs.) per week
d u r ing t he fi rst three
m onth s a nd 400
gram s (1 l b.) per week
during t he remaining
months
• Patient's blood pr essu re
w i thin normal llmlts
based on he r previous
blood pressure
readi ngs
• Fu ndic heigh t w ithin
the expected llmlt
based o n AOG Head is
occupying the
255
RED
S/S or HxD
• Marked swclll nc of the
legs and fee l during
t h e fi rst six months
o f the preg11ancy
• N ostrils spread out with
e ach breath
YELLOW
GREEN
S/5 o r HxD
S/S or Hxo
• More than one fetal
h eart b e at is noted
in pregnan cy wit h
more than 20 weeks
AOG
• Anothe r abdominal
m ass ;:islde from the
growi ng wom b i s felt
• Pale lips. nail b e ds and/
or in ner nspect of
the eye lids
• Runny nose
• Whistling or noisy
sou nd when t·he
pa tient b reathes
• Temp erature o f 37. 5 •c
and a bove
• lncrensln g t r e nd in the
BP reading based on
previous vi sits
--
• lower portion of t h ; - womb wh i l.:e the
buttocks occ upy t he
upper portion
• Only one f et al heart
bea t a pprecia ted
• Fe tal heart rate o f
120-140 beat s per
m inute
• Sligh t swel li ng of th e
fe et duri ng the last
th ree months of
pregnancy
-
.
.
256
..,
-
LOGIC TREE FLOW CH ART NO. 29
Pregna n cy
at least one
RED
s/s o r HxD
I
Yes
~
~
Proceed with
Plan C
!""
Yes
at least one
YEI.I.OW
s/s or HxD
Procee d with
Plan 13
No
at least one
GREEN
s/sorHxO
-
J
Proceed with
Plan A
·
257
MANAGEMENT PROTOCOL
FOR FOLLOW- UP PRE-NATAL CHECK-UP
(Flowchart No. 29)
PLANA:
2S8
1.0
Advise the patient to continue her multivitamins and iron supplements.
2.0
Remind the patient about the importance of proper nutrition, personal hygiene,
taking enough rest, using the right kind of clothing and the i mportance of
exercise.
Advise the patient to do the following to relieve t he minor discomforts of
pregnancy:
3.1. For nausea and/or vomiting ("morn ing sickness"):
3.1.1.
Have a light breakfast.
3.1.2. Eat small frequent m eals instead of three full meals, if the nausea/
vomiting occurs later in ithe day.
3.1.3. Avoid fatty foods.
3.2. FOi:· "heartburn":
3.2.1. Have small frequent meals.
3.2.2. Do not lie down imme diately after eating.
3,3. For constipation:
3.3.1. Drink plenly offlujds.
3 .3.2. Eat plenty of leafy vegetables and raw fruits especially ripe papaya.
3.3.3. Avoid eating banana (especially the latundan variety), apple or staT
apple.
3-4- For varicosities and hemorrhoids:
3.4 .1. Do not stand or stay in one position for a 1011g time.
3.4.2. Whenever possible, s it down and elevat~ the legs for at least fi ve
minutes.
3.4.3. Do leg r a ising exercises.
3.4.4. Use support o r e lastic stockings, if necessary.
3-4-S- When ly ing down, lie sideways (either left or right side) with the top
leg forward thereby placing th e baby's weight on the bed.
3.4.6. Do knee-chest position if there are hem orrhoids.
3.5. For increased non-foul smelling mucoid vaginal discharge:
3.5.1. Take a balh dailv.
3.5.2. Wash tl1e genitltl area frequently ,,.,ith soap and water or with one
tablespoon Del Monte vinegar mixed with ½ utabo" lukewarm
water.
3.6. For shortness of breathing during the last tlnee months o f
pregnancy:
3.6.1. Assume a semi-sitting position with the back well supported by
pillows.
3,6.2. Discourage the patie.nl from wearing "biglds~.
3-7- For leg cramps:
3 .7.1.
Rub or massage th e affecte_d area gently.
3.7.2. Elevate the feel o ften.
3-7-3, Keep the leg ·warm.
3 · 8 · For swelli11g of the legs:
3.8.1. Rest frnquently.
3 .8.2. If an activity can be done while sitting down, sil down .md don't do
, . . . . __ _ _ _ _ _ _ _ _ _ _ _ __ =
3.8.3.
it whil~ standing or squatting,
Whenever possible, elevate the legs.
4.0
Advise patient to prepare the haby"s things as soon as possible.
5.0
Encourage the patient tq have regular pre-natal check-up.
6.o Do home visit if patient fails to return for follow-up.
PLAN B:
1.0
Refer the patient to a doctor within 24 to 48 hou_rs.
2.0
Advise p atient to continue taking multivitamins and iron supplement.
3.0
Encourage the patient to follow the advice given during the :fitst visit, especial1y
those pertaining to personal cleanliness, proper nutrition and exercises.
4.0
For the supportive ma.n.agement o f th e problems presented, follow the
instruction given in Plan B of the Management Protocol for Initial Pre-natal
check-up (Logic Tree Flowchart #28).
5.0
Pi:ovide the doctor to whom the patient is being referred to with the appropriate
record or referral note containing tl1e briefhistory, physical examination findings,
laboratory results (if available) and management started at the referring level.
PLAN C:
1.0
Refer the patient iinmediately to a hospital (preferably the nearest one).
2.0
Keep the p atient and her companion calm.
3.0
Make the p atient lie down quietly.
4.0
If she h as difficulty breathing, place the patient in a semi-sitting position with her
back well supported.
5.0
Provide the hospital where the patient is b eing referred to with the appropriate
clinical record or referral note containing a brief h isto ry, physical examination
findings, laboratory results (if available) and management started at the referring
l evel.
259
ASSESSMENT PROTOCOL FOR HOME DELIVERY
(Logic Tree No. 30) ·
DIRECTION: Determine/identify which o f the following symptoms/signs (S/S) or
h is tory data CHxD) are present and fo11ow the flowcb.a rt for the app·rop riate p lan of
managemenl.
RED
S/S orHxD
• Severe and p ersistent
h ead:>ch e, dizziness.
.. 81LJrtinc: of vision
• swelling of the face a nd
finger~ or con vul-s1on
at any time durina the
course of the pregnancy
• Vagina l bleeding, <p ecl ally
lf p ainless, a1 any point
during the course or
pn~gnitncv
• Rupture of b~S or water
before labor pains
started
• Either s ys.t ollc or dia stol ic
b l ood pres<UrG Is higher
than pre- •p r egn ant state
or 1-r this not known, BP of
.
GR EEN
YELLOW
S/S or HxD
S/S or HxD
• AOG is 38 to 42 weeks
• AOG Is l ess tham 38 weeks or
more than ti2 weeks.
. course of pregnancy has been
.. Suspicion of mul lipl e
pregnanc:y
uneventful (I.e., ther e has
b een no problem)
. Previou s precnancjcs w ere
uncomplicated
. Pa tient
i s 1n good heal th
• History of' p reviious
complicc1·ted delivery
• Hist·o ry of al least one
. Physl cal e><amln.ition find i ng
c;,c.s arlan section
• Patient is givine bir-th fo r t he
firs t time
• eoby Is in a b reed, posilion
Fet a l hean bea t less than
120/min or more than
w ith in normal limits
• No ramily history of multiple
pregnancies
• Baby I n ceph alic position
Feta l h ear t bea t t20 • 160/mln
• No probl em duri n g the first
.
.
160/min
. Patient's gene r el c:onditio n
.staee of h1hor
Is poor
• No core coll
• Baby cded spontarieously
Placenta came out withi n 15
.
.
m o re than 140/90
Baby In a h orl2on1al position
• Patient has h e art problem
• Cord came out fir~t
• Labor more t h.sn 24 houn
without anvorograss
• Plac.enta not delivered within
15 minutes. after birth of
.
the baby
Exccs!ii,.;,c b leeding .:ifte r b irth
of the baby
. Lacera
tion s·ecn on
lnspec.tfon or t h e- p erinea I
nre a
, Parts or the placen ta still In
the womb as suggested
by profuse bleeding a her
delive ry of thee pt.acenta
Of by incu mplete
plnccnla on ln~pectfon
• Sl,gn~ and s-vmpto,ns o f shock
• Uler\JS doc~n ·t 5-l JY
c-ontr.ac.ted
260
.
rninute.s
No l3cerat1on ob~•e rved
• Pl acen ~ i s complete
• Womb l s well contracted
• Very minima l b l e e ding a fter
the t hird st:igc of i abor
.
LOGIC TREE FLOW CHART NO. 30
Labor Pa i ns
Yes
at leas t one
RE D
Proceed with
Plan 8
s/s or HxD
Yes
Yes
at least o ne
Yes
YELLOW
there is s till
time to b r ing
patient t o the
hospit al
s/s or Hxo
l
•o
ot least one
I•
GREEN
s/s or HxD
Proceed with
Pl an A
:
.
1 . G ive the mother son 1ti ,, ourlsh .
mant the n tct her slcco;
2. Attend to the baby;
3 . Givo a fter core instructions.
4. Register the baby's birth or
instruct the fam lly 10 do it.
I No
1. At lease one RED s/s or H•D has
develo ped durinr. thtd eUvt!'ry
or inirncdiately after
2 , More thon one baby W i)$ born
(twins. lrlpleu. &tc)
3 . Baby IS premature (AOG less than
36 week•)
261
MANAG EMENT PROTOCOL FOR HOME D ELIVERY
(Flo w ch a rt No. 3 0)
PLAN A:
l.O
Do the following d uring th e first stage of labor (from onset of true labor pain.
until the cervix is fu lJy open):
s
J. J .
Advise Lhe pat.il:!1ll not to bear down during this stage.
1 .2. Do not give the patient a heavy meaJ.
If possible, d o not g ive the pat ient anyt)1ing by mouth until after the
1 .2 . 1.
d e livery.
1.2.2.
If she is hungry, a glass of milk an d/or some cookies could be
given.
1.3. Keep the p atie n t calm.
1-4. Prepare th e work are:1.
Choose an area in the home which would provide enoug h privacy
1 . 4 . 1.
und comfort for hoth the patient and health personnel.
a. If a r oom is not available, an area can be sealed off by d raping a
dean bed s heet or bla n ket over a chair thus tlie blanket acts as a
curtain.
J. .2.
Wash yom: hands with soap and water and dry them using the clean
4
h a nd towel in the delivery kit.
Place the following things for the baby in one part of th e working
1.4 •3 .
area:
a. clean clrHh to dry the baby
b. baby's bhmke t a nd bonnet
c. p ack of cott on bulls
d . 70% alcohol
e . bowl of warm watc,·
f. one cord dressing pack
g. abdomin a l binders
h. diaper
i. large safety p ins
j . sando or camisa
1-4.4 .
Place the following things for the mother:
a. Put at the b ead part o f the patient a change of clothing Oike a
housccfress).
b. Place the followin g at U1e foot of the patient (if plastic lining is
available, spread it o ut and place these things on it):
□ a pair of s harp scissors or blade soaked in 70% alcohol.
O bowl with warm previously boiled water
□ bowl for th e placenta ("inunan")
D one pack of umbilical ties
O one pack of cotton balls
O paper waste basket
0 di aper
c. Improvise a pad: wra p any of the fol]owing in a clean cloth: old
newspapers, clean rags a nd/or old clothes.
d. If another plastic li nfog is available, place the improvised pad on
t op of it.
e . Place th e p ad (with or without the plastic lining) under the
patient's buttocks.
With a bros h, scrub your bands with soap and rinse with warm previously
boiled water using the pouring method (that is, ask so meone to pour wate~
262
J.6.
1.7.
2 .0
over yom· h a ods).
If available, use a n apron.
If t rue labor pains h ave just s tarted, a dv.ise th e patie nt to urin ate since a full
b ladd er m ay delay progress of lab or.
lf s t erile glo ves are avai lable, do a n internal exa m and determine how wide
the opening of the cervix is.
Do the following during th e second stage ofl abor (from complete opening of the
cervb, up to the birth of the baby):
2.1. lf you arr ive d uring tl1is s tage, do th e following:
2.1.1.
Wash hanlls willi soap a nd warm, p reviously boiled wa ter . us ing
th e p ou ri n g method for rinsi ng.
2 . 1.2.
Spread on t h e wor king a rea at least th e following thiogs or ask
somebody to spread tbem out while you assist in the delive.r y of the
baby:
a . dean cloth tu dry the baby, b lanket a nd bonnet
h. :.i pa i 1· of scissors o r a blade soaked in 70% alco lw l
c.:. h owl o r bnsin with warm pre viously bo il<.:<l wa ter
d. bas in for th e placen ta
c. lw o s terile 11mbi lical clamps 0 1· cord tics
f. pack o f cotton balls
)!.. p :qwr was te bnskct
h
dc:,n rl1JI h 1r, s11 ppo rt Lh e pe rin e u m
., d1n t1 i:?,c of clo1·h in g for I h e mo t her
2.2. Clea n th e p e rinea] area of the palient usi ng cot1:on balls and warm water
every t ime fecal mater ia l comes o ut when the pat ient bears down.
2.3. W e a r a pair of s terile gloves. Make sure to cha nge the· gloves if it gets in
contact with a ny fecal m aterial.
2 -4. Instruct the patient to bear down properly.
2.4.1.. Mouth must be closed and the force directed to the perinea)
area.
2.4.2. Bearing down must be d o ne only while the womb is con tracting.
2 .4.3. P atient mus t rest between con tractions.
2-4.4. Patient must continu ously b ear down d u ring the whole time the
uterus is contracting.
2.6.
Watch for ruphue of the bag of water and wait for the crowning of the
b aby's bead.
Support t h e ar ea j ust b elow the openin g of the birtl1 canal with t he palm
of the hand (either left or right) using a piece of clean cloth or diaper as
lining.
Deliver the baby's h ead:
2.7.1.
Extend the b aby's h ead up gently to prevent it from g etting io
contact with the anus.
2.7.2. As soon as the baby"s h ead comes out, pass the fingers of one
hand to th e baby's n eck t o check if th ere is one or more coils of
the umbilical cord, s upport the baby's l,ead with the other h and.
2..7.3 . If t here i.s a cord coiled arou nd the neck, do the following:
a. If the coil is loose, slip it over th e bead.
b . If the coil is tight or n ot loose enough to slip over the head,
q uickly tie t he co;rd twice (the ties should be around o ne inch
apart) , then cut the cord b el:\'lleen the two ties; deliver the baby
promptly.
2.7.4. Instruct the patient to stop b earing down and breathe thrn the
mouth a fter the baby's head bas b een delivered.
263
\\;ipe tl1e baby's face with a dry piece of cloth (or with your hands)
to remove I.be l,lood :1nd/ or mucu s which might be covering the
baby's face.
2.8.
De liver th e baby's shoulder:
2.8. 1. Gr ,1sp the head wi th both b ands.
2 .8.2. Apply a gentle downward pull until one s h oulder is d e livered.
2 .8.3. Apply a ge ntle upward pull to d eliver the other shoulder.
\Vith the le ft haod (or righ t band if you are left b a n ded) sup port the
l,ab y's body a s it go es out.
With the o th er hand. g ra s p the baby's l egs as soon as they come out. Place
2.10.
the middle finge r be tween the a nkles t o preven t the baby from faUi ng.
2.U
Dry th: s kin oftb: newborn ";·t l1in 30 seconds of birth. Stimul ate t h e baby
to cry 1f he does n t do s o s ponta ne ously.
2 . 12
\Vit hin the 1irst 60 s econds, pl.ice Lb e baby in a prone posi ti o n on t h e
mother·s ch est. Co\'er his bac.k with a clean dry b lanket and his head with
a clea n dry b onnet.
·
2.13
V\lil h in 3 111 i uu l{'S, after the un1b ilical pulsation has s topped, clamp tbe
cord: cm from the base ifit has not ye l been cul yel. Place anoth e r clam p
S cm trom the b ase and cut the con.I between the two c lamps. D o n o t m ilk
tlw cord.
Do not pull the cord unless there are s igns of placen tal separation.
If there are signs of p lacental s e_paration, deliver it _c ompletely.
3.2.1.P u ll the cord slowly a n d gen tly until t11e placenta spontaneo us ly comes
out.
Rotate t he placenta.
3 .2 .2.
3.2.3. Place the placenta in a basin or bowl and inspec t it a s well as its
membranes untle r a good Ught.
3.3. Feel if the womb is hard a.nd well contracted o r soft a nd r e laxed. I f it is soft,
massage it ge ntly to make it contract . If ice is available, ice pack can be
applied over lhe area belo-.,· the mother's umbilicus.
3.4. I nspect lhe perine um for any lacerntions (tears).
3.5. If there are no lacer ations, clean th e pedn_eum witJ1 cotton and warm
water.
3.6. Remove the pad and the plastic lining under tl1e p atient 's buttocks and
change Mer clothes. Do not apply "bigkis~.
3.7. Give her no m-is hme.at like s o up, milk, tea , etc.
3.8. AJ lo w the mo the r to s leep.
::?.7.5.
3
264
4.0
Stay w ith the patient for two bours after the deHve ry of the placen ta. Do the
following d u ring t h is per iod:
4.1. Oh1:e rv<" the pnt ien t for any untoward signs and symptoms (like bleeding,
dizzi11es s, cold ,mcJ clammy persp iratio n , etc.)
4.2. Attend l o ll1e ne wborn.
4.3. Take down data need ed for the birth certificates (]ike the m o ther's age, h er
ma ide n na me, lter o bstet r ical h istory, etc.)
4 .4. Give cifte r care i11s 1.ruclio11s like t h e d iet for b ol:h U1e m otl1er a.nd child, cord
care, e tc.
5 .0
lf th e baby is in br eech pos ition ("suhi") a nd th ere is n o tim e to b ring the pati ent
to a doctor or hospitnl, do the following:
5.1. Do tl1c :;amc prepnrutions dur.i ng tJ1e 6rst stage of lab o r.
5 .2. Perform the follm,;ng mnne uve rs during the second stage o fl abor:
5.2.1. Delwer t he baby u p to th e shoulder .
a . Urasp both feet of the baby.
b. App~y a downward pull s tead ily but gently, holding higher
portions as they come ou t (like the calves the thighs then the
hips).
.
'
'
5.2.2. D eliver the shoulder usi ng e ithe r of these two methods:
a. While m aintaining the gen tle do"'1Tlward pull, slowly tum U1e
body s u ch t hat one shoulder and arm appear at the opening of
t he birth canal and can tlms be released and d elive red firs t; then
turn the baby again so that the other shoulder and acm could be
delivered.
b . While still maint aining t h e gentle outward pull, grasp both .feet
again in one hand tben gently draw the baby upwards; with the
other hand, free the shoulder and a m 1, then gently pull the baby
downwar d and deliver the other arm and shoulder.
5.2.3. Deliver the head.
a. After delivering both shoulder , support t he h ahy's body with one
hand. \\Tith the fingers of the oth er h and, check the neck for cord
coil. ff there is cord coil, see if it is loose enough to pass over the
·baby's h~ad as it is delivered. If n ot. tie the cord twice, with the
tics arou nd a n incb apart, t h en cut between the ties.
b. lntr oduce the left i nd e.x finger (or that of the right if you are left
h anded) into the mouili of the baby.
c. Hook inde.x and mid die fingers of the oth er hand over the b aby's
neck a n d grasp ilie s houlders.
d. While still maintaining the p ull, elevate tbe baby's body until
head is completely d elivered .
5.2.4. Gr asp the baby's feet and h old the baby secur ely while ensuring
drainage of secretions . Stimulate ilie baby if it doesn't cry
_5.POntaneously.
5.2.5
Dry the baby's skin, p lace him o n his mother's chest and cut the cord
as expfai n ed in section 2.11 to 2 . l3 of this plan.
Man a ge the tJ1 ircl stage of bboor and th;, t"·o hours imm edi,1tely afte r birth as
in Cephalic present :rtion (h ead first) as explained in items 3.1 t o 4-4 of this
pla n
5 :J
6.o
Befo1·e leaving the p atient, be sure that :
The womb is b ard a nd contracted and remains so.
6 .2. There is no excessive bleeding.
6.3. The place nta is complete.
6 .4. The baby and mother are both in good condition a nd wi thout any untoward
s igns and s ymptom s.
6.1.
PLAN B:
1 .0
Refer the p atient im m ediately to a hospit al ( preferably the nearest one).
2..0
Accompan y 'the patient to the referred level.
3.0
If the p atient hasn't d elive red yet , be prepared in case the patient gives birth on
the way t o the hospital.
4 .0
Keep h e r calm.
5 .0
[f tbet"e is shock, do the following:
.
265
5.1. Make her lie down \\ith the h ead lower tha n the body.
5 .2 . Cover the patie n t ligh tly.
6.o \-voile patien t is in transi t or wa iting for the services of the higher level fa c T
where p a tien t is being r eferred to and there is massive bleeding after the thlity
s tage o f lr1bor. uo th!' folio,,; ng:
rd
6 .1. Apply cold co mpress o r ice car belo w the patie nt's umbilicu s.
6.2. lftJ,e bleeding d ocsn ·t s lop. press the a b ove menlioned area.
6 .3 . If there is still some bleeding, g rasp the womb i n bot h hands and slo
.
w1y
press ,t.
Endorse the patient at the referred le,·eL See Figure 3 .2 for a sample re fi
form.
e r ra l
7 . 1, Gi,·e th e brief histo ry including t h e obs tetrical history if possible.
7.2. Gi"e the phys ical e.xamination findings a s w ell as the manage ment st
at the re ferring le ve l.
arted
266
-
Sc..:~rn ticJ wiln C1m1Soam1t:i
-
....:;,-1
I
I
I
I
ASSESSMENT PROTOCOL FOR CARE OF THE NEWBORN
IMMEDIATELY AFTER BIRTH
{Logic Tree No. 31)
D IRECTION: Determine/identify which of the following symptoms/signs (S/S) or
history data (H xD) a re present a nd follow the flowchart fo r the appropriate plan of
management.
INITIAL EXAMINATION
RED
YELLOW
S/S or HxD
S/S or HxD
, Baby is w i t h p i n k body and
blu e e><tremities o r is
blue a ll over
. Baby Ja; 1, to cry afte r
• Cl ub f eet
• Extra finger/toe
• Non•developm e nt of one
part of the extre mity
$:·tJmul ation or g.ives a
GREEN
S/S or HxD
• Bab y i s pink all over
• Sp.onrnneous crying o r
b;,~y cried efL~ r s light
stfm u lao on
• Heart b eat i s 100 beats per
very w eak cry
m i nule o r more
• Heart b eat. ls l ess tha n :too
• Baby gives a good sustai n ed
a n d vig010u ~ cry when
stimulat ed
b e~ts. per minute
• O:i.by h:is v ery w eak cry or
h as no r~sponse when
stimulated
• Extr-emil:i~s h ave a ctive motion
• 5 10•.n (H irregula r b r eathing
• Abdomen Is
• Ext remities are flaccid
.
• Flat abdomen o r h a ~ an
o p eni ng with o r without
expo sed internal organ~
conge -nit al defett
.• No obvious
(cle ft lip, etc.J
glob u l ar
• very matked concave breast
bone
• Saby·:s head eithe r v e r·y
small or v e ry big w ith or
witho ut ten~e fo ntanelle
DETAILED EXAMINATION
• Ba by's head Is too sm.>11 o r
too big
• Baby's we igh t v ery low
• Baby hll• difficul ty of
breath inr,
• Temper.H u re i s low (belo w
36° C)
• One o f the tes tes h asn' t
d esc.e.nde d vet
• Openi ng ofth ~ urethra
ob·served lo be at the
underside of the penis
• Baby weigh s about6 l bs
(aro un d 3 kilos)
• Temperature at l eas1 36 ~c
• No.br uJs:es or .rushes on the
skin
• F.qu al e xrrnn si on o f the ch e st
• Bo th te st e s have d esce-nded
Openin g of the ureth ra
n o t ed t o be at t h e tip of
the penis
Female infant h as both
vaginal and u rethral
open ings
V/ ith 3nnl openi ng
Extremitie s w ith equal
lengt.h and strength
Fecd mgf. are well
tolerated
Vi gorous suckJng
267
RED
YELLOW
GREEN
S/S or H><D
S/S or HxD
S/S or Hxo
• Baby's head is too small
or too big
• Baby's weight very low
• Baby has difficulty of
breathing
• Temperatu re is low
(below 360C)
• Cleft palate,
specially if the
w hole palate is
Involved
• Rashes or bruises
on the skin
•
Inequality i n th e
movement of the
chest
• De f ect in the
breast bone
causing difficulty in
breathing
• Ma ss or lump along
the midlin e of the
back
• Either vaginal or
urethral opening Is
absent
• Abdomen is flat or
with an opening
• No anal opening
• Inequality in the
length or strength
of the extremities
• Vomiting specially
dur ing feedings
• Failure to suck or
poor suck
•
• Bleeding from any
source specially the
cord
• Baby weighs about 6 lbs ~
(around 3 ki los)
• Temperature at least
36°c
.
.
.
268
~
• No bruises or rashes on
the skin
• Equal expansion of t he
chest
• Both teste s have
descended
• Opening of t he
urethra noted to
be at the tip of the
penis
• F,emale infant has
both vaginal and
urethral openings
• With anal opening
• Extrem ities with
equal length and
strength
• Feedings are well
tolerated
• Vigorous sucking
LOGIC TREE fLOW CHART NO. 31
at least one RED s/s
or HxD noted on r----------.►•
i nitial examination
Proceed with
Plan C
___I"----,
0
at least one
Yes
s/s o r YELLOW
HxD noted on
!-------------!JI.~
initial examination
l'roceed with
Plan B
No
at least one
Yes
GREEN
s/s or HxD not ed on
Initial examination
No
Proceed with
Plan A
i-- ~
at least one RED s/s or
HxD noted on detallcd i -- ,~
examination
Proceed w ith
Plan C
at least one
YELLOW
s/~ or H,cO n oted on
d et alled e,camin ation
Give aftercare
inst ructions to the
f amily
269
MANAGEMENT PROTOCOL FOR CARE OF THE NEWBORN
IMMEDIATELY AFTER BIRTH
(Flowchart No. 31)
PLAN A:
1.0
Within the iirst 30 seconds, whi le waiting for the p lacenta to be expelled,
dry the baby, cleal· l 1is air•.ray and stimulate h1m to cry if h e does not do so
spontaneously.
1.1
Gently wipe th•~ baby's face, neck and hody but do n ot wipe off
veroix.
1.2
Do not s uction unless the baby·s mouth aud/or nose is blocked with
secretion s or other materials.
Do a quick physical examination and observe the following:
His color : blue all over, complet ely pink or b lue extremities with pink
body.
2.2
Heart or pulse rate : absent, below 100 b eats per minu te or 1.00 beats a nd
ahove.
2.3 His grimace o r response to an i rritation (li ke the suction bulb being placed
in his nose) : no response, gives a grimace or gives a good, vigorou s and
sustained cry.
2 .4 His activity or muscle tone: flaccid/soft, some bendingofth.e extremities or
has active motion.
2.5 His respiration: absent, slow/frregula{" or he is crying vigorously.
2.6 His physical ,ippearan ce: a n y obvious congen ital defect, like abse:ace of an
extremity, concave b reast hone or flat abdomen.
3.0 Wi t hin the first 60 seconds:
3.1 If the newborn is hreatbing or crying and Lhei:e are no abnorm:
'-' in his
a bdome n or chest, place him in a p rone position on the mother's cb r ·.vith his
head turned to e ither breast. Ensu re that there is skin-to-skin conta , h etween
2.0
2.1
the mother and the ne,vbom
3.2
Covei: his back with a clean dry blanket and hi s bead with a clean d ry b onnet.
4.0
W ithin 90 m inutes of life, initiate breastfeeding.
4.1 Make sure that the newborn is properly position, and 1us whole hody well
supported
4.2 Observe for feeding cues such as tonguing, licking or rooting.
4 .3 Encourage the mother to n u dge the newborn towards her breast.
4.4 Do not gi ve sugar e d water, formula, milk or any prelacteals.
4.5 Do not throw away the colostrums.
5.0
After the first full breastfeed is completed, separate the newborn from his mother, do
the following:
5.1 Administer eye care a nd give immunization (BCG and Hepatitis 8) if avai lable.
5 .2 Postpone giving the b aby a bath ti ll at least six hours after birth.
5.2.1 Clean yo\Jr hands with soap, water and alcohol.
5.2.2 Wet some sterile cotton balls with warm water and use them to clea n the
baby's eyes. Start from the corner of the eye near the nose bridge and
then move gentJy towards the outer corner of the eye.
5 .2.3 Clean t h e baby's skin with t h e wet cotton balls.
270
5.2-4 Start by cleaning the face, the scalp then co ti
special attention to the skin folds.
n nue downwards. Pay
5.2.5 Wrap the baby in a clean blanket.
_
Dress
tl1e cord after the giving the baby a bath.
53
5.3.1 Clean the hands thor?ughly with alcohol again.
5.3.2 W~t the cotton balls m the cord dressing pack with alcohol
5.3.3 gs~ng fl:e ~et cotton balls, clean the area around the umbilicus
5.3.4
smg c1rcu ar stro1ces, start cleaning the center mov·
tw
Do this several times.
mg ou ar s.
5.3.5 Throw away the cotton ball after each circular stroke.
5.3.6 Clean ~e cord with t~e alcohol-wet cotton balls starting from the
base gomg up. Do this several times, discarding the used cotton
ball each time.
5.3.7 flace a piece of sterile gauze that has been cut halfway thru the
middle at the base of the cord bringing the cut edges around the
cord.
5.3.8 If the cord stump .is long, clump or tightly tie the cord around one
inch from the base. Trim the cord aroqnd an inch from the clump
or tie using a sharp sterile blade or a pair of sterile scissors,
5.3.9 "\Vith a piece of sterile gaure, express out the blood from the stump
and clean the top of the stump with alcohol-wet cotton ball~. .
5.3.10 Put another sterile gauze around the stump and wet 11 with
alcohol.
5.3.11 Put the top dressing and tie the abdominal binder.
d
6.o Do a more complete physical examination after the cord dressing.
6.1 Take the baby's weiight if possible.
6.2 Take bis temperature by rectum. .
.
d b e if any of the
6.3 Examine the baby's skin under a good light ap. 0 serv
following are pre~ent:_·
Birth mark
. tbe bead for obvious defect
Any rashes or bruises 6-4 E~mreabnormality in the eyes, nose,
like very small or ~ery dlar/ge le~p,alate, and absence ofskull.
mouth ears, cleft lip an or c .
'
-· 'f there 1s:
6.5 Examine the chest and observe 1 t fthe chest.
6.5.1 Inequality in the movemen : breast bone) which could cause
6.5.2 Any defect Oike a concav
.
difficulty in breathing.
fl t or if the abdominal wall is open
6.6 Observe if the abdomen is globular~~ a
. .
with or without exposed internal orgass ~pecially along the m1dlme.
01
6.7 Examine the back for any lump or ·
6.8 Examine the genital area.
6.8.1 ln a male infant: tes have descended. . . at the tip or at its
a
Feel if both tes
. of the pems ,s
.
·f tl1e opemng
al
b. Check 1
.
ening and a urethr
1
' a vagU1a op
un dersi·ae ·
ck 1"ftbere J.S
·
f
nt
che
)
·
to th e
6.8.2 In a·female JO a ' . cornes out • .
articular attenaon
opening (where urine rt.remities paying p
6.9 Examine the upper and lower ex
fi gers non-development or
·
"1:ra n ,
following:
t Jike club feet, e. m·ty
•
defec
f e.xtre1 ·
'ties
6. 9.1 Any obV1ous
lopmcnt o nn ,.., of the extrenu .
improper deve
gt11 or leni,~1
• · the stren
1t
6.9.2 Inequality in
ning is preser .
•
271
6-10 &-..amine if the anal ope
6.3.1
6.3.2
•
I
j
7.0
8 .o
JI there is an abnonn ality observed during th e examination refe r the p atie nt to
th e hospi tal. See Figure 3.2 of Cbapter 3 for a sample r e ferra l fonn.
If the baby·s temperature is be low 36 °C, do th e follo"ting:
Wrap him in a blanket.
8.2. Place the baby under a ligh ted b u lb or Uu orescent Jamp. Ifth e la tte r js used,
the bab~ ·s l.~-e::. sh o uld be cove red since the light of the fl uorescent lamp can
cause clamaie lo the baby's eyes.
8.3 Create a n impro;-is ed incubator especially if the baby has to be b ro u ght to a
hospital.
8.3.1 Put w arm water in s ide bottles ,...,jth tight covers.
8.3.2 Place th e bottles insid~ th e boJ, large enougJ1 to contain the baby and
the bottles. Place the bottle a lon g a1J the sides of the b ox.
8 .3.3 Cover th e bonom of the box v,;th a warm hlankeL
8 .3-4 Cover the bot tles an d blanke t with a n oth e r blan ket o r w ith a towel.
8.3.5 Place the baby inside the im pro,i sed incubato r .
8 .L
PLAN 8 :
LO
Refer the patient to a d octor within 24 to 48 hours.
2.0
Manage the baby as in Plan A..
3.0 Pro,.ide the doctor with ap propriate cli n ical material or referral note containin g
a brief his t ory , physical examination findi n gs, an d management given at th e
referring level. See Figure ~1.2 of Chapter 3 for a s ample referraJ form.
PLAN C:
1.0
Refer the baby immediately to a hospi.tal (pr efera b ly the nearest one).
2.0
If the baby doe.sn't breathe wilhin one m in u te after birtl1, do m outh to m o utb
resuscitation at o nce. Mak e s ure ther e is no mucus in the baby's n ose or mouth.
3.0
lflhere is clif:ficuJty o f breathing, dean the nose and mouth .
4 .0
If th ere is no heart beat., d o cardiac mass age AT ONCE usi ng the index a n d middle
fingers of o ne hand.
5.0
If thereisa.n ope ni.ng al th e abdominal wall, aodsomeio ternal organs are exposed,
cover it with a clean cloth that was s oaked in warm b oiled water.
6.o If there is bleeding. try to stop it by a pplyi ng d irect press u re. If the,bleeding is
coming from I.he cord, p ut another tie and make s ure it is tig h t enou g h .
272
7.0
lfthe rc is a mass al ong th e baby's back place hioi face down (nakada pa) with his
h ead turne<l to one side.
8 .o
Accnmrany the baby ro t he hnspila l o r if th is is n o t p ossible, provide the h ospi tal
\,it h a re fe rral no te co nt aining a brie f history, p hysical exa mination fi n di n gs, and
a ny mnn agcml'n t given . SP.e Figu re 3.2 for a s umplc re ferra l form.
ASSESSMENT PROTOCOL FOR POSTPARTUM CHECKUP
(Logic Tree No. 32)
oIRECTION: Determine/identify which of the following symptoms/s igns (S/S) or
history d a ta ( H xD) a re present and follow the flowchart for t h e appropr iate: plan of
m a nagement.
RED
YELLOW
GREEN
S/5 or HxD
S/S or HxD
S/S o r HxD
• Profuse vagin al
bleeding
• Abdominal p ain
• Alter ed level of
cons ciou sn es!.
• Patie nt in p ain
• Pulse is w eak a nd fast
• Bl ood pressure
eith er very h igh
(systolic above
l 6 0 mm m e rcu r y)
or very low (on ly
p alpatorvl
• c old, clammy ski n
• Womb is soft and not
contract e d
• A bdomin al wa ll
very r igid
• Foul -smelling vagina
disch arse
• Vaginal discharge
contin ues to b e
bloody e ven after
the third day
• Temperat ure o f 37.s•c
an d above
• Blood pressure slightly
high (systolic of 140
to 160 mm mercury
and/or d iastolic
of90-100 m m
mercury)
• Pale lips, n allbeds or
inner aspect of the
eyelids
• cracked or bleeding
nipples
• Breast is painful,
swollen and red
• wound at th e genital
area, e specially if
i nfet1ed
• Vagi nal discharge cha nge
from bloody d urine
the first f ew days and
gra dually becoming
w hitish b ut n on -foulsm elting
• Br east engorged and
heavy but not pai nful
and swollen
• Patient Is alert
• Pulse is strong and
regular
• Blood pressu re w ithin
norm.I limits
• Temperature i s below
37 ·c
• Womb hard and w ell
contracted (gradually
becomes smaller)
.
273
er t o Logic
Numbers
7 and 15
at least one
RED s/s or
H>'O hilS
developed
since Iii)! v,sll
at l ea!.t one YELLOW s/s
o r HxO h as developed
since l a!.t v isit
~lp:irl um
~cvcnth
tic nt has
MANAGEMENT PROTOCO L FOR POST-PARTUM CHECK-UP
AND CARE OF THE NEWBORN
(Flowchart No. 32}
PLAN A:
1.0
Visit th e p:il'ic nt :ind her n e wb orn ba by at le11st once a day untiJ the seventh day
and as o fte n a s necessary aft erwards depe nding on their needs.
2.0
De t e 1m·i ne knowled ge of th e patient o n post-pa rtum care and o f the n ewborn.
3.0
Based on 2 . 0 , advis e th e p at ien t o n th e following aspects during the first visi t:
3.1. Nutritio n 3. 1.1.
Liqu id die l (mil k, s o u p, elc.) o r soft d iet ()ugaw, oabneaJ, etc.)
s hould he given o n the fir.; t day.
Start full or rr.g11 la r diet on the s econd day afte r delivery.
3. 1.2.
:-3. 1.3. Sl rC.'i/'\ th e importa nce of eating the right ldnd and the right a mount
o f food especially i f t he mother is breas tfeeding the n ewborn.
3.2. Pe r son :il clea nl iness 3.2. 1. Advis e p:llicnt to take sponge bath dail y du.ring the first two days
after d e livery b11 t n quick full bath can be st arted as early as the
third day if she is str on g enough.
3.2.2.
Breast a nd n ipples s ho uld he clea ned with soa p and water before
a nd after ench breas tfeed ing s es sion.
3.2.3. Per in eum (puerta ) sh ould be properly washed with soap and warm
wnte r eve ry time sh e urina tes. Do not a pply alcohol on the area.
3.3. F.a rly am b ulntjon 3 .3 .1. On the fi rst day, patient m ust stay in bed but should move freely in
i t. She c:rn s it do wn aud dangle her legs at the side of th e bed, s h e
ca n go to th e batl,room o r toilet if she is assisted.
3 .3 .2. On th e second c.f ay she should start walkin g around even if it is still
pa infu l to d o sci.
3 .3.3. Discourage th e pat ient from staying in bed for long tim e unless
th ere is profuse vaginal blced1ng.
3 .4 . Bowel habits - pntic n t sh ould have daily bowel movement.
3 .5. Abd ominal mnssage - patient should not hav e h e r abdomen
111as.-.~1ged.
3.6. Clothing ;3.6.1 . Patient sh ould wea r dean, loose, comfortable clothes.
3.6.2. Discourage the patien t from wearing a ~bigkis".
4.0
Based on 2.0, advise p atient on how to give milk feed properly.
4 .1. Br ea s tfeeding s hould n ot be done if any of the following are p resent:
4 . 1 . 1.
O n th e part o f the patient :
a. u ntrc:l'ted t ubercuJos'is
b . a ny serious illness
c . s wellinp,. i ntl11mm11tion or open wound in the chest.
4.1.2. On th e p ;t r1 of the baby:
a. ,my d e fect in the mou th , like cleft lip and/or cleft palate.
b. baby is too wea k to su ck (e .g. , baby is prem ature or small for his
3A'C).
4 .2.
I low lo breastfeed the baby:
4 .2 .1.
Both b reasts should be washed b e fore and after feew ng then dried
with a clea n towel.
275
4-2.2.
Give the baby both breasts evecy feeding t in1e to prevent nipple
from gro,,in g sore. During the first days , feeding time should be
limite d to five minut es. This then is slowly increased up to 15- 20
minutes p e r feecling.
4.2.3 . TI1e milk feedings can be given every three to four hours or it can be
given per demand.
·
4.2.4. Both the baby a nd the mother should assume a comfortable
position.
a. If feeding is done ·.vith t he mother is lying dov.'Il, she should
be on h e r side with her bead supported by her arm; the baby
is placed on his side facing his mother and s upported by a
pillow.
b. IfU1efeeding is done whilet he motherissitting up, a comfortable
cha ir m u st b e used: if possible, h e r feet should be placed on
a stool; 10 make both mother and baby more comfortable, a
pillow may be used to support the arm carrying the baby or it
may b e placed under him.
c. Make sw·e th at th e breasts doesn 't press on the baby's nose.
4 .3. H ow to bottle -feed the b aby:
4.3.1.
Keep all s upplies clean and sterilized.
a. With a bottle brush. scrub the bottles, artificial nipples and caps
with soap y water; squeeze some water through the holes in the
nipples ; rinse well.
b . Place bottles ( up side down), utensils, nipples and caps in a large
saucepan with enough water to cover the things being boiled;
allow water to boil.
c. Re move artificial nipples and caps (with a lndle or a pair of
tongs) a fte r the water has boiled for around three minutes;
keep s terilized artificial nipples and caps in a clean covered
container.
d. Allow the o th er articles to boil for two minutes then remove;
keep in clean cover ed container together with the caps and
rubber nipples.
4 .3.2. Observe clennliness w h en prepari ng the milk formula.
a.
Wash ha nds before mokj ng the milk formula.
Whe·n usi ng canned milk, wash th e top p art vnth soap and
water b efor e opening; wash also th e can opener.
Use tl1e righ t proportion of milk to water.
a. Powdered milk - d epend s o n t he bra nd being used; most i_nfant
formulas produced b y Mead J o hnson (like Alacta) and by Wyeth
(like Ro nna, S-26 and S MA) need one scoop of powdered milk
for every tvvo ounces ofhoiled wot er whil e Nestle p roducts Oike
Lactogen, Nestogen. Nan a nd PeJa rgon) need one scoop of milk
for every o ne o un ce o f boiled water.
b. Evaporated o r reconstituted milk- depends on the bra nd being
used, but usually o n e ounce of milk is needed for every ounce
of hoiled wate r. To make sure, cJiec:k the direction given in each•
b.
4 .3.3.
can.
4 .3.4. Always use boiled w ater .
4 .3.5. DO NOT USE CONDENSED MILK.
4 .4. Advise p atie nt to burp tlie baby after each feeding.
5.0
276
Based on 2 . 0, instruct the patient on how to bathe the newborn during the first
visit:
Sponge bath 5.1.1.
Undress the baby and wrap the baby in a forge towel or
blanket.
With a piece of cotto n, clean the hAby's cars and nose gen Uy.
Using a piece of clea n soft wash cloth dipp ed in clean warm water,
wash th e baby's face gently.
5.1.4. While supporting the b aby's b ead and b ack with one hand, soap his
head with th e oth er hand. Us.e ci rcul ar motion going from front to
back.
5.1.5. R:inse well and pat dry.
5.1.6. Soap t h e rest of the baby's body and ri.nse well.
5 .1.7. If the b aby is a girl, clean her genitals "-ith a piece of cotton soaked
in clean warm water usi11g a downward s troke.
5.1.8. Pat dry. Do not apply powder.
5.1.9. If the cord hasn't fallen o ff yet, change tlie dressing using sterile
gauze prnvided by heal th worke r.
a . make s ure the gauze placed around tl1 e cord is wet with
aJcobol.
b. cover with dry gauze and apply a binder.
5 .1.10 If the cord has fallen off, the umbilicus should be cleaned gently
with alcohol and a piece of clean cloth.
5.1.u
Dress him in clean and comfortable clothes.
T ub b ath - given a s soon as the co rd fa lls off an<l the 'umbilicus is dry.
5.2.1. Fill a big basin (big enough to accommodate the baby) with about
Urree inches o f w.i rm waler. With the elbow, check the temperature
of t he wate r to m ake sure it is wann enough.
5.2.2. Clean. the baby·s nose, ears , face an<l hail' fo llowing the same
proced nre as in $ponge bath . Use sh ampoo (mild) for the hair.
5 .2.3, Soap your hands and quickly soap the baby's body paying particular
attention to skin folds.
5 .2.4. Lower the baby int o t h e basin with water. Be snre to support the
head a nd t be back oftbe baby.
5 .2.5. Rinse with washcloth. Rinse also the genital area especially if the
baby is a girl
5:2.6. Lift the baby and place him on a towel.
5.2.7. Pat dry, m alting sure the areas between the skin folds are also
dried.
5.2.8. Dress him i.n clean comfortable clothes. Do not apply powder.
6.o
During the subsequent home visits, do the following :
6.1. Ask the patient tf any of the YELLOW or RED ·symptoms developed since
the last visit.
6.2. Examine the patient for a ny signs which could h ave developed since the last
visit.
6.3. If new signs or symptoms have developed, proceed with either P ia.a A, Plan
B or Plan C as indicated.
6.<1. If there are only green s igns and symptoms, tell the patient to:
6.4.1. Follow advise given during the first visit.
6.4.2. Continue taking iron preparation given during the pre-natal
period.
6.<1.3. Do the following if the breasts become engorged.
a. Support the breasts with a well-iitting brassiere.
b. Pump the breast (with the use of a breast pump) or manually
expr ess out the milk; if there is a refrigerator, the milk can be
277
c.
7 .o
placed i n a clean feeding bottle and stored in tbe refrigerator;
this can th e n be given to the baby during the feeding time.
Warm the milk before giving to the baby.
Apply cold compress, ice cap or "i,aha n g saging" over the
engorged breast.
Advise the p atient to visit the health cent er six to ejght weeks after the delivery so
the doctor can give her a final check-up .
PLAN 8:
1.0
2.0
Refer the patient to a doctor with in 24 to 48 hours .
Determine knowledge of th e p at ient or that of her compa nion on tl1e supportive
m anagement of the.problems presented.
3.0
Based on 2.0, do the follovving if ther e is a fever:
3.1. Give/prescribe ove r-th e-counter med.kine or herba1 medicine for fever,
specifying accu rate ly the dose, freque ncy of intake and the method of
p reparation (sp ecifically for he rbal m.edicine).
3.1.1.
Give/prescribe a para ce tamol prepru·ation wtless the patient is
allergic to sucl1 substances.
3.1.2. If the patie nt is allerg ic to the above mentioned substan ces, give/
pr escribe a pur ely asp irin prepar ation .
3.1.3.
Advise p a tient t o take the medicine after meals.
3.2. Advise the patient to follow instructions on general management o f patients
,Yith fever.
4 .0
Based on 2.0, do ~e following if t he breasts are s wo1len, p a inful bar d, and
accompanied b y a crack in t h e nipple:
4.1. Give/prescrib e over-the-counte r medicine or h e rbaJ medicine for pain,
s p ecifyi ng accurately the d ose , method of-preparation (specifically for he.r bal
medicine) the dose and fre quency.
4.1.1.
Give/prescribe parace tamol preparation unless the patient is
a llerg ic to such substan ces.
4 .1.2.
If the patient is alle rgic to the abov e-mentioned s ubstances, g ive/
prescribe a glafenine p r eparation.
4 .1.3. Advise the patient to take the medicine only if t h e p ain is
severe.
4 .1.4. Advis e p atie nt to take the m edicine after m eals.
4.2. Advise the patient to do the following:
4 . 2 .1. Stop bre as tfee dj ng.
4.2.2. St1pport t}1e breast with brassie re.
4.2.3. Apply cold compress, ice cap or "saha n g saging'' over the b reast.
5.0
Based on 2.0, do the follmving if the nipple(s) is (are) cracked and /or
b leeding:
5 .1. Do not allow the baby to nurse on th e a ffected side.
5 .2 . Pump ou t or m a nually express out t he milk from the affected side. Do not
give the m il k to the baby.
5.3. Wash the nipple with mildsoapand wa rm wa t er before a nd after pumping or
expressing out the milk. Apply breast milk around the nipples as lubricant.
5.4. Use a nipple shield if p ossible.
6.o
Based on 2.0, do t h e following if t here is a foul-smelling vaginal d ischarge and/or
278
infected woun d in the genital area.
A,dvise patient to wash the perinea! area with soap and water more often. Do
n ot u se aJcol10l.
6.2. Advise patient lo o bserver personal cleanU ness.
Based o n 2.0, do the following if the p atient is pale:
7 .1. Give/prescribe over- the-counter medicine for anemia ( iron p reparations)
specifying accurately tl1e dose and frequency of intake. Ad vise her to drink
the medicine after m eals.
7.2. Advise patient to eat iron-rich food such as melunggay, a mpalaya, live r,
etc.
6.1.
s.o· Based on 2:0, d o t h e following if the patient has slightly h igh blood pressure:
8.1. If patient is a known hypertensive and she is taking something for it, advise
her to take it.
8.2. If the p atient is nol taking anything foi- l1er hypertens ion, give herbal
medicine that will increase hei- urine output,
8.3. Keep the p atient calm. ·
9
.o If th e patient's blood pressure is low , let her have more rest and ask another
1 0 .o
me mber of the family to t ake care of the newborn especially a t night.
If the p atient .is depressed, try to determine the cause of her d epression and
h e lp her through the ei.'Perience using appropriate nursing intervention s (e.g.,
support: informational, technical, em otional/ affective, interpe1·sonal). Refei- to a
p sych iatrist if necessary.
u.o Provide the doctor to whom the p atient is being referred t o with appropriate
clinical m ateriaJ or referral note contain.log a b rief history, physical examination
findings, and management initiated at tile refen·ing level.
PLAN C:
1.0
Refer the patient immed.iately to a hospital (p referably the nearest o ne) with the
duly accomp lished referral form.
2.0
Do the following if there is profuse vaginal bleed.log and tile womb is soft \Vh.ile
w aiting for medical llelp:
2.1. Apply an ice bag over the womb_
2.2. If there is stilJ b leeding, p ress oo the area of the.womb.
2.3. lf there is still profuse b leeding, grasp tile wound in both hands and gen tly
squee;,;e it.
3.0
Do the following if the patient is .in shock (fast and weak pulse, very low blood
pressure and cold, clammy s kin) .
3.1. Let the p atien t lie down with the head lower tllan tile body.
3.2. Cover the patient J-igbtlyshe feels cold.
3.3. Give her some wai:m water to sip if she is fully'conscious.
4.0
If there is abdominal pain, DO NOT GIVE .ANYTHING FOR THE PAIN.
5.0
T ry to keep th e patient calm especially if her blood p ressure is high or she is in
pain
279
A SSESSMENT PROTOCOL
FOR WELL BABY CHECK- UP, N EONATAL P E RIOD
(Logic Tree No . 33-A)
DIREcnON: Determine/identify which of tl1e following symptoms/s igns (S/S) or
his tory dal'a (HxD) m-e present and follow the flowchart for tht: appropi-iate plan of
mannge.ment.
280
RED
GREEN
S/S or H)(Q
5/S o r HxD
• Patient has not had first bowel
movement or urine within 72 hou rs
from birt h
• Weak. unsustalned cry
• Poor suck (patient could hardly
•
finish one ounce of milk formula)
• Weak or unequal movement of the
• extremities
• Convulsion or twitching
• Patient is lethargic
• Marked increase in head circumference
(more than 1/2 im:h in on e month)
• Yellowish color of the skin or eyes,
esp ecially If noted Immed iately
after birth or if ob served to be
in t ensifying instead of \ubsid ing,
st arting the fifth day o f life o r i t
persist s beyo nd two wee ks of l ife
• Bl uish or whitish color of the skin, lips
and i nner asp ect of t he eyelids
• Full or tense fontanelle or sunken
font anelle
• W eak. unsustained cry when started or
wh en stimula t ed
• Foul-smelllng umbilical cord
• No startle response to loud noise
• Inequality in the movement of the
eKt remlties
• Patient had first bowel movement
w ithin 72 hours f ro m birth t hen
followed by greenish soft stool s
• Patient has urinated within the first 72
hours of life
• Strong, sus t ained cry
• Good suck
• Pati ent cries and shows increased
activity wh e n he is hun gry o r
uncomfortable (w et, e tc.) but
becomes quiet and rel axe d after he
is fed or made comforta ble
• Patient i s ac tive with generalized
activ ity when awake
• Slight yellowish color o f th e skin n o t e d
on the second d a y o f life but begins
to subside star ting t he fifth d ay a nd
completely disappear after t wo
weeks
• Pinkish colo r of the ski n
• Fon tanell e Oat and soft
• V igorious cryi ng when stimulate d
• Patient shows violent startle respon se
when loud noise is made
LOGIC TREE FLOW CHART NO• .33.A
f
f eve r, c ough, cold s,
diarr h e a o r oth e r
p r o bl ems
-!
Yes
Re fer to
ap propriate
Logic Tree
►
N~
o
Yes
Pati e nl is more t han ;-- - - - - - - - - ---_.
on e month
!,~
at leas t o ne
RED
s/ s o r Hx O
!
refer to Logic
Tree 1133- B
7 ------------.,)1.-i
Yes
~-
,
Proceed with
Plan B
No
Yes
a t least one
GREEN
s/s or HxD
l -
Proceed wit h
Plan A
at least on e RED s/ s o r
----------,-,)1,
developed si nce
7j
r
last visit
HxD
advice co m panion t o
b ring back the baby
after one month
28'1
MANAGEMENT PROTOCOL FOR WELL- BABY CHECK- UP,
NEONATAL PERIOD
(Flowchart No . 33-A)
PLAN A:
1.0
DeterminP knowledge of th e m o tlier or t h e patient 's com p nn1on o n tl1e proper
care of the ne wborn.
2 .0
Based on 1.0, advise mo ther or com panion to give the p a tien t a tub b a th d aily
(eve n on Tuesday and Fridays). Give the same in structions enum e ra ted in secti o n
5.0 of Manage ment Protocol for Flowcl,nrt No. 32.
3.0
Based on 1.0, show Lhl! p a tient's companion how to cl~a n tl1e umbi licus with
.ilco hol and cotton buus during the first visit.
3. 1 ,vhen th e cord hasn't dried u p yet, make s ure t hat the s terile gauze p laced
around th e conJ ( n ot the lop dress ing) is soaked w ith alcohol.
3 .2 After the cord has fallen off. the navel sh ould be gently cleansed using cotton
buds and alcohol.
4.0
Based on 1.0. advise compa n ion on infan t feedin g d u ring t b e first visit. Give the
same ad,-ise s t.i.ted in section 4.0 of Manngement Protocol for Flowchart No. 32.
5.0
Based on 1 . 0, advise compan ion to e::...l)ose the patient t o early n'lorning for t en
minutes e,·erydny if s light yellowis h skin color a p pear starting on the third day.
6.o
Ba.s ed o n 1.0. give/ prescribe over-the-cou nter m ulti-vitam ins if Lhe b nhy is at
least one week old.
6.1 On tJ1c fir.st day the medici n e is to b e given, give th e patient only one drop.
lncre.-.se the amount by o ne drop p e r day u p t o the te nth clay. So o n the
second d;,iy two drops ' ";II be given then on the tJ1ird day tbree dro ps and
so 0 11 unti l o n th e te nth day the b a by is gi ven ten drops or 0 .3 cc. F rom the
elen: nlh day on,,·ar ds. give 0.3 cc.
6 .2 Give tJ1e medicine oncl:l per d aiy only.
6 .3 S top the medicine if th e patient deve lops any rashes or sign s of allergy o r
dfarrhe:i.
7 .0
Based on t.O , advise the companion to bri n g the pat ie n t ei t her a privnte
p ediatrician or the Healt h Center fo r BCG vaccination and 1s t d ose o f H epat itis
B. vaccine
8.o
Advise companion to bring patien t back a fl er one month.
PLAN 8:
282
1.0
Refer the patient immediately to a h os p ita l (preferably tl,c n earest one).
2.0
Do the following if th e re is bk.'<.--di:n.g from lhc c.-or d w h ile wa it ing for medical
h e lp.
2 .1
Re mo\'o:t Lh e cord d ressing
2.2
\'\Tith a clean piece o f cloth or ~auzc, r,r ess the cord b etween the l.h u mb and
index finge r.
2.:l If th e rt is still bleedj n ,i_, place a nother tic.
Jf there i~ _yellowis h c~lor of the skin, place ll1c baby under a fluorescent lamp
3.o while wail.Ing for medical help. Cover his eyes with a clean piece of cloth.
4.0
Jf tbe patient h?sn_'t had bowel_moveme nt nor passed out flotus within 72 hours
after birth, don t gwe any laxative.
provide the hospital where the patient is being referred to with the appr? Pri:3te
rnical reco rd or referral note containing a brief history, physical exanunation
~~dings a nd managemen t started at the referri ng level. (See Figure 3 .2 for a
sample referral for m)
283
ASSESSMENT PROTOCOL FOR .WELL BABY CHECK-UP,
PATIENT IS MORE THAN ONE MONTH OLD
(Logic Tree No . 33- B)
DIRECTION: Detennine/ident ify which of the following symptoms /signs (S/S) or
history data (HxD) are present and follow the flowchart for the appropriate p lan of
management.
284
RED
GREEN
S/S or HxD
S/S or HxD
• Show ed delay in d ifferent
developm ental mil estones
• Poo r suck o r appetite
• Pati ent does n 't seems to gain weight
• Patient is lethargic
• M a rked increase In head cir cumference
(m o re t han l/2 inc h per month up to
th e 4t h month; m ore tha n 1/4 inch
p er m o nth u p to t he 12th month;
more than one inch during the
entire second year and more t han
1/2 inch per year from the t hir d to
t he fifth year)
• Patient is severely malnourished or
overno u rished
• Unequal movem ent of the
extre mities
• No startle response wh e n there is a
loud n oise
• Pati e nt i s able to do th e d ifferent
deve l opmenta l milesto n es on the
expected p e riod
• Patie nt is apparently h ealthy
• Patient has good suck or appetit e
• Patie nt is at least two m onths o l d
an d h as not had any vacci nation or
in comp lete do se was given like only
one w a s g iven instead of t wo)
• Patient i s active a nd alert
• Head circumference increase is within
normal limits
• Patient's weight is within normal limits
or he is e i the r m ild or mod e rate ly
Patient's weig ht is within normal
l imits or he is either first or second
degree mal nourished
• Pa tient shows violent startle
response when t here i s a loud noise
mal n o u rished
• Patient shows vio le n t startle
response wh e n there is a lo ud noise
LOGIC T REE FLOW CHART NO, 33-B
fever, cough, co lds,
d i arr hea or other
p roblems
i
Refer to
a pp ropriate
Logic Tree
Ne
Patie nt is more t h an
one month
!
Yes
---------=- -:1~
refer to Logic ( Tree #33 -A
Ve,
Yes
at least o n e
RED
s/s o r H)(D
Proceed w ith
Plan 8
Yes
at l east on e
GREEN
s/s or HxD
!
Pro ceed with
Pl an A
,
.
at least o ne RED s/ s or
H><D developed since
last visit
L..-..-
-.-..--
-_j
advice companion to
bring b ack the baby
after one m onth
285
MANAGEMENT PROTOCOL FOR WELL-BABY CHECK- UP,
PATIENT IS MORE THAN ONE MONTH OLD
(Flowchart No. 33- B)
PLAN A:
1.0
Determine the knowledge of the companion o n the care of the ch ild .
2.0
Based on 1.0, advise the co mpanion t o s tnrt g iving solid food at· the age of four
months.
2.. 1
Ad,-ise compa ni on o n bow to prepare d e licious, nutritious b u t economi cal
supplementary feeding. Re fer to Ch apte r 14 for preparation of protein
powders..
2.2 lntrodoce one kind o f food a t a time and ob serve if the patient is a ll e rg ic t o
any o f the food introdu ced.
2 .3 Observe cleanliness when preparin g the food.
3 .0
Based on 1.0, give/ p rescribe o,·e r-the-counter mul ti-vitamin
specif)ing a ccura tely the dose a nd freque ncy of intake.
4-0
Ba....<:ed o n L.O . advi...-=:e the companion to have the patien t immunized usin g t h e
following scbed u.le:
4.1 If the family couJd affo rd to buy ·th e vacci ne
4.1.1.
2 m o nths o ld : firs-t d o se o f D PT a nd OPV
4,.1. 2 .
4 mo nths o ld : seco nd dose of DPT, OPV and Hepatitis B
4 ..1.3. 6 months o ld: thi r d d o se o f DPT and OPV
4. 1.4 .
12 m o nt ~ old : Ml\,fR
4. 1.5. a1 lea."1 6 mon th s fro m 3rd d ose o f DPT: fo urth dose of DPT
4. 1.6 . 14 mo nths o ld: th ird d ose o f H e pati tis B
4-2 If the fam ily could n ot a ffo rd t o b uy th e vaccine, ad vise the compa nion
to ha ve the b aby iinm u n.i7..ed during th e s cheduled da tes sel by the h ealth
cent er (~l edici n e is s up p lied by th e Departme nt o f H e.c-ilth) .
4 .3 If the sched ule give n in 4 . 1 could n o t be follo w e d for s ome reasoo (like the
patient was s ick a t the ti m e ), th e folJo,...,j.ng sch e d u le s hou ld be followed:
4 .3.1
D PTFir.-t d=e give n at the earli est possib le pe.riod.
a.
b.
c.
d.
4 .3.2
prepar ation s ,
Seco nd dose given ·with in si>C mon t hs aft-er the fi rst dos e .
Tiiird dose gi ve n within sL" m o nths (o r a t least withi n o ne year)
af1c r th e second d ose.
Booste r do<:e given one y<mr a fte r tJ1e third d ose.
O PV -
First do:;e given t ogeth er .,...; th first d o s e of D PT or a l Lhe earliest
possihlc peri od.
h. &-crmd d o<c to be given wi t h in s ix to e ight mo11tJ1s after the
firs1 d ose.
c. TI1i rd d o se to be given with in s ix lo twel ve months after the
second dose .
BCG - a nv-ri m e be{',,'een t h e d o ses o-f OPV
Measles :_ anytim e after t.h e 9 th month o f a ge
a.
4--3- 3
4 .3-4
s.o
Advise compa.nioo 10 bring patient for we ll baby check -up 11s.i ng the following
schedule :
S.t Up to o ne p,ar old: m o nthl y (m..inl mum o f e igh t visits the w h o le year ) .
... .I
5.2
5.3
5-4
6.0
One to ·n:vo years : four tim~ the whole year o r every tliree month,;.
Two to sax yea rs o ld : three time..,; a year.
T h e patie nt can h ave check-up more often th a a the above schedule if he has
some h ea Ith prohlems Clike heart djseasc, etc.)
Duri ng the follow-u p vjsits, determine if any of t he yelJow signs or .symptoms
have develop ed.
6 _1 r f at least o_n e ~1~s developed, patient should be referred to a doctor,
ceferably a p etl1atnc1an (Pla n B).
~-
2
'
If none has developed, advi.se companion to bring the patient b ack
for follow-up. Follow th e schedule given in secti on 5 .0.
pLAN 8:
J .0
Refer the patient t o a doctor within 24 to 4 8 hours.
2 .0
Provide the doctor to whom the pati ent is being referred to 'With the a~pro~riate
linical record o r referral note containfog a brief his tory (including f~dang h~tory
th e re is ma lnutritio n or poor weight gain) and physical examination :findtngs.
See Figure 3.2 for a sample referral form .
fr
287
Chapter 11
NURSE-MANAGED
MATERNAL CARE IN THE
COMMUNITY
Ma ria Brigette T. Lao-Nario
INTRODUCTION
The role of nurses and mid,.,,;ves is twofold-to help create posi tive situations and
oppo rtunities for women exp<?riencing pregnancy, birtlting and the postnatal period.
The othe r role is lo pro,ridc care based on ava ilable evidence t hat becomes t h e basis
for clinical judgme nt and inte rve nti ons. Re p ublic A ct No. 9173, an act provi<'ling fa,; a
more respons ive nurs ing profession, states thatthe practice o f □ ursiJ1g includes b ut not
limited t o unursi11g ca re dudng conception, labor, deliuery, infoncy ...As i ndependent
nurse pr-actitioner·s, nurses are primarily responsible for the promotion of health,
prevention of illness". (1) This law sets the basis for nursing practice on maternal
care.
The governme n t bas s et goals for the he.i lth sector which are intended to h elp attain
better health outcomes, a more responsive health system and a more equitable health
fin ancing. The goals pertainjng to mothers a nd th e newborn are listed b elo w together
with b:iseline indicators from the 2003 N a tional Health D emographic Survey (2,3):
1.
2.
3.
4.
Maternal m ortality is reduced from 172/100,00 LB to 90/100,oooL B
Perinatal mortality is i:educed from 2-4 perinatal deatbs/1.,oooLB t o 18
perinat11l dcaths/1,oooLB
Low birth weigh I infants are ceduced from 12 ~ to 10%
Risk fa ctors assm:iMcd with materna l m orbidity an d mortality a r e r educed
through acco mplis hi ng t h e fol lo1,11ing:
4.1 the p reval ence ra te of iro n deficien cy an e mia a mon g th e pregna nt is
reduced from 4 3.9% to :J8%
4.2 T otal contrace ptive pre valen ce is inct·eased from 48.9% to 80%
4 .3 Mode m natural and a rti lficial prevalence is increased from 33.4% t o
60%
4 .4 Pe rcentage o r d elive ries ass isted by skilled birth attenda nts in a
h ea lt h care facility is increased from 53.9% to 70%
5.
6.
4.5 Percen tage o r postp artum visit within t h e 1st week of delivery is
increased from 5 1% to 80%
Neo natnl m o rtali ty is reduced to 1 0 deaths /1 ,oooLB fron1 t7 deatl1s
/1,oooLll
Neonatal te tan us is reduced to less th a n one case/ 1, 000 LB from
0.07 /1,000 LB
Special attention is net!Cled oo the nutritional state of women. The woman 's s tate of
nutrition before and during pregnancy is vital for a good pregnancy outcome. For
example, maternal undernutrition is common in some parts of As ia whei:e more
288
than 10% of women 15 yea rs-49 years are shorter than 1,15 cm .:ind h,we body mass
index of< 18.5 kg/m". Short stature is a ris k facto r for cesarean delive ry whil e low
maternal body mass index is associated wit h intrauterine growth restri ction While
maternal und crnutrition has little effect on the volume or com p r,sition of breast mi.l k
unless malnutrition is s e vere, the concentration of som e micronu tri ents (vitamin A,
iodine, thiamin , ribo flavi n , pyridoxine, and cobalamin) in breast m ilk is depende nt
on maternal s t atus and intake, so th e risk of infant dep letion is increased hy m atern.il
deficiency(29 )
current r esults on th e nutritional state of Filipino pr egnant and lactating mothers a re
as follows: (:30)
Percentage classification of p regnant wom e n hy weight -for-height classification:
Philippi nes, 19 98, 2003, 2005
year
1998
2003
:.,uOS
Tota l sun1ects
Nutr m onslly at Kl5k
2880
594
360
3 0.7
26.6
2 8.4
-
Percentage distribution oflactating mothers by n utritional status: Philippines, 1998,
2003.2 005
Year
This ch apter is inte nded to help the nurse deliver her ca.r e based on standard and to be
a partner in creating positive, enriching and m eaningful experiences in pregnan cy an d
birthing for the woman and the unborn child . The objectives are as fo11ows:
1.
2.
3.
descri be the stan dards of prenatal, delivery and postpartum care
illustrate the use of the nursing process in implem enting a nurse- inanaged
maternal child care
discuss home visit as an intervention
ROLE OF MATERNAL CARE
Maternal care is an important service that helps protect the mother, fetus and
newborn. By screening a predominantly healthy population, ri sk factors are detected
and optio n s for treatment are taken . Ideally, risk assessment is done n.ot onJy for
each pregnant patient but also for someone plan n ing a pregnancy. Th ere is a s hift
in e mphas is from th e '' risk approach ·· that iden tifies high-r isk pregnancies during
the prenatal period tu an approach Lha t prept1res all pregnant wo m en for t.he risk of
complica tions at c hi ldbirth. This shift is r e fl ected in the t hru st oftJ1e Women's health
and Safe Moth erhood Project 2 for 2006- 2012 It also incl udes improved quality
of Family Pla nning ( FP) coun seling a nd exp anded s1::rvicc avoilability , as well as
organization of mor e itineran t te ams providing permanent met hods and I UD insertion
on outreach basis and I nteg ration of Sexually Transmi tt ed In fections (STI) services
into matern al ca re and family planning p r otocols, wherever app ropriate (4)
The detection a.n d management o f preg.nancy-r elated problems is directly related -to
reducing the c auses of maternal mortality and morbidity. \Vhen. conditions that make
289
deUvery r isky are seen in a pr.egnancy v is it, the woman is referred t o a su.itable facility
or h ealth p.r ofessio na ls who are skilled in managing h e r n eeds. The visit , then, b ecom es
an indirect way of reducing maternal complica tions.
Conti nuity of care is an important element in p1·ovision of services. Nurses a re an
importan t link in e nsuring that curre nt and s ubsequent pregnancy visits are d o n e
in a manner that conform to s tandard. Nurses are highly skilled in making cHnical
judgments t h at form as a basis for p l:rnnin !;!, a nd int e rventions. They ca n h elp th e
woman make a commitm e nt to a good pregnancy o utcome. Hod n e tt (2000) performed
a m eta-analysis of two s tudies involving 1815 women. Cn the studies, the wom en we re
cared for by (nurse) mi<lwives wh o perform ed continuity of care and anoll1er set by a
combination of p hysicians and (nurse) michvives. Women who had continuity of car e
from a team o f (nur.se)midwives were less Ukely to have prenatal hospita l adm ission,
and more likely Lo participate in p re uatal e<lucaLloo programs. They wet'e .Liso less
likely t o have drugs for p ain relief during labo ur und th eir newbo1·ns were less like ly to
requfre resuscitation. No d ifferences were detecte d in Apgar scores, low birthweigb t
and s tillbirth s or neonata l deaths. They w ere mo1:e likely to be pleased with their
ante natal, intrapartum and postnatal care (5). T he results of this study highligh t a nd
beneficial effects of contin uity of ca1·e which ls in part is dependent on the health care
provider.
STANDARDS OF PRENATAL CARE
P renatal care is the monitoring and management of the patienl dud n g preg n ancy to
preven t complications of pregnancy and promote a h ealth y outcom e for both mother
and infant ( (B ulecheck et al 2008, p. 580) (6) In the N HDS of 2003, 9 out of 10
m others received can? from nurses and 01-idwives (50%) and physicians (38%) a nd
tradit ional birth attend ants (7%) while 6% did not r eceive any prenatal care.
A wom an without pregn ancy compl ication s n eed.,:; to have one prenatal visit every
4 weeks up to the 28 weeks, a n d every 2 weeks from 37-36 weeks and every week
thereon until birth. (Mu rr ay & M acKinney, 2006; Lowdermilk & Perry, 2004) (6,7) The
frequency is incr eased in th e 3"1 tri mester because of the possibility of complications
thntmay arise. This wa rrants more frequ ent monito r ing.
The more risks a pregnant woman has, the more visits a r e needed . Information from
the 2003 NHDS show t h at one (1) out of ten (;10) had the 1"' prenatal c heck up at 6-7
months of pregnancy. Three out of ten had their prenatal check up on the 4 th to 5 th
month. There is a segment of Filipino wom ,en w ho are at the highes t health risk during
pregnan cy (2): (1) preg;nant women less th au 18 years o ld, (2) women who r eceived
only up t o elementary education; (3) women in 20% of the poorest households; (4 )
women in areas of armed conflict ; (5) women victims of domestic violence; and (6)
pregnant women with concurrent chronic illness (iron deficiency anemia, tuberculosis,
cardiovascular diseases, diabetes mellitus, etc)
The goal of the government is for aU pregnant wom en to have at least fou r (4) a n tenatal
visits in a pregnan cy. The 2007 WHO st andard recommends at least 4 prenatal visits.
T h is is largely based on a study d o ne by Villar et a l (2001 ) who reviewed ten trials
in volving ove1· 60,000 women. Seven trials evaluate d the nu mber of antenatal clinic
visits, and tliree trials evaluated t h e type of car e provide r . A reduction in the n umb er
of a nt enata l visits was no l associ:1ted with an increase in any o f the n egative maternal
a nd perinatal outcomes reviewed. However, trials from developed countries suggest
that women can be less satisfied with the reduced number of visi ts and f eel that their
e :icpecta tions wi th care ,ire not fulfilled . Antenatal care provided by a midwife/general
290
titioner was associated with improved perception of care by women. Cli ni cal
~c tive"l1 ess of 1nidwife/genera] practitioner m a naged ca.re was :similar to tha t of
ec trician/g_vnaecologist led slmred care. The authors concluded that a reducrion
?b~e n uinber of antenatal care visits with or without ~111 increased e 1nphas is on the
111 ttent of the vi sits could be implemented witJ1out any increase in a dverse biological
con erual
·
.
1 outcomes. ( 8 )
and pennat.a
(11:J t e
Below is a com parisou or p 1·e natal visits from the DOH (9) a nd the ICSl (1.0):
SCHEDU LE OF V ISIT
1
.
2
3
4
5
6
7·
8-11
Age of ~ station (AOG) In weeks
DOH Sentrong Slgla
ICS1
4 -16
17-28
29-36
31-40-
f, 8
1.9-12_
16-18
22
28
32
36
38 -41
'
.
.
COMPONENTS OF PREG N ANCY CAR E
Health services are in place in our health care delivery system for mothers and their
unborn ch ild T he essen tial health care package include:
1. antenatal r egistrati on
2.
tet anus toxoid immunization
;3. macro 11utrient and micronutriuenl su pplementation
4. treatment of diseases and oth e r conditions
5. early det ection. and management of comp1ications o f pregnancy
6. clean and safe delivery
7. support to breastfeeding
8. family planning counseling
9. STD/HIV/AIDS prevention and management
10. Oral care
These are all integrated in acti.v ities done by nurses, midwives and doctors during
pregnancy visits. A list of w hat can be expe<:ted in each visit are included in t h e p ackage
of health services (9):
First t rimester
4 -l.6 W e e ks
second ttlmesier
.Compute AOG & EDC;
prepares Home Based
& confirm EOC;
Maternal Record
(HB~ ~) ,
Phy.sl!!:al exam inatio n
& vit,a l s igns
EDC; u pdate HBMR
update HBMR
Physlcal examination,
fundlc h eight,
q ulckeninl & vital
sig ns
Physical
•omlnation,
~It al signs, fundlc
lieight. fetal heart
Physlcal
examination,
vital signs, fund~
he
ione
291
3 7- 40 w eeks
!icreenlng for
medlaal problems
and danger signs
(initiat e first ald
measures as
needed & refer to
physician)
5f.:rean for d~nger
s igns:
Sc:l'een for danger
signs
Screen for danger
signs
- l)allor
- Pallor
- Pallor
- bleeding
- abdominal pain
- bleeding
, abdominal pain
. - abdominal pain
s c~nfor;
- pre-eclampsla
{20th week)
-~
Uonal
diabetes (24th
- bl eedin g
Screen for.:
- p ainless vagin al
bleeding
Screen for:
- preterm labor
• headache
- preterm tabor
- p uffiness ed ema
- puffines s edpema
-p a inl ess vagina l
b l eedlng
headache
week)
Urinalv.sts and
randQm blood
sup ,;.If availa ble
~avlde 1st a rd '
m easures, as
needed & refer to
phvSlctan
Provide routine
pre8JJBnCV care:
- tror, supplement
- Low dose Vlt A
- Tet anus toxold
Immunization
- Malarta prophylaxis
for endemtc;: ,mys
- CBC~ Urinalysis
Pr:ovlda routine
pregnanc;v care:
- lr.0 11.suppfem ent
- Low &is.; Vitamin
A supplement
- Tetanus toscold
Immunization
'
Pr ovide rou ti ne
pregnancy.caret
~ Iron supplement
-Low dose
Vltamtn A
sup plement
- Te tanus to><(? ld
A supplement
~ Tetanu s toxold ,
immunizati on, If
ne,eded .
lfineeded .
- Repeat
,
h.emoslobin,
p rotein In urine
- J\e'p eat CBC/Hgb,
"blood ..typing, If
b fo o d sug~lj If
available
292
•
Proyid e routi n e
pre gi:ic1n c;;y ca re :
- Iro n supple merit
- Low 9,os.e Vlcamln
Immunization, ·
a nd ra.nclom
I
ava ilable
I
First semester
Second semester
4 -1 6 weeks
17-2Bweeks
provide counseling
messages and
in fdalize birth plan:
~. r,Ji.Jtrlt1Of1 &
hygiene
olscomforts in
pregnancy
oo's and don't's
1n pregnancy
Warning signs In
pregnancy
Fertilit y
awarenes-s apd FP
□ Breastfeeding,
Child care and
family health
g Delivery and
Provide counsellilg
messages and
review birth p_
l an:
- Nutrition &
hygiene
Dlscomrorts in
pregnancy
1
1
' D0 s and d on't's in
pregnancy
U W arning signs In
pregnancy
l. Fertility
awareness and FP
1 Breastfeeding,
Child core and
family health
l, Delivery and
emergency
emergency
pre parations
prep aral' ions
Schedule 2nd
p re natal visit &
up d ate HBMR
schedu le'2nd
p~enatal visit1~
update 'HBMR
If this Is the 1st
visit, ensure that 1st
t rimester activi ties
have been done
•/
Third Sem ester
Z9 -36weeks
37- 40 w eeks
Provide coun seling messages
and validate
Provide lnforma -tjon
and valid ate birth
plan:
[] Do's an d don't's
birth plan:
17 Nutrition &
in pregnancy
hygiene
0 Nu t rition &
hygiene
n Do'sahd
d on 't's In
p regnancy
0 Warning signs in
I , Warning signs
In pregnancy
[l Fertility
awareness and
FP .
pregnancy
[.I Fertility
awareness and
FP
0 Breastfeeding,
Child care an d
family hea lth
lJ Delive ry a nd
emergency
preparations
D Breastfeed fng,
n Per sonal hygiene
Child care and
family health
0 Delivery an d
after delivery
emergency
pfeparations
D Personal
hygie ne after
delivery
Schedule 4th
prenatal visit
preferably 1-2
weeks befor e
dellvery
ANT ENATAL REG I STRAT IO N
When a woman comes in for "the first prenatal visit, whicl1 the government aiD1S on
the 4 th to .16 weeks of pregnancy, the healtb care provider comp utes the age of gestation
ond the expecte d date of d eli very. 'The h ome based m ate rnal reco rd (HBMR) is also
prepared. (.u) The HBMR is nc!taiaed by the woman anti serves as her "pass port" to
appropriate healtll care. It is a simple car d designed to facilitate the easy recording
an d interpr etut ion of comprel1ensive infor mat ion on the h ea lth status o f a woman
b efore he r firi>-t pregnnn<.:y, d u ring ll1e c u r r e n t pregnancy, delivery, postpartum and
neonatal periods, and during l,vo subsequent pregnancies. The cards can also be used
to record inform.ation duriug tl1e periods between pregnancies and o n the woman's
breast-feeding, family planning, and tetanu s toxoid immunization status .
.
TETANUS TOXOID IMMUNIZATION
Tetanus is caused by a n an aerobic spore forming bacteria called clostridium tet ani that
enters the body of the newborn through unsterilc techniques in cutting and dressing
th e umbilical cord. Wh~eit is found in the environment, t11e organism can only s urvive
293
..- First sem ester
Second
17-28weeks
4 -16 w eeks
-provide counseling
Provlde counseling
m essag-cs and
me ssages and
review birth pla n:
lnltfalit e birth p lah:
U Nutrition &
r J Nutrition &
,, hyglt:me
hygi e ne
' I Discomforts in
' ! Discomforts In
pregn a ncy
preg na ncy
f
oo's an d don ' t's
Do's and don't's In
I '
pre ena ncy
in pregnancy
w
arning
signs
1n
l
J
Warn
ing signs In
1J
pregnancy
pregnancy
I • Fertility
Fe
rttllty
'
aware ness ahd FP
awi.lren ess a nd FP
Breastfeeding,
l
Breastfeeding,
r.;
Child care and
Child care. a nd
famrly h ea lth
fa mily health
L
Delive ry a nd
J Oellverv a nd
emergency
eme rge ncy
preparaHons
preparalion!.
-
Schedule 2nd
prenatal visit &
upda te HBMR
Third Semester
Sem ester
I
l
Schedu le 2nd
pre natal visit &
upda te HBMR
H t h is is the 1st
visit, ensure that 1st
trime ste r actiVlties
have b een done
29-36 w eeks
37-4,0 weeks
Provide cou nsel- '
Ing messages
and valrdate
Provide lnforma-tion
and validate birth
plan:
lJ Del's and do n't's
in pregna ncy
0 Warning signs In
birth plan:
~ 1 Nutrition &
hygiene
!.J Nutrition &
hygiene
C, Do's and
don't's in
pregnancy
0 Warnin g signs
in pregnancy
0 Fertility
awareness and
FP ,
pregnancy
iJ Fertility
awareness and
FP
C Breastfeeding,
Child care and
family health
U Delivery and
e merge ncy
preparations
I] Breastfeed ing,
0 Personal hygiene
Chtld care a nd
fa mily healt h
[J Delive ry a nd
emergency
preparations
r, Perso nal
hygiene afte r
delive(y
after delivery
Schedule 4 th
prenatal visit
preferably 1-2
weeks before
delivery
ANTE NATAL REG ISTRATION
Whe n ,t w o ma n co m es in for the firstprenntnl visit, which th e governmen t aims on
Lhe 4•h L<> 16 w11cks o r pnign~m cy. the health care provide r computes th e a ge of gestation
:incl ll 1l' cx pl'c tccl date of d e li very. T he home based maternal record (HBMR) is also
prc:pn 1·c·ll. ( u ) T lw llBM R is re tained by Lhe woman and serves as her "p assport" to
.tpp rnpl'ial c ltl.) alt h ca re. lt b a s irn ple card d esigned t o facili tate the easy recording
and int c q)l'et ation o f co mpre he nsiYe infor m i\lion 0 11 the health status of a woman
befor e h e r lirs t p regnan cy. during the curre nt pregnancy, delivery, postpartum and
ncona l.al period:-; antl during t,w, s ubseque nt pregnancies . T he cards can also be used
tn r ecor d i11form:1tio 11 thu; n g the p e r iods hetween p1·egna ncies and o n the woman 's
brcns t-fec ding, fam ily plnnning, a nd tetanus toxoid immunization status.
TETANUS TOXOID IMMUNIZATI ON
Telanm; is ca u se d b y an anaerobic spore fo rming bacteria called clostrid:ium tetani that
enters th e body of the n e wborn through unste rile techn iques in cutting and dressing
the um bilical cord. Whil e it is fo und in the environment, the organism can o nly survive
293
in human tis "Ue.<- so environmental eradic.,tion is not an option. Stanfi e ld et a l (19 73)
report hat 2 d ,;,ses o f tetan us can protect tbe person for J.- 3 years. (1.2) This protection
is m ost benefic ial if t be las t dose of the to:.:oid is given at least 2 w eeks before delivery
(\\ 'HO. 2007 . p2 ) Toe international goal is fo r all women giving birth a nd a ll t he
~ -.-born to be pro tected from tetanus. (13)
The 2003 ~ abonal De m '>graphic Health Survey reports that ·wom e n who received 2
dO$e5 o f TT c.l e<.- r ~ fr<Jm 38% to 37%. Davao Region has the hig h est cov<:: r age at
49.1% a.id Caga:,-a n \' alley at 47.9%. ARfu'\I as ,~;th the 1.998 NDHS is still the lowest
at 23-4"".. followed by CAR at 28.7% The □ u.mberofdeaths fro m tetanus h as decreased
through the years. [a the 2007 . there were 12.i reported cases of neonatal tetanus. In
the country sur,eillance report of the \VHO.
According tu DOH Adrninistrati,·e Order no. 1 ~ 1995, IT shall b e given to women
on their 5'" to 6 "' month o f pregnancy. ( 14) The list in cl udes th e estimated period of
protection for the woman when immu.oized (\cVRO 2002, p . 130) (14 )
Pe riod of
Protection
None
3 vear.s
cv
5 years
10 years
(ltprd1ess of
All child-bearing
ears
The guideline s uggests that no woman should be given more than 5 TT doses in her
lifetime. \\'ben the woman is inun une to tetanus, she also conveys five (5) months
irnmu11ity to the infa nt. This pro tects th e n ewborn from neonata l t eta nus.
MA CR O N U RI ENT AND MICRONUTRIENT SUPPLEMENTATION
lnte l"\·enti on s fro mate rnal hea lth include s upplementation for folic acid, i ro n ,
\'itamin ,.\. and bala nced energy and prote in intake to im prove maternal a nd fetal
outcomes . Tht- im porta nt years for interven tion r elated to n u tri tion are frmn p regnancy
to two ve..irs of a~I!. Inability to m ake the essential interven ti ons available causes
inm:er.,ible da m ages an d increases th e r~sk of girls becoming m a lno uris h ed m oth er s,
,,·ho t ben haYc a low- birth- we ight babies ( 31)
MICRONUTRIENT SUPPLEMENTATION: IRON
SUPPLEM ENTATION
lro11 dcficicncv ,1nemia is the most com mon micro nutrient deficie ncy. It affects
the nc,,·h om a nd infant in ways ranging fro m low b irthwei~ht t:o cognitive p roblems.
Pr1:11,1rnnt women a t or 1war :-ea level are ~ah,g(1r ized as having a n em ia if t h e h emoglobin
( H I).) i,; l<:-,-s thn 11 11 ,:\/ d l o r hl"rnatocri1 (I le t) l~s than 33% . At higher altitudes, p eople
h,w<: hi~he r H!i, an<l I-J ct lc\'cls ( FishbHtCh and Punning, 2 1Jo9) (15 )
Pag:m:.i and
Pa~a oa ( :mo: i ) report that at 5 1000 fco::t above sea level, a H g level o f less th an 14g/dl
is indica tive o f a n<.' n1ia. Thjs info rma tion is importl:lnt esp ec iall y for prrtients living in
hi$:h a ltitude nrcm, (.10)
294
lron supplementation is vita l hecause of the blwd loss in <lelivcry. I! the woma n ic;
already anemi c befo re d e li very a nd in t he p ostpartum period, iti ncrcas1.>s the p<Jssihility
of needing b lood l ran s fusion whic:h not only opens her to mo re risks but also very
costly.
Jn 2003, 77% o f p regnan t women receiv,ed iron supplem en tation.
The Nationa l
Nutrition S urvey o f 2or,3 r ep orts 4~t9% of wo m f!n as having iron dcfic:icn cy nnemia.
111ere w e re 43.9% o f pregna nt a nd 42.2% o f lactati ng women who had iron <leliciency
anem ia. T h e goal o f t h e g<Jvernme n t i!> a reduction tu 38% of the number of women
with anem ia .. Accord1n~ lo the WH O (2no7) , a dai ly dose of 60 mg iron and 400 ug
folic acid da ily fo r 6 months is adequate to meet the physiologic needs o f r,regna nc.-y.
(13) T he HBM R gives a sta ndard prescription for Filipi no wr.>men to take iron/fol ate
supplements twice a day (60 mg/tahlcl) sta rting on the 5 11> month of pregnanc.-y up to
2 m onths pos \partw:n or for a periud o f 21 0 d:.ys. If an ,m:!a has a high p reval ence of
anemia, t h e sup plem e nt a ti on of 100 mg iron and :350-500 ug foli c acid is reco mmended
for more th an 16 \veeks nn d s uggestecl to continue for 3 months pm,1:partu m.
Nurses must know how to use a multiple-s.i te assessment for a nemia. Stoltzfus et aJ
(1999) identifies the in feri or conjunct iva, palm a nd n ail beds as some o f the sites to
assess aside from 11sing the resul ts of laboratory exa minatir,n.( 17) r ·a lc conjunctiva
was found to he high e r amo ng rural compa red to urban dwelle rs (Ve landria, et al,
1995) ( 18 ) It is also Lmportant to inquire about history of malaria or other parasitic
diseases s ince they can also cause anemia.
VITAMIN A SUPPLEMENTATION
Vitamin A s u pple m ents have been recomme nded in pregnancy to improve outco mes
that include m a t ernal mo rtality a nd morbidity. Broek et al (1996) performed a review
offive tri als in volving 23,4 26 wome n . One large population based trial in Nepal showed
a pos.sible b en e ficial e ffect o n m aternal m o·rtality after 1.veekly vitamin A supplements.
In this study ,1 reduction was noted in all cause maternal mortality up tO 1 2 weeks
p ostpartum ";th Vi t amin f\ s upplementation N ight- blind ness was assessed in a nested
case-control stndy within this tri:11 and foun d to be reduced but not eliminated. Three
trials examin ed th e e ffect of vit am in A su pplementation on hae moglobin levels. The
lrinl from Indonesia s howccl a beneficial effect in women who were anemic ([Hb] < 11.0
g/dl). A fter supplementation, the proportion of women who became non-anaemic
wns ;35% in tl1c Vi t amin A supplemented gro up. 68% in the iron-suppl emented group,
97% in the group s uppl emented with both Vitamin A and iro n ancl 16% in the placebo
group.(19)
In the Philippin l:!S ,women receive 10,000 IU of Vitamin A during the t•1 µ·renntal visit in
the 1"' t rimes te r and throughout the pregna-ncy. The women are given the supplements
and t h eir intake followed th rough during pregnancy. Only 77. percent o f pregna nt
women r eceive <.! i1·on supplcmcnt.1tion during pregna ncy wh ile o nly 45 percent of
postpa.rtum women received a dose of Vitamin A. In 2003, 17.5% of pregnant women
an d 20.1% of lactating women hnd Vitamin A deficiency.
TREATMENT OF DISEASES AND OTHER CONDITIONS
Iodine d eficien cy is one o f the preventable cause of m ental retardation and brain
damap,e. It is also a ssociated w ith cretinism, lower me an birth weight a nd increased
infant m o rtality. locline cleficien-cy is conlrollecl through di rect s upplementation
with o ral o r intram uscula r iodized oil. a ddi tion of iodine to water, or most cnm monly
irJu izat io n o f saJL In the Philippines, about 36 out of every 100 children (35.8%) have
295
moderate to severe iodine deficiency dis orders ODD). All 4 p r ovinces o f Northern
Mindanao (Region 10) are high-risk IDD areas. About 6 to 7 out of every 10 childr en
am moderate lo severe fDD cases. The government's presci:-iption is to administer
one capsul e of iodi7..ed oil is given to all pregnant women in areas where goiter is
endemic. The nurs.:e cau assess the pregnant woman's t hyroid gland by pal p.;ition. The
importance of this examination is based on the report that 30% of pregnant women
have goiter (Safe Motherhood Survey. 1993) (21)
Malaria is t11e 9 11> lending cause of morbidity among women (DOH ten leading causes
of Morbidity by Sex, 2004) In areas where malaria is endemic the health car e provider
gives 2 tablets of chloroquine phospate (250 mg /tablet) every week for the duration o f
the pregn an cy. ln endemic areas, pregnant women are also provided ,"vith long lasting
impregnated nets (LLINs) as a protection
EARLY DETECTION AND MANAGEMENT OF COMPLICATIONS
OF PREGNANCY
The nurse needs lo l1ave the skill in detecting the danger signs o f pregnancy.
Patients man ifesting these s igns need to be referred to the nearest facility or physician.
Interestingly. the results oft'he stu<ly by A.DB on41 out of 79 provinces in the Philippines
show that o nly 56.6% of women were advised to go to specific public facilities (35.4 %)
and private facility (14.7"/4) in case of pregnancy complications( 21 ). _The rest were not
adequately info rmed where they can go if they e ncountered pregnancy complications
Prompt detection and management vvill help in decreasing the chances for mate rnal
and fe tal mortality and m orbidity.
Specifically, the nurse needs to report vaginal
bleed ing, edema oft11e face and hands. headache, dizziness, blurred vision, pallor. In
the prenatal check up, tl1e health care provider also takes the woman's fu.ndic height,
temperature, blood pressure, weight, signs of urinary infection (pain and frequency
in urination) and signs of eclampsia especially starting the 20•" week. The results of
uri nalysis a re also r eported for proper m anagement in case of infection'.
The blood pressure is the most sensitive sc1·eening test for diagnosing hypertem;ive
dis.o rders in pregnancy \.vith a 71% sensitivity, 95% specificity and 40% predictive
value for pre-eclampsia in pregnancy, labor and puerperium ( H all 1992, p.22) (22) It
is measured in ll1e same arm (at the hea11: leve l) and position d uring each visit_
.
Below is the classification of blood pressure for adults aged 18 years or older: (23)
I
Dependent eaema is common in normal pregnancy ·while generalized edema is seen
in pre-eclampsia. Edema is best assessed on the face, bands and sacrum and taken in
conjunction with blood pressure readings. Abnormal -findings warrant referral to the
physician.
296
FAMILY PLANNING COUNSELING
The Women's H ealth Safe Motl1erhood Project 2 reports ..As tli e 2 003 N DHS n wca/s,
the acnml total f ertility ra te (T FR) of 3.5 is lriy lw,· thmi 1oanted .(ati/ity of 2.5. a, 1d
unmet family p fa1111i11g 11ced exists J o,· one 0111 of.fii.'C' wo men (19.8 ~t, }. The 200.;
Family Planning S uruey show s tlrnt th is co11/'in11cs to be: rhe mse. ,dth :Jo. , 'J;; tota l
unm et need , of w hich 10.9% is for spacing bir-tlts u m/ 9.2\"\5Ji:i1· /imi11·11g /Jirt'l, s. naecl to
make a decision on family plan ning is dnn e cluring preg11n11cy. ( 2007. p .Ci) (21)
Family planning aru.1 fertility awareness are part of whal .is uisc:ussed in I he firsLprcn.it,11
visit and the s ubsequ e 11t visits. After d elive ry, the benclits el f fam ily pl:rnnin~. 1is ks of
a pregnancy too soon a nd most ;;ui tahle fa mily planning meth ods fo r a breastfeeding
woman ,Lre discussed. Th e choices offered nre IUD. condom. prvi;csleronc unly pUI.
natural fa mi ly planning , spermicides ,111d pern1anen t methods. (9) 1\ s:sistu n cc is i:;ive n
to tl1e couple to help the m decide on a choice of n fam ily plnnni11g mctbocl.
STD/HIV/AIDS PREVE NTION AND MANAGEMENT
The WHO standard aims for nil women seen during prcg11.1ncy. c:hilclbinh and
the poshia.tal p eriod lo be given approprLate inform:1tinn on the prC'vcntio n ~111d
recognition of sexually tr,rnsmillcd inl"ettio n::; (STls) and rcprnd11clivc tm t·t infections
(RTls). They shoul d be :1ssessed fo r ST !s/R,Tl s :,ml, when rcquin:d , pro\'idetl with
prompt and effecth·e trcatmenl fo r the mselves :incl. in the case nf STls. their partners.
Effective managem e nt of STls is key to their cnnt rn l, :,,: it prc,·c nts the developme nt
of complications and sequelae, reduces the s1iread of these dise:iscs in the community
and offers a unique opp01i:unity for ta rgeted ed11 catin n on I I IV prcvt:ntion.
The p revalence of STls is increasingly becn ming a source of concern in the country.
A May 2002 su.rvey nf the general populntion showeci n relatively hig,h prevalence o f
chlamydia1 infectio ns (5.75% for women , 4 ,4% for men. 7.7'X, for female youth and 9%
for male youth), rrichomonias is (3. 18% for women) and p,nnonhca (0 .75 % for women ,
4-4% for me n. 0.7% for female yo uth and 1.7% for mnlc- youth). T he !-lituaticm :1.mo ng
h1gh-1;sk groups is more disttll'bi11g. Peliollic slUdics fro m L994·:!.00:!. t'Ollducled in 18
sites sho..,,,· t hat amon~ high-risk females. hacteri.il rnp,ino,;is is tJ1c mo:st predominant,
reaching 70%, followed by chlamydinl in fections fup to 36%), gonorrhca (up to 3 1% )
and syphilis (up to 7%) . .1-\m o ng high-risk males, chlatnyd ia leas lhl:! highest pre,·ulcnce
(up to 16%), then syphilis (up to 11%) o1 nd gonorrhe(I (up to 3'X,). The problc m is
cowpo unued by the emergence of antibiotic resistant s trains. Ncnrly all gonorrhea
isolates were found res istant to peni c.illi n iu L997 whil e 63% wl! rt! fo und rl.'sistant
to quinolones in 1998.) (21). The health services for STls in cl ude !>creening. hc:ilth
edltcation and referrals for lhose who need manage ment and treatment.
STANDAROS IN HOME DELIVERY
A plan for birth and ways of deali ng with u ncxpeded adve rse e vents, :-uch as
compl ications or emergencies, lhat may occur dming r 1·cgnnncy. d1ildbirth or the
immediate pos tn<1tal peri od should always l>e avai l,1ble. This pbn is HrnH.:thin~ that is
done with tl1e b ealth earc provider at each ante natal visit ancl nt least cine mon th prior
t o the expected date of birth. Historical e..,,; dence s hows that nu co unlry has managed to
bring its maternal mortality ratio below lOC> per 100 ooo live birlhs " ~lhout c ns u1;ng
that all women are attended by an appropriately skilled health professional during
labour, b irth and the period immediately afte rwards (24)
In focus-group discuss ions, midwives and hilots consi<lcred the delay in rt!femd
297
treatments as one of the main reasons for m aternal death. The servi ce providers faced
more difficulties convincing women from ethnic minority grou ps t o seek treatme nL
T his hesitatio n stems from cultural barriers and language unfamiliarity (21)
Births attended by hea lth professionals iucceased from 56 percen l in t 998 to 60 percent
in 20 03. The goal is to hnve So% of al l births attended by skilled heal th atten dan ts.
Based on current data, 61% of births occurred in tJie homes while 38% in health
facilities.
Hornedelive ryisanotherimportant .n ursing inter vention. Republic Act No. 9173 states
that nursing care of individuals, families and communiti_es in any health care settin g
and includes but not limited to nursing care during concept.ion, labor, ddi very. It also
the duty of the nurse to perfom1 internal exam ination during labor in the absence of
antenatal bleeding and delivery.
Birth attendance by professional health ¼lorkers will be a significant step in having
b etter risk assessment and referral. If the person handling the delivery is well trained,
t]1 ere is a greater chan ce of detecting pelv ic inadequacy and fetal malposition. The
client vrul benefit from a more skilled practitioner doing abdominal and internal
exam ination.
The DOH came out with a Protocol for Horne Deliveries tb.rough DOH Department
Circular No. 187-As. (Compiled Policies 1994, p.46) (4) This circular allows licensed
nurse-midwives and nurses trained in deliv e.r y to conduct h ome deliveries. Licensed
physicians, midwives and trained traclitional birth atten dants o r hilots (allowed only
in areas where there are no licensed physicians, nurses, midwives or n o available
health professional at the time of delivery) are also listed as o ther legitimate birth
attendants.
For nurses adequately trained in labor and delivery, this is an important o pportu n ity
for nursing practice. Since most b i rths in the rural areas happen in the homes, the
Protocol for Home Deliveries v.ill help in ensuring safety of the woman and b aby.
The list below shows the DOH criteria on w ho are qualified to hav e h ome deliveries...
AdctitionaJ assessment pointers for the nurse are a l.so included:
Quallflcatfons For Home
Pointers
Take a complete history and examlnadon on
current pregnl!ncy. Compar:e the l!!Stfmated age
of aestatron by the last menstrual by the last
menstrual period (LMP) and the measurement
of the tundlc height. Complete lnformatfon on
Gravrda, Parity and TPAL score.
298
Delfverv•
Full term (9 months)
2nd to 4th delivery
.
Point e rs
Make a p ysica examrnation
olhgt &Leopold's maneuver for the fetal position, Ile and
presentation, lntema I i!Xamination to d ete rmlne
pelvic adequacy, rupture of membranes,
en gagement and signs of Imminent delivery
This presupposes that the nurse had previous
trralning on Internal e>camination_ (IE), The nurse
can also u se maternal h eight as a possible
predict o r of cepha lo-pe lvlc disproportion.
1nspec:t abdomen for CS scarfs.
comp ete ata on present eal condition an
past obstetric h istory with emphasis on the
following:
Presence of a m edical condition, hlstor y ,of
difficult delivery, prolonged l abor, hemorrhage-or
previous caesarean section
Qualifications For Home
Dellve •
Cep allc presentatfon
Pelvic: adequacy
No premature rupture of
m embranes
Imminent-delivery
Di cu t and pro onged la -or
(greater than 24 hours for
prlmlgra111das and more than 12
hours for m ultigravidas) durfng
previous deliVfilries
..
Hislory of h emorrt,age
A previous caesarean section
For rmme ate re erra , t e i Ft atten ant must
accompany the patient together w ith a relative.
For other refi?rral s, the birth attendant may
not accompany the patient but Instead make
a r eferral s lip which Include the following
information, a 5 suggested by the DOJ,l: name,
complete address, age and reason for referral
Imm
ate re erra must e
done to the nearest faclllty with
cap.ibllity of handling the needed
servlce/s in the followin g sfgns:
DANGER:
•
Vaginal bleeding.
• ·convulsi on
•
Blood p ressure above
140/90
•
Severe abdominal pain
Re~rral but not lmmedlarelyr
O A pregn ant woman who
is not qualified for hom e
delhtary
A woman who develops
abnormal signs and
symptoms b u t NOT dang!!r
signs during pr egn ancy
and postpartum like
·edem a and pallor
299
The nurse n eeds lo make preparations for a delivery. The DOH protocol (listed
below) pres ents a lis t on what are needed for a delivery:
A deU11ery left • contalnlns the ft:lllowlng:
IJ Pair of sterilized scissors of a new and cj~I) st9rilJied razor blade (to be used for
cutting the cord)
0
0
D
0
Sterile cord stf\np (for tylns tt,acordl
2 pair s of clamps (If avaOa~
Anttseptl!= (may UM 70" a laofiol)
Soap for washlns
O ~ean tow el or a c:ifin pi
C
0
Flashllght
Sp-hvs,n11manometer
□
Stethoscope
Plastic sheet (as delhlefV~rhtce)
s uctfon bulb (for su.ctloolns newl;,om $e«et1e,ns)
Spring-type we,lghlng ~ ·
0phthaimle SOIUtlon
Clean towels or pleces of cloth (for drying and WtappJng newb9rn)
N.all cutter {to cut-11nd clNn the nlllls oftha birth attendant)
Sterile gtol,es
• It Is a ve ry good l'!Urslns practice tt>11lwavs have a deJlv,ery kit on han d . The following may
be added: cor:d clamp (IMtead of cord str.J11g$}, at lea'$t 2 sets c:if 2"l<2' ga1.1ze (to help wipe
secretions on the baby's face and used for perinea! :support), povldon-e ioclir,e antiseptic
(for elean l" g the perinea! area before deltverv ar,d:clear,ln,t·the bir th attendant's hand-s).
In th e DOH Sentrong Sigla Supervisory Package, s pe c ial e mphasis is g ive n to the 3
Cs. 111ese are clean h ands, clc 11n d e livery ~mrfacc, clea n ct1tting nnd care o f t he cord
(DO H,2003, p. 3 1). The nurse is a lso a!Jowecl to sul'ure s upe rfic ial 1.-.ce i·a Li ons and
administer necessary intrnm us cular ,m d intrave nous medication, pr-o uided , however
th a t th ere is adequate trninjng for such procedures.
Monitoring o f the woman with in the first 2 hour s post delive ry is a l so don e. This is
through th e vital s igns and noti ng for s igns of bleeding. Br easlfeedin)!. is also initiated
right ,1fte r delive ry. The n eed t o refer to the nearest h ealth facility any complicated
and difficult d eli very is a]so mentioned. B-irth registration with in 30 days a fter is also
em.pb:isi7.e<l
STANDARDS IN POSTPARTUM VISIT
There i s an increase in the perce ntnge of women with. a t least one postnatal visit
from 43 percen Lin 1998 to 51 pe rcen l in 2003. The goal of the goveran1ent is to have
80% of women be nefit from postpartum l" visit within the 1•• week of delivery.
The DOH Sentroug S igla Technical assistance Packi1ge for Integra ted ,-vomen's Health
s t ates tJJe gove rnme nt's goal of having 80% of women rece ive two (2) postpartum
visi ts d one within two (2) dnys afte r de livery and a month after and licn·e received the
300
essential services namely:
•
•
•
•
Physical and abdominal examinat io n
Vitam in A 2uo,uoo lU wi thin 1 month after dclive1y
lron su ppl ementation (.1t l east 9 0 tabs)
Cotu1s cling o n breas tfeed ing ( BF), family planni ng (FP), persona l hygiene,
newborn care. ST D/ HIV/ AIDS prevention
To en s\lr e th at U1e goal is me t, Lhc Scntrong Si~la Supervi sory Package provides
•nfo rm at ion on th e important activities that th e nurse and midwi fe need Lo d o wh en
~r ovicling care for a wo mm1 <luring th e post partum p~riod.
Postpartum visit
Provides m anagement for postpartum problems (mastftis and breast abscess, sore
or cracked nlppl~, engotgemenl & Insufficient milk, postpartum fever, depression,
1.1r lnary pr oblems, signs and symptoms of a fistula-poor control In urination and
elimlnation); lf beyond capab,lit , refer s to the doctor
Glves mlcrqn1,1trienl supplementation (Vlta,min A 200.000 1U Immediately after delivery
or within .a month, 2 tabtets of lron/Folate (60 mg elemental Iron plus 0.25 mg fohc
acid dally for 2 months and longer if she h as oallor)
G[ves postpartum messages ([j(cluslve breastfeeding, famlly planning, hygiene, routine
bab care ca re of the cord,
Gives adv(ce when to see~ consultation or when lo ceme for follow- up visit (problems,
artum visits. i mrn11nii;<1ttons)
One of the important concerns in postpartmn care involves breast feeding. TI1e
m irsc belps t h e wo man 1·0 make a decision on breasH·ceding. The Philippines . being
supportive of the 198 1 lnternationa l Code o f Marketing o f Breas tmil k Subs Li lute by the
World H e alth Orga n ization ('vVH O) is pu rsuing strong advocacy worki n the promotion
of breastfeeding. We recommend brcastmilk as the best form of in fant fcccling for the
first sh: months.
The Nursing Ou tcome Classificotiou (NOC.2008) provides practical gujdauce on
brea stfeeding c:;tab lis h m1m l. ( 2 4 ) There h; a !isl o f indi cato rs Lliat Lhe n u rse will look
for in the moth e r tha t poin ts to• cst;1blis hing p ro pe r breastfeedi ng. Some of them
incl ude the co mfo rt pos ition wh ile n ursing a nd use o f t he "C.. hold, recognition o finfont
swa llowing nn d hreaking t he sucti on whe n removing from the breast . The beauty of
the NOC is the list ing of infant indica tors 11la1 dete rmine tl1e success of breastfeeding.
Some of tJ1e t:ue s Lhal nw·se ,vill luok for :are: proper a reolar g rasp and compre ss ion,
audible swallowing, coneet tongue placf!men t and nursi ng for a minimum of 5-10
minutes pc1· breast.
·
The Nursing Interve ntion Classification (2.008) h as a list of 40 activities that th e nurse
can do to prepare a new mother to· b reastfeed her infant.(25) Some of the activities
include a wid e v..11·iety ofinstn1ctions on wha t the m other ca n do, need to watch out for,
to avoid , and actions to better take ca1·e of t he self and the infant.
ln the p·ostparti.1m visit, the nu rs e can ass ist the woman to maintain her physiologic
stability and a dapt at ion to her new role. She can be a resource person in h elping the
woman gain sup p ort in contin uing breastfeeding an d maki ng decisions regarding
fertility control.
301
THE NURSING PROCESS IN A NURSE-MANAGED CARE
A nurse-managed pregnancy care is best described as t he nurse ~taldng owners hip"
of th e delivery o f pregnancy sesv_iccs. Her roles include being a practitioner, h ealth
cduc,1tor. nn d coordinator. This means that t he nurse h as a level o f expertise and
decision rnakinp, capabrnty to work with the client and family i n attaining the expected
outcomes nfc:1re . \Nh eth er she works "'rith the clien.l tb1·o u gh a clinic 01· a hon1e visit,
Lhe nrni11 respons ihili ty of ensuring that the woman is a h ie to undergo a l'isk assessment,
receive visiH;pccilic s creenings tesls, education, immunizations ot· supplen1ents and
interventions. The use of nurse-m::in::igcdl ca re is also part o f unple1nenting current
evidence that wome n benefit most when the re is continuity o f care. The nu r se will also
bridge the gap of m aking effective refena]s so that women know where to go and w h at
t o do in the focc of complications in pregnancy.
NURSING ASSESSMENT AND DIAGNOSES
Nursing assessme nt identify human responses to states of health and illness which
become th e focus of nursing interventions. Gordon's Functional Health Pattern is
a typology that links assessment and human r esponses to actual or potential health
problems.
·nie use of available standards of care \'I.ill be very helpful when making the assessment
tools. The Board of Nursing, t h rongl1 Resolution 459 cecently approved the Standards
of Mother and Child Nursing Practice for th e Guidance/Observance of N u rses e ngaged
in the practice of Mother and Child nursing as init iated by the Maternal Child Nursing
Association of th e Philippines (MCNAP). ln the DOH , a ll personnel use a standard
form in assessment called HMBR, a tool to identify risk fact ors, danger signs and to
hel p delive r appropriate measu res. lt is kept by tbe woman and is b r ought to t he clinic
every visit.
Nursing has progressed in such a way that we have standardized language to
communicate the results of assessment and clinical judgment (n ursing d iagnoses),
nursing ou1co1m:s and nursing interventions . It makes it easy f or nu rses to t a lk about
somethi rig wh en we use a standard language. It is also a great step that will help nurses
charge fo r their services.
Allen (2000, p .26) presen ts a way of clustering data using the framework by Go rdon to
include s ubjective and objective cues. This m ethod hastens the identification of nursing
diagnoses. Students and nurses with beginning skills in m aternal care find t his way of
clustering data vei:y usefu l and practical. A sample is presented on the next page:
302
Subjective Cues {SuslltSted q ue5ttons)
Op you know nutritional neea.s In
-111utrttJon and
Metabolic
pattern
pregnancy? Relationshlp between
w eight gain and fetal development?
Food likes & dislikes? Restrictions
cravings & feod taboos?
'
Vitamin and mineral supplements?
Experience In taking lrori tablets?
What discomfo11ts related to eating
& digestion do you experience?
Manage_menti'
Fluid fhtake?
Fiber intake?
- Elimination
pattern
Wh at changes in ellmlnat1on (urinary
and bowel) are you experiencing?
Management?
Objective Cues
Weight (gain or loss)
Height;
Results of a 24 hour
dietary recall or
typical food Intake;
Condition of the oral
cavity Swallowing;
Signs of anemia;
Parasitism; Results
of C8C(Hemoglobin,
Hematoor l t); Thyrord
gland en largement
Bowel sounc!s;
Flat ulence,
Use of. laxatives & stool softeners?.
Hemorrhoids;
Bladder distention;
Results of urinalysis &
History of u rinary tract infections?
frequency a nd pattern
fecalysis;
1,
1,
of urination and
defecation
What do you usu!llly do doing the day?
Do you ·have any change in your
activity level since you got pregnant?
Are the're any changes in your
1,athing/hygienic pra ctlces? How do
you feel about tl\is? How is your level
of·energyi"Experlence of shortness of
breath?
Do you experience any back pains,
varicosities and eramps; other body
pa ins? '
What do you t hink about prenatal
Actiyity-
Exerc:ise
Pattern
"
,1
1,
Vital signs;
Fetal heart·rate; Chest
examination;
Range of motion;
Posture & musculoskeletal deformities/
problems;
Varicosities; Areas of
tenderness/
pain
exercises?
·
Do you have any previou~ Injuries/
joint problems that are affecling
your activity? Hrstory/cunrent
cardiovascular/respiratory diseases?
DETERMINING OUTCOMES OF CARE
An outcome of care is the health state of a clien t resulting from health care. It can be
used to assess quality of care. When th e expected outcome is dear, it is easier to reflect
the inputs of the team on the health of the client.
The NOC (2008, p 4 62) lists 13 areas of knowledge on labor and delivery. When
the nurse assesses knowledge on birthing options, effective strategies on promoting
comfort on a n d the birth process using the criteria of 1 (no knowledge) to s (having
substantial knowledge), it becomes easier to keep tra.c k of the gaps in knowledge that
the health care provider need to fill up.
303
Thl' I'\' i» :iii,,, li'-1 ,,1 ;q p , •..ccl p n rt 11111 11\!lh' r n nl h c h nv it,r.; {:1cH1 8 , p . :,(>6-:,C>7) l h n l th e
1n\1~c- ,·.in h tt•k fpr i n n p, ,~1n.1t.1 l ,;s it. T he h <'l i:wl,11-,.: i1 w l1 u k nd io n.-. ln k c n hv t h e
w, •111:111i.1 m nn,11.:c• lwr ,-1111, h l im1 a 1ul lwr c11pa h1 lil~ 111 m n n it 1•1• I h e p n ·:-c n ee o f pro l; l<•m s
,11111 d i ,,·<>1n1 nrt,- l'\ •1111111111 111 tlw p ,·ri,~l hlll\~" , n ~ d\'11vt.• 1) ·. Tl1,· n ·ilc ri a i111·l11d c a :,;cal c
fn " " 1 ( n,·, l'r d ,•n,p n st n il L-..-l tu ;, tn•n ,-,s t t" n t ly u,·1111111s t n 1\ l'd ).
,., , r ,·nm i,.1,·. tlu: 111,r,- r dsit,- Con11.-lu. ::o .IJC"<II':< o h/. 1Plit1 i:,; 011 /r e:,· t liin l po s t
/'>V.<lpurru,11 .in11 ·11w n :1~-rrui 1ec1s ,fuc ru p r <>b /n 11s in ,w(f care c, nc/ 11r 1u /,on1 care.
l l'it /1 u 11111·si11y dt,t!,}•it>.~1·$ c:f 1'.' 11 <•tdl"d/l (' <ii:tic:it r.·lo tt•cl to s c•{(<ln<i 11c 1v h a r 11 c <1 1·(' . tl, e
, :..t f )(."f"-ft'"\I ci irri l ~1rrt.,~,rrtt' ~ er r"(.·
0
D
D
D
D
0
~ho ,, ad,•,1u a t,· k1Hlwkdf.'-' c, f i 11crc:1s i11g brc:i~t m il k pro d u ct io n
Shm , c ..,rnx t , 11 fo 111 p ,, ... , t i,111 i n i, in h r c :t!:- 1focd i n g
P l•-.,-rilw tlw pro p ,•r .::h•p :: in p c r i n ,• a l hyg ie n e
D,·-.,·n hl· prorwr , , .,y~ 1,1 ,·a n · fo r l b e cpis io l o 1ny
l dc11tit~ t hl.' •<1 ~ n s tll pos t p .i r l un1 c o m plic uli o n s th at n eed 11,cclica l
i 11 t <' l'\'l' 11 t io n
E 11um ~r:it <! , , ·a~-s to mu n ~1p.c s t res s
C HO OSING NURS I N G INT ERV ENTIONS
>:u r-.inc: 1111e r v,•nlio n :,. a n.• "h:11 "L' <l o as nun-c..'<. T h ey :11-e th e rc a i-o n for th e
a,nf~•n u L nt .,f a liL,' ll'-'-' lo p crf, or111 ,., u r du t i,.•i-. T hey c a 11 hr• indL'pe1 1dc11 l a nd
c o lbhn r:1 t 1,·,· 111.l,·p,·n ..k n t 11th 'l'l l' lllit11 , ~ a n• i11ili :11c<l by t h ,· 1n 11·-.e in n•s p n 11s ,• t o
n nn t,i n~ ,h,1~n,,, ;.... C11ll:1t,nr:.i 1h ,· .1c li11n s are th o ~ t l in t tlic lltll'!--L' p-c rfon 11:: i n
..-nllal'<, i-" 1111n ,, i1 h ,,th,-r l:,·.,ll li c.1n · p r11k-<, irn1a l:< 11 nJ tha t 11111:, r._•q11 irt" a phys ician's
,1nkr .t nd 111:11 l'-: 111 n '!'p• u1 , ,· t,> b o th 111,'<.lka l :1nd 11urs in ~ di:1~11<Js t•s . Cn.:.1 t effort s
h m t> 1-.-.•11 d o n,• 1,, lidp ... 1Jnd ,◄ rdi z1: m1 n-i 11 g i11l erve11 t iu11,.,
Du l,'"t'h •'C.h. <'I a l ( :ino8 pp H:.!l -8:.!:.!) ha <: c.:n cgorizc cJ n u rs in g i11 1c r·vt.• 11ti<>n s fo r
J\h ~h \lfrn· ;-.:u~1ni: ,i n d :--:,•1111.11 a l Nur-.i ng. S u m c i 111 c n ·.,11 tjon .., u n <lcr 111ic.l w ifcry
n 1,1r-<1nr. 111s tu.It!
.11!1111, ..11111 co n:. antic-i p ntury J!Uid a nt•t •, :i1t:1(''1 111cn 1 pro1111, t ion .
1, ir1h111~ ll n•,; ..1 ,·'\.11n m a111111 , ~hfhll,irt !i p n •pa r:i ti 1111, f:i milv pla nn i 11g , lrat·1:. 1i1>n n n<J
h ea lth .md 1•,irt•111 ,·du..., 11,m i:,,, 11 , .,. 11 ,1 ta l 11ur,i11~. , ,11 11,· i n 1, •n·,•11 1io11 , a r<· " " i',, llowb;
bru., -.1tu •d111~ ,h, 1,1.111 ,· ,· . l1' 1lll l· ft•,-di11~. 1a·,, ·tx, r n ca r e . f:11ni ly in vo lvc n 1<.: n l p ro111 u l iu 11,
::!Np c nh.1m·,•11knl . knn~ an10 t·a r,· ond n11 tri li D11 m n 11:i'1,c·111c n t.
HOME V I SIT AS AN INTERVENTION
Te> :IC<:'UlllJ)li<"h 1l1<• 1,,·0-folrl rot,• •>f rite nu r-.e rJ n d m idwife In pro v id e p o s iti ve
r, pc ,; 1-rn ,. t n '"mu 11 .111d <1 ,, 1;~,· r C":1rr· th,H iJ- h ;<1~, ·d 0 11 s t1111tl n r d s i.e. t h t• r c• :-1 1wc cJ 10
,·, 1:, h l1 ,h ,, tit, r a p, •111i, r.-l.11inn'-h1p " 'i l h t h ,· c lt ,•Jtt. -n,is l' a n b e ucc.:ompl is lw<l in t h e
C'r, 11 1,•,1 t1J l h,· cli11 11· 111 th,· ltum,· ' "' I \ n~ d1 ,•11 1 1h :, 1 who ••111 1•rn l lti!-- 1·,· lat ion.s hip has
<'IJ IH-~•r n,- d u 1 ;11 , • , , . .. ,.,,11 . . f\·1• ltJ 1H1r-,i 11 g i11ll•r.·,•n l1on s . Th o, n11 r-.l· l'<H n <·.- . vv it l, a b o d y
.,f knuwlt·tl ~•· .,11.J -.). ill .. l i;a,, •d 11 n <'' 1d1·111 , . ;, 11,I '- la 11tl11 r d -. o f c ;, rt • ;, n d i.s 0 1w11 lo h c in g
tully p r , ·.,, 111 111 th,· , " q><.· 1·w111·t · ol 11 111• r 111-t 111 ).( \\ 1t h tl w c.:li c n t. T iu: lllll'M ' g , 1es bl:yo nd
l n◄ Jl..i Ill! ,11 1111• d wn l .,. Jt1,1 1111,: u f I h,· p n·gn ,111 1 •
,1nd -. 1.11 t-. ltv I n·a I i 11 g c :it: h cl ic nt
wi t h n ·,p ,..,·t I la ,· 11 t11 -..• - d,, 111 1·0 111 ,,.·1 t l rn l I ..i rn d,·.,.-riln n g , ._ aki 11 1<> tl w v•.-ny .-.0 1nc
IT,,.i ,1 1«11• 11 , ",tl th ,· m 1, -,,.,· 1u,n bt•1,,·, ... n ll h ,·al , ·r an d II f}H l i,·111 •-- h •· in g a :-111· r e ~I work
o nc.l I hu"' l n ·ar.-d \,')t h «11111lol- t r,·,p<·ct. All 1, nrn c·.., Hnd o t ~w r CCltl C.-1,'rT1S an• u II owed l o
'"'° ' ·
· th il" .i' ?.11d V\111110'-I (,1c u ._ 1,-. t'<>II IPn•u n n Lht- t:lit•nt.
3{)4
A home vis it is :,n inlcrvenlion by itself. It becomes an opportunity to help the client and
the fam ily Lo d evelo p ;w cJ imple me nt a pla n IQ pro mote positi ve birth expcric n1:1·~ a nd
01.1tct1111c...:; . In th e l'hilippi11c scllinv_, dienl1, nccdi n~ 11 home visi t are typically listt•d as
prioritie s in the· 111:ilc rnal n .:)c\is t r:.:i1ion o rth1: h enl th c:e nt e rs nr rural h calth 11 ni ls. The
nu rse and 1hc 111iclwife d d crmirn:s who of the clicnls need to br visi ten. Wit h ;1 go;il of
havini; Ao'¼, of prc~ nnnl wn m t' n have at leas t 4 p rcnat:-i l visits . il sometimes h<'rnmcs
esse nt ial l o com e to the worn.111·.s hom e tu llelp her make a commitment to having a
good prt'gnancy ou t1:0111c. Similarly, if the gual is to have 80% of pos t parturn wumen
10 Jrnve the 1" vis it within th e J" week o f deli very, the im portan ce of the home visit is
much m o r e gla ring.
Various cul111 rnl nnd ethnic practices in the postpartu m period calJs fo r having the
wom an a nd h l!r baby within the confin es of the hom e at this period . 111erc are nlso
cnllll ni l nnd social 1,;x p cclations tha t need l o be given import;m ce for th e visi t to be
mutua ll y s :1t isfy111g. Fnr cxnm ple, tJ1 e 11 ursc pays a tte n ti on to the social custo,m;
cxpcclecl in a hnm e "i~it ranging from her conveyance of respect to the clien1 to her
demean or whi le doi ng the visit.
Given th ese prem ises, it now becom es importan t l'o understand the p reparati on needed
to acco m plish t'I m utu ally satisfying home visit. T he tabl e on th e next page shows n lis t
of activi ties thnt will serve as a guide in doing home visits.
305
_j
,
(Ji
0
O'I
I
ACTUAL HOME VISIT
PRCPARATORYPHASE
RtNlew record· faue~~rnH,i h\·otn~r
mernbrr, of the ht·.i!:h I Nm, CSC,
1monl~lli.. ~putum m•cro~cop,•, l"llcl.:ir~1
~rnl'ar>, clcl & rd tm.l d&~
Pn,pdre ~u1arnent ,.1up;iit~ ;;ml at:t;-ic--,•
i pet,iit forms tHer.111. i.etc)
No\1t,, cl1tflt/h rn "ly <,,I \lit , lit
lnt1ocut1: ~ell
'' c:~w~\ thr purpo,t of thE: , i~,,.
ilttiv,nc\
'
Set an appo,111rnent !d.:e ;111d
t~timJl~d dura1ro11 of thP. v,~h)
[n\Ure safot~ ll!Qui1t:mLnt~ Lr~ adequate
Complete recor<llng of data on the chart or agencyspecific form~
II th!: 1.1 the HI cont.ict with the thent/famlly, state
As)essment data and nursing diagnosis
.
mr pu:po~ec o! th: v•~Jt and a,lo~, d,ent/iamily to
Ptan of care
decide ii ·,011 ,an gc, c-n mth the v1~lt as planned or
Interventions
done
~tt anc.lhH ctn>! for tr.e appo:ntirent.
Outl0il1es of visit: respoMes, deciilons,
U:e ag~.nw-j,pe.:lhc v ,messrr<:ru tools and forms
problems, concems
ba~d 011 ~lc:.dard
Other s,gnlhu nt lnformalJon for fottow-up;
schedule of next visit
OocurT.H,t ·101:: t' ni:al 111dgment !nursing
r:i1:ieno~e.;l
De1•r:lop.-i r.ani11g c:;;rc plan w,1h client or farnllv a11d
to:ne up v,it'1 agreements on e,~cted outtome.s
Sel~n arid c;,rry out int&rvention~/acffvilies, seek
th~ por!lopanon of family ca1egNers, a5needed
Pro~ldl! brochuru, health education mate1ials and
education
it
Sumll'tame de.cis,ons made and familyresponses 10
care
S°·
Complete pr ogress notes and now sheets
g_
ij,
~
"~
POS1'VISIT
NURSINGPROCESS
Introduce st l! am; p.;rp:>sf! of the v1s1t
dowmen; the outcome or resuhs of the health
&>
I
Set the schedule of the next visit with the fam ily;
leave a note or reminder
Inform the client/famtly of referrals and need for
irste,dlsciplinary servlces communlc;at!on system
Ensure practice of safety precautions
racllit.ites referrals (to other health professionals or
agencies)
lnlt1,11e and complete discharge from nursll)g care, as
appropriate; Prepare aiummary of care given
REFERENCES
1-
Philippine Nursing Act of 1991 (R.A 7 164) a nd Im p lementing Rules
a n d Regulations ( M arch 8 , 1994). Series .No. I Professional Regulation
Commission . Hoa rd of Nursing.
2.
National O bjectives of Health 200.5-2010.(onlioe) August 23, 2008 http://
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3.
National Dem ogra phic Health Survey 2003 (online) August 23, 2008 http://
www.ce11sus.guv.ph/daLa/t1::cha otes/notendhso3.btml#sample
4.
Compiled Policies and Guidelines for Comprehensive M aternal and Child
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Hodne tt ED. Continuity of caregivers for care during pregnancy and
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Mu r ray SS and McKi nney ES (2006). Foundations of Maternal and Newborn
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Lowdermil k, DL and Perry S (2004) Maternity and Women's Care. M osby,
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Villar ,J, C,i rroli G, Khan -Neelofur D, Piaggio G, Gillmezoglu M. Patterns
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Senlr ong Sigla Supervisory Package Program Flowcharts and Checklist
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In s titute for Cli nical I mprovement Systems (lCSI). August 2007. Rou.tine
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l-10111e 13ase<l Matern al Record. Guidelines for Development , Adaptation and
Evn l11ntion (1994) Noose.r ia l Publication World Health Organization
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Stanfie ld ,Jl>, Gall D, Bracke n .PM. Single-dose antenatal tetanus
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btt-p://whqlil>d oc. wh o.in t/ hq/2007/a9 t272.pdf
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15.
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worthwhi le? la Roo ney, C. A11le natal ca,·e and maternal health: /-low
c;/)ective ts it? i \ review of cuidcnc:c. World Hea lth Ori;n nization
23. The Sc, ·ent h Re pn1·t of I he ,Joint Natio nal Com m ittee o n Prevention.
Detecth111. Gv,1 lua1ion a nti Treatment o f High Hluotl Pressure. US
Depnrt111 c nl of [·le nlth a nd 1111man Scn; ccs, Nntional J.n slitule of hcollh,
National Hea rt. Lung,ond Blood Jnstitutc, National Hig h Blood Pressure
Education Prtoiz;r:un. NII-I PublicaLion No. 0:3-5233 D ecember 2003
24. Moo rehead S , J o hnson M, Maas M , Swa nso n E. Nursing Ou tco m es
Classific.1Lion . (2008) Moshy, Tnr~
25. Bulcdwck, GJ\11 , I-Jowa1·d, U, Doch terman, ,JM (2008) Nursing Interventions
Classi fi cation. Moshy, Tn c
26. S/<111dardsfur· the Safe l'rnctice of J\lloth e 1· a11d Child Nw·sing in the;
Philippines. (::ioo1 ) . 1\l nt-ern.:11 and Chil d Nursing Associatio n of ll1e
Philippines (MCNAP).
27.
Philippi n e H <.'nlt h Statistices (:;?004) Lai;t Updnte: February 11. 2008 DOH
Ten Leading Causes of Morbidity by Se.x (2004) in h ttp://www.doh.gov.ph/
kp/ stat istiC$/ morbidity
28. http: //v,,•ww.wh o.int/ nu lrition/challenges/en/index.html
29. Black RE; Allen LH; Bhutta ZA: Caulfi eld LE: de Onis M ; Ezzati M; Mathers
C; Ri\'crn ,1; Maternal and Child Undernu t r itio n Study G ro up Ulnce t, 2008
,Ju.n 19-25; 37 1 (96()8): 243-60 (jonrnal article - re.s;c;1rch) CSSN: 0 099- 5355
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Philippine Nutrition F;:icls and f.igiures 200s. Food Nul riLion Research
Institute. Deparlment o f Science and Technology. Bicutnn, T aguig City; Juy
2007
ttp;//ww,v.who.int/making_pregnancy_safer/events/2008/mdgs/
31. hnutdtio
n .pdf
309
Chapter 12
DEMONSTRATING
INDEPENDENT NURSING
PRACTICE
Ma. BrigeN'e T . Lao-Nar io
GloboJly. countr ies Llult arc in m e mhc ri;hip with Lh e ln tcrnnt ionnl Council of Nu,rses
(JCN) a re d eveloping inn()vntive m odels: of c., re th at t h rust nurses into new r o les
a nd res p o nsibil ities. 111es e new models create changes in the b ou nda ri es o f nursi ng
practice . Mm·h in terest h a.-. been ge n e rnted in th e deve lopme nt of a dvam;c nursing
practice (A.NP) and nurse e ntrepre ne urs hip which have differen t fa ces in v(lry:ing
cou ntries de pending on the needs of the l>l!ople
rCN h as identified ch a racte ris tics of ANT' by thr ee (3) d imensio n s .name ly: e du cational
p r e parati o n. na tu re o f pr.ictice and regulatory mechanism. ANP s have advanced
level of a n educational program a nd :'.I fom1a l s ystem of lice nsu r c . regist ration a nd
certification o r credentialing (Sc hobe r and Affara 2006: 23). They :i lso d e mons trate a
h igh<' r n pgr ee of :rnto n omy a nd indepe nd e n1 pr:ictice a nd ha,·e a <lvan <'cn ;is.-;css m e nt
and decision - m aki ng s kills ,,;th recogni7.t!d adqmced dinic.11 competen c ies. Aside
from ca!<t! manage m e n t. ther also have th e a b il ity to in teg rat e resea r c h, ed uca tion and
cli nka l mana~cment, p e rfo nn case ma nagement , aJ1d provide consultant services to
othe r health pro fessio na ls a nd are recog ni 7,ed as fi rst point o f entry fo r servi ces. T here
are co u n try-speci fic regula t ions tha t g ran t a u th orities fo r ANPs th e rig ht t o pres cribe
m edic.., tio ns and trea tments and autJ1ori ty to re fer to o th e r professiona ls, ad mit lo
h os pitals a nd title p ro tection.
On the o ilier hand., we bave the nurse entrepreneurs and intr:iprcneur who have
Ll,e ability lo perform a w ide range of acth-ilies a nd services wilh foc us o n healtJ1
promotio n , diseal-<' preve ntion . re ha bilita t ion a nd m an agement co ni;:ul t an c;ics. Based
on the IC."N defini tion. a n urse inlr::ipre n eu r is "a propri e tor o f a b11s in('.'lS I hat o ffers
nursi n g se rvices o f a di rect ca re, educ.1 Lfr, nal researc h , ;idm in is l r:J Hvr· o r consu ltativc
nature" (ICN 200 4 : 4). 111 this a rr:ingem c n1 . tJ1c n u r.-c is a ccount1,1l,lc to th e clien t
to \,·h orn the services arc offe r ed . A nu rse intrapre n cu r a s IC N <l c fin es is ",J sa la ried
nurse w h o deve lo ps, pro m o te:.s a nd d c li\'Cr.. inncwa t ivc hea lth. 11urs ing programme or
projects withi n a g iven heal th care sett ing" ( JCN 2 004 : ,i) .
In m ost countries. nurses are legally pcrmit1•ed t o offer nurs ing services tlrn t faJls
,,,,ithin t h e dom a in of the nu rsi ng pr3ct,ic-e- a ct.s or nttr.;ing I.aw. They are at a liberty of
offeri n g i.ndepende nl practfre tn areas o f h ea lth promot ion, disease pre vention tm d
rehabilitation.
The ,-ision of the go" e mme nt as retleciod in th e M edium T erm Oc vc loprnent Plan o f
200 4 -2n10 is t o 11ttain .. H e:ilth for All Filipi n o~ - a nti th e mi-.s i o n i.<: t o c n ;;urc ncccss ib le
and qu al ity hcaJth care to im p rove th e qualityofli fe of a ll Filipinos es p ccialJy the poor.
(NOH 2005-2010; 35) This includes health sen·iccs t hat are resp o n s ive, access ible a n d
affordable to the peopte.
310
The Philip pine Nu rsi ng Lnw, Re public Aet 9 173, s tates that «;is ind ependent nu rs,~
prnctilioncrs, nu n;cs arc primari ly respon sible for the pro motion o r health und
preve n tion o r illness» . Also, 1h c Br) ard of Nurs ing was l-\iven the mantl..i rc l o "s upe rvise
nnd regulate t h e pra ctice of n u rsing". /\ recent clcvc lCJpmcnt i,; lhe ava ilab ili ty o f
gu ide li nes for Nu ri;i11g Srccinl ty certification brisecl on Lhe BON llesol111 ion n<J. t 4
s. 1999. This is in line with the a im or providinl-\ ;i nH!c.:lrn nism o f ensuring tha t :,
practit io ne r was a ble lo h 11fill t he requirem ents of practice. As pa r t o f lliis tm, k. Bon rel
Resolu tion No. 4 59 was promulgnlcd with ru le~ a nd regulations govern ing the practice
of nu r s ing for th eob servauce and guid,rncc of prnct itiuncn, <Jf mother and ch ild nursin g.
The document en t itl ed "Standards fo r th e Safe Pracliccof Mother Chi It.I Nursi ng in th e
Phi li ppi nc.s" inclu <lcd n section whkh makc:s the ,\'l alem.il ChilrJ Nursing Association
of Lhe Philippines (MCNAPJ lht! ,lccredil ing organiz;ilir,n for m oth er chilrJ nursing
specialty at:crcdi t,1t io11. Tl1e levels of .specia li7.ation arc as fo LJows: Generalist (level I),
Nurse Clinic ian I ( I .eve) ll), N urse Clinician 11 (Level 111 ) and Clinical Nurse Specialist
(Level rv). The requ irements for s pecialization combine educational p reparation,
work experience and passing th e s pecia lty qu a lifying examination (MCNAP 200 L
4 5). However, being just recently promulgated last October 200 1., the imple menting
guidelines a rc in th e p rocess or bei ng im p lem ented. This development is a good step
towards the establis hment of creden tiali ng for adva nce n ursing practice.
EXPERIENCES IN SETTING UP INDEPENDENT NURS IN G
PRACTICE
Nursing is com monly associated vnth practice in the hospital setting. The p ublic
hea lth nurse us u a lly comes to mind whe n we think of the role of the nurse in the
community setti ng. With the thmst of t h e government to deliver essenti al services
to th e F ilipino throu)!;hout the different phases in t he life cycle, the time is rife with
opportu nities to be p art of the providers of basic and essential health services in all
localities.
This chapter describes experien ces in d ohlg independent nursi ng practice among
presch oolers in an urban poor commun ity, provis ion of consulting services to
an education a l institution and operating a health promot ion n ursi ng cUnic in a
u n ive rs ity.
One of tJ1e key elements in establishing a practice is to determine the roles, services
and tlie work settings. The ICN guidelines point to the importance of the assessment
of the client/p o p u lation's health needs and creation of a plan that will ensure that the
proj ect o r program will be viable
METRO MANILA DEVELOPMENTAL SCREENING FOR
PRESCHOOLERS
l w o rked v.rith a non-profit organiwtion (NGO) based in 11.f a nil a. This organization
provides s ocial services among selected families living in Smokey Mountain and its
nearby com munities wi th th e core va]ues o f self-reliance, self-sufficiency, peacefulness,
j ustice and h ealthy e nvi ron me nt . The NGO has a day ca re center that also offers
preschool ed uc.i t io n at minimal cos ts t o U1e family. The cen ter provides a learning
en vironme nt that r espon d s to th e emotional, social, physical, intellectual and spiritua1
needs of childre n and to provide opportunities for parents to have a meaningfu]
participation.
Smokey M o untain now called Paradise Heights, is a densely populated community of
311
.-.l,-tU1 .1.uoo low-inco m e familie« h ouo;c-d in 28 five s torc.,y-b u ild in A c:il led Pri r n1 a n1·nt
11 ..u.,.mg. 11,r 11 vf'n1Jtc fom1ly ~iT..<' o f (, h n,; hou..~: h<>ld fi ends w o rking 11 <; :w;i v,·riw:n,,
('11lf1l< \ ' C<."" tn nr:1 rln· l-,uc:tne<."<-"- like lhc .,lnus::h tcr hou:-~· and :-ihnul a t hird n,., l111vin,i
:,n, <Hllrt'(' ,,f i.nc-o m e. On~inally n dur11 p o;ite to .ipprnxisn:ttl'ly r,n,~ th ird t1f M•!trr,
:-1aml:i w.t<:t~. lhe com munity i,; beset " ·ith ;i l01 o f ,;oc, al problem s. Chil d rt!n Art
C'"q)'1.;;•d 10 the <.'ffccts of eo n ~c,;tcd livin ~ ,poverty and lack o f npproprhJlf.: .o.;1im11 1~1tion
to fo<;l!.. r s::rowth and d.c--elopmcnL
r-:ur-ing en trepN?neu~hip io,·ohes selling of s e rvices anc.J healt l1 ca re p r0t.l u 1,;L<; nnd
utill:r.ini <tand.ard1' o f care.. ·n,e nurse e ntrep reneu r can assume t he r ol<· o f :i c linicia n,
a•aMil!f .ind con.sukant. The work setti n:g can be flexible as it c.:in b e in the o ffice or th1!
'-'--'llin~ mCJ!.t comfortable ~,; th the clicntile.
I nfft<rc<l to perform developme ntal screenin g for th e p res choole r s who n rr- ~fl ing
1n be enrolled in the :-.:Gos prog:rnm. Since J am abl e to u ti li7,e th e M e t ro M,, ni1;1
r>,-.. ,-tnpmtntal Screen ing T~<t ( ~1!-tDSll wi t h a hig.h lev el of profic ie n cy a ~ tr:iinccl hy
Lh • L'f' Crlll"Ji!~ nf :,.;,ir;in)!. this hcc.amc t h e b as is for est ab lis h in g ;i c nntrn c--1 r,f .;,.rviccs
,,ith i ii,- ••r,:;.•ni7.at1<1n. ~!:,· ~ r-'ices were diS(;uf.se<l with the fio:Hd of Oircctor!' a n d the
t,·rm, nf :izr,_.,•m !!nl ,~·er10 laid forth . Th e JC]\: g uidelines c ite th e n ec-d for r·n ntr:i r:l s o r
dltI'\.'- ln••n t <. mfJrder tu protect the nurse and th e cl ienL \Vhat w e want.-.cl l(J a ttai n was
- ~ l pn--.c_h11olt:!r.- ,H.lmit,~ \c> the sch ool will be sc:recne<l for d e-..·clorm11mta l t.lclay a nd
:ippmpriatc act1on."' ,-,-i.JJ be done to help them.· The follov.i n g s ummarizes th e r~u ll~
of I.he :i~emf.m L using tbe standards o f ca.re as a frame,,ro r k:
JJr;.,eda siatement to a ll teacher s.
~ eff Pf'eschoOIPr.. w rll be
rooms for prfvacy and
ns. !.Ch~dule of
each chlld given ao
t:estlnc
to help~
11Jt111i.011111latal lanauqe.
.,P<ollqe of
.to promote
3 .12
In th e proccs:~ ,,r ruHillfn g 1hr: 11: rm·; 1,f :ip,r,!1: rnenl , m,J m th an fsfl y (.50/ c..l1iJ,Jrrm w r;:r-e
rested w i1 h I h,: ;,1 M f.JST . It wa,; mrr,t ;,,pprr, p ri;,t<: trJ J>(:rfo rm I hr: •,<7t-1•ni n~1 in th e
communi ty b•~•~:JLJh': tlii,. will ,~n1,ure th:,1 t h•: ·,i·rvir:1 • W 'J', vi:ry :iu:1:~;ihl•:. C.'l1ildn:.-n
wen: accr,mp;rni <.:-tl t he ir parent.<, with m;,j,, nty e r,mi n~ with rh<·ir mr1th 1 :r•.. In c;;1~
when the p:,rc nt o,m e v:ith more th:m r,n1: child, ;,rran~ m•;nl<; w•:rt: ma d•: tr, make
sure that on ly th <: t esll; r , ch ild and pare nt ;:in,: in th•: r<1<,m. Th;,t arrang<:rnE:11t w;i ~ the
respom,ibili ty o f th e NGO.
To m ake s ure that tJ,c s tandard <Jftesting waP. followed, th(: , ,,..,te rs utilii•..cd the kiL,; and
forms nf MMDS-r. The s t.andard,i c,f rcrfnnmanc,.; v,ai;;Jls•J fr,JlrJwed a s stipulated in the
manual. O nly t h e test ing ma teriaJs in th<: kit wr;re u,,;cd.
Schobe r a nd /\ fa rra (2006: 7 0) cite the importanc:t of interfaci ng with the organi7.a tion
as an impo rtant s tratc,zy in m le and practice developm<:nt. In this project, th!! interface
came in th tc! form o f m eetin g with key officials in th e r,r;!pni7.?lio n a nd tc;ich-.:rs. The
sta ff of th e NGO took t he rc:.s ponsibility o f er.plaining th<: act ivities trJ the fam iii es within
tbe cat,chment area as part o f bu ildi n g accepta nce and making <;urc that the screening
,,.,;11 b e s u cc essfu l.
After th e scree ning was done, there was a training-work'ihop •;;ith lhe teachers to
give the m a feedback on how the children performed <1od how to hr.:lp children wit h
d evelopmenta l d elay.
Since t h e co mmunity is de ns ely po pulated the children's concept on certain words and
objects is bas ed o n lheir experience. Fo r cx.imple, when asked about "'·hat a · roof' is,
most child r e n respo nded by saying " rn ay gulong ang bu bong" (A roof has automob ile
tires). This stemmed from their visua l expcricnc:t~ that roofs in th e community have
auto ti r es as lnads to prevent them from bci.ng carried away by the s tro ng \•,ind. Their
concept o f a 'rive, ~ is "pu no ng t ae at basura" ( a river is ;i du m p ing site garbage and
huma n feces). This is du e to their experience of seeing the nea rby body o f water full of
garbage and huma n excreta, Their co ncept of a 'e11 rta in" i-.; 'pin w ng ha hay- (A curta in
is used a d oor o f t h e house). This concept e ma na tes fro m the experie nce o f having the
curtain as a 'd ivider' in lhe house which they usually s hare with ull1er fami l.il:!S. This
sessio n with the teache rs helped in creating learnin g experiences th at foste r growth
a nd deve lopment.
Eve ntua lly, selected s taff from the orgnn i7..ation ,,;ere trained by
tJ1c U P College of Nursing to perform the devel opmental sc ree ning to boost the NGOs
seJf-r efomcc.
PROVIDING CONSULT ING SERVICES
One of t h e avenues for n ursing practice is· to p rovide consulting services. The
ICN guid e lines identify some personal qu alities of a nurse entrepreneur as follows:
indepe ndent, risk-taker, visionary, good org:mizer, planner a nd proactive. This must
also b e couple d with adequate professional expe rience, compe tence and knowledge.
(ICN 2004: 2 4).
WitJ1 a comprehe ns ive e..xperieoce and backgrou nd in developing. implemen ting
a nd evaluatin g c urriculum using a com pete ncy-based framework. a proposa l was
s ubm itt e d t o o tech n icol h etil th school to strengthen the existing program and improve
structures in t he company for cost effec tiveness a nd e ffici ency. Part of the p rogram is
doing a pe1·forrmmce audit lo ·find areas of strength and weakn esses. TI1is was done in
partnership with ::t nurse who had extens ive experience in nu rsing administration.
Before any o f the activities started, the tenns of agreem ent were laid down together
with the cost, du.ration, expectations of the service. Meetings were held to fi na lize the
313
(manaaement and service delivery)
ney of Its operations.
Of-,q\lllltyendlh~ Orpnlration B's t o re values.
l'i'IINltors aforaanlatlon 8
lnll'l'"il'll'S with k1'Y I' 1'1~ 11\llll'l am\ l llp onidnh: Wl'l't• d!>llt' with l h,· l'I Il l ,·iew 11r k11owi 11~
ll(m' th,' C\l');:mi nllio11 ,11wrn1t·:: in tlw <litii.·n•nl hrn nl' hv,: :1ml wil liin lh,· 1,r~;111 izal io11
:111d 1111its (,•.i:. al':11l,·mi,· ,:,,,·11,111. m\111i11i,:trntiw. 111nrkl'li11g) 1111.I h:n·inh :1 gl imp,:(• n(
llw o~m1 i'tnti111111l n 1lt111,· nnd km!t-r::h ip ~h-ki<. ~tml,•nt s ,,·,•re :ilst> i111<'1Tit•\\'t'd on
wlrnt th,·y lik,•11 1111•,;I and l,·a~ t 11ith tlw t•ri::111i1.111io11 and their h•,·,•\ nf ,:a ti,:f:H'tion
with th,• l' t\')!111111. \\',• :1l;;11 n·Yi1•wt•d d<'1·11111t•111::, rt't'onl,:; ,md rt·p,,rt,: - pnilik nf th e
f:wnhy, ,·111,,lh1\\•11t :md )\n11l 11:lli1ll\ l\)\tm•,:, ,·orri1' 11l11111/ 11111d11k-::. fi11 1111dal ,;lat,•111,•nt::
11ml m,'111nn1ml:1. l1:1dlitit',: w,•r.• dnJ,•k,•d 1111d nbl'ern•(l. ,\divitie:: of the ,• mpl oyccs
\\"\'t\' nls,i nh.,,'l'\'l'cl in rdt1tiClt\ to lht' 1't11'1' \':lh1t'!: ot' llw orp.:rn izalion :mt! th,• pt'o~rn111
of m:th)11.
Tlurill!! th,• int pk11w11tu tio11 )'\'(ll'<'$!', tl\i'1·..- Wt'rt• mcl'lin~s with lhli lwml 1it· lho
c>t~nnin1ti,,n In rnlidnt,• i111111'(•::si1>11$ nml :ah11n.• ,·ritknl obsc r \'nlinns l hn t ll!'l'dl'd In
1,., !\iwn 11111•1Hio11. :\t th,• t'ml ,1f th,' 1111di1, llu' p ktm·c c m c rgcd n11d 1wrfor111a11cc
imlil'nlMs ,,,..,.,. i,_k11ti li,,,I lO!\<'tht•r with key q11nlily mcmmrcs. :\ wrillt.:11 report wn~
i:.in•n tn)tcthcr ,dth a nll'din~ with thl;) h,•ml of the orp.nniznlion.
Afkr the n.':mll s w,•r,• ,-ubmill,'tl. on e of thl! nrc1t!' thnt nccdcll strenp.Lhcninp. were
c11rric11lill' in ur1t111'\'. A 1~om1l<!t<'ncy-hn:-,•d henlth ca re wc,rkc r pre>grnm n nd 111tm1111l
", ,~ d.-,....•lnp,"<1 wi1 h n t'flrrespond inlt tr:iini np. prop.mm for lhc faculty.
"~•=-
Tl11• 11111111ml
,•11,·i:<ione<I :1~ lw inR the wmp1111y blncprint thnl enshrines the core
vnh1,•:< nml :it 1h,• ~a nw tinw ful!illing t h,~ l'<'<Jllirem enls of the p.ovcrnmcnt. It was
C't>m pr..•lu.•nsil·,· :111,l ,·n111i1ilwd 1111 lht• ,·nmpl'lL'lll°il's. conte nt. a nd 1h0 c1·al11al'io n tools.
Th e 1m11m:1! b ~1,111,•lhi11)\ "t:()1\$1:tu l°' ti~ ll'adll'r!< n 11.11c a nd go wi thin the orgnnizntion.
It ,,ill b,• tlw n•~1mn-,· of th<' 1•11::mization to be s ure th:11 the comJ>ctcncies in the
difforini: S<'l.'ti,,11~ nnd t,,,,,,[,- ,1re com:i;:tcnt.
After tlw con~truct i,,n llf th e mnnnal. train ing o f lcachc1-s wns don e with lite use of th e
11mm111l. 0 11 the ne•. _ l pa.ge is n pnrtion oft he progTUm for the trai n ing:
314
TEACHER TRAINING COURSE
course D escri ption: This Is a twelve-hour course for teachers of a techntcal school to
nhan ce teachin g com petencies. It wlll IntlLide theoretlcal Inputs on t h e co mpetencv
:ased framework and t eachl ng-learnlng exercises.
..-ed compet encies:
f,c,,---
Glvefl q uestions:
1 explains the features of a competency based curriculum
2: Discusses the compariy's phtlosophy and framework for health care
Given hvpod,etical sjtuation/si,
1 . tdentifies the appropriate teaching-learning activities
2. oemon str ates the proper use of teaching met:hodotoates
3, constr ucts test Items
4. Formulates a performan ce evaluation toot
progra m:
Time
Topic - -- - - - - - -- - -- -- - -- - -- - - - - - - - - - .
7:30 a m
1-2
Registration/Opening ceremony
Teaching M et hodolostes
8;00-8:30
Company's philosophy and
fram ework for health care
2:00-3:00
Practice session on t eaGhlng
methodologies
8 :30-9:00
Competency based framework for
healt h core: utfllzlngthe manual
3-4
Evaluation of Stud ent leamlns
4 -5
9 :00-10
Practta!' s_essloTl on Constr uction
Designing & Implementing the
Instructional Plan
of Test Items
10100-10:30
Break
Presentation
10:30-11:30
W orkshop: Designing and
Impleme nting the lnstruotlo«111l.,._n
Performance Ev1lu1tton
S-5;10
5:ICJ..6
11!30-1 2
Present ation
&-?
P.racttt:e 5esslbn: developlna
~fOfmanCII evaluatton tools
1.2-1
Lunch Br eak
315
The shared experience of pro1-iding consulting services dcmonstratec] the Poss ii ·u .
that are open lo a nurse who has the preparal'ion, t:xperience and tl1e attitude to Ji hes
•u
.
..
explor
a d111erent avenue on independen t nursmg practice.
·
e
THE HEALTH PROMOTION NURSING CLINIC
The Department of Health has recently launched lbeir program on the Prom .
of Healthy Lifestyle. This includes risk as~essmcnt on hypertension, alcohol afhon
physica I inactivity, smoking and family history of <l i seas es (for a sa m pie tool, sec Ch Jtise,
~• Table 2 .1 on Assessment Database for Family ~~irsing Practice)._The intcrven~fote~
mclude th e promotion and reinforcement of pos1t!ve ~ealt~ _practices. Counseli ~s
also provided for clients al-risk of the obesity, physical mac Liv1 ly, smoking and .,1 •s
abuse. 111ese clients a re also referred to the pl1ysician, as needed.
' co 10 1
"1
Jn ,January 2000, U1e Health Promotion Nursing Clinic based in the Univers·
the PhiJippines Ma nila College of Nu rsing formally accepted clie nts with con~ty of
such as nutrition, health maintenance, mobility and sleep patterns. There ,~rns
!WO p,~actitioners, a_ faculty member a~d- :-in apprentice ra~ua~e studenr doing•~;~
intensive field experience. !twas an exc111ng prosped because Lh1s was an opportu .
to demonstrate imlepem.lenl 11urs iJ1g practice. On lhe basis of pre-form ulated prc1c~!ty
guidelines, general estimates on consultation fees and confidence on its success t~e
clinic formally opened to the public. It would later offer regu lar service to clie tJe
seeking assistance i11 making lifestyle changes
ns
7
There are many ways of maki?g sure ~hat nur~in~ care is delivcr~d with high level
of competence. The firnt requirement 1s establishmg the legal basis for the practice
This makes $Urc that the nurses who deliver the care have advanced cornpelencie~
and capability for decision-maki ng. Recen t development in t he Philippines is
U1e move towards credentialing. The Maternal Child Nursing Association of the
Philippines (MCNAP) will serve .as the accrediting orgaufaation for mother child
nursing practitioners. The levels of specialization ,tre as follows: Generalist (level l)
Nurse Cli n ician I (Level TT), Nurse Clinician JI (Level HI) a nd ClinicaJ Nu rse Specialist .
(Level TV). The requirements for specialization combine ed ucational preparation
wor k experience am.I µ.issing the specialty qualifyi ng examination (MCNAP zoot;
45). Promulgated Inst October 20.01 , this development is a good sLep towards the
establishment of credential ing for advance nursing practice. Credentialing is always
linked to a country's resources and regul atory practices. rt can be done by licensure,
certi.f ication, registration, and recognition (Schober and Affara 2006: 89).
Another way of ensuring quality care is the development or utilization of standards of
care. J ohns (2004: 228) defines a standard of care as a local practice situation that is
professionally agreed and both desira ble and achievable. For the nu rsing clink, it was
don e in the form of the following concerns:
• Defining the type of nursing services to be provided
•
Listing the cri teria for admission, enrollment, discharge from tl1e
program or services
• Delineati.ng the ai:eas of responsibilities; functions of t he h ealth team
members
• Establishing a system of documentation
• Setting up a system of reimbursement, payment
• Mrs Feda Llon·to lsaloc was a former faculty men,l,,,r of the. Notre Dome U11iuersity, College of Nursing
and a graduate srvdcnr ofclw M.A. Nursing ofUPCN.
316
An co.n crete exa mple of s tandards uf ca rt! is t he American Nurses Association (ANA)
Standards of Clinical Nurs ing Practice (2004) which lists fiftee n (15) s tandards of
professional performance \vi-th appropriate m easu remen t criteria.
The use guidelines is also beneficiaJ . For example, the.Philippine Guidelines for Periodic
E.xamination (2004) provide fo r e ffccli ve screening for diseases among a pparently
healthy Filipinos . Guidelines provide flexible rc:commendations that can be adapted to
sped fie n eeds. Tbis reference is a useful tool for nurses in making decisions as to what
tests clients need lo have.
Another vita l need in indepenc.lenl pract ice is the u~e of accurate and concise
documentatio n. l f sometl1ing was not docume nted, from a legal pers pective, no nursi ng
care was done. To cite, a you ng pregnan t wo1m111 was discussi ng with the nurse her
concern for h er hack s tool. 'f11e nurse replied" Did you remem ber ou r discussion about
the effects of iron supplementa tion~ The client co uld not remember it, ln lerestingly,
there was n o docume ntation of 1hat encounter. II Is imp<>rtanl to have ent ries like
"client verba lized understa nding on the effocts of iron supplcme nlal ion on the color of
stools". In the principle of doc umentation, it is alwa~·s good practice to document as
much as poss ible nnd reflect importa nt clinical information . In count ries where health
services payment is done tl1rough i nsurance reimbu rsements, a comprehensive system
of documentation is part of regulatory requirem ents.
In the nursing cli nic of UPCN, clients coming in with nutritional concerns ,vill:
□
Be assessed using the appropriate anthropometric measmements like
triceps skinfold thickness, weigh t and height, body mass index (DMD, waist
circu mference (WC), hip circumference (HC); 2-4 hour dietary recall for at
least one regular d ay and one weekend
□
Have a d ietaiy and body composition analysis
□
Participate in meal planning to ensure that it -is p atterned to personal needs
and based on the Filipino Pyramid food Guide and Recommended Energy and
Nutritional I ntake (REN!)
□
Be given pointers on therapeutic diets wi th emphasis on what can be eaten and
what needs to be avoided
D
Upon detection of risk conditions and medical problems, will be referred to
the doctor
□
Be n;ionitorcd on their p'rogress
This nursing guideline helped in ensuring adequate care was provided
for clients with problems of Allered Nutrition. Experience showed
that the development of guidelines for pmetice is an ongoing process.
A quali1.)' circle among UP College of Nursi ng faculty was held to
discuss the case of nvo clients ,~ith Alte,-ed NutritiorL· mo,·e than body
re.qu iremcmts who sought c-t1 re in the nursing clinic. Th is became an
opportunity for colleagues to look into how the nursing assessment
and care was delivered by the clinic practitioners. It became a chance
t o d.iscuss the use of waist to hips ratio (WC/HC in cm) as a national
standard to determine android or central obesity (2:, 1.0 for males a.n d
~ 0 .85 for females), proper w:iy to take waist circumference (WC) and
317
the value of using the BMJ in nutritional assessment. It was also a
chance to review· the Nutritional Guidelines for Filipinos 2000 a nd the
Filipino Pyramid Food Guide for Today"s Lifestyle. In this case, it was
clear that the guidelines provided a mechanism for ensuring th;it the
nurse deliver will deliver care that is evidence-based.
In general, the nursing practice guidelines included basic components like:
a What data is essential to assess the client's condition? How should the
assessment be done
o What are the intervention options: independent, dependent and collaborative
interventions?
a
What are the signs and i"ndicators that the client needs refcrrnl to a doctor/
other health profcssionaJs?
a
What are the signs lliat the client is/not making a progress?
There was a need to determine the nature of assessment data in the
consultation. It was a question of doing a comprehensive physical
assessment and rmrsing history or making a focused assessment. TI1e
two approaches have their own merits..
This was a dilemma tha t we opted to solve on fill experiential basis.
Taking a comprehensive assessment has ils merits. However, it
lengthened the consultation time conside rably. Some clients, too,
did no t want to discuss m atters th at are perceived as unrelated to the
cause for visit. lil t he end, the amou nt of data in assessment was based
on the client's condition and the judgment of the nurse ha ndling the
consultation. The key was to be balanced in assessment, being focused
on the client's concern and at the same time looking at the holistic
aspect of heal th.
COMMONLY USED NURSING DIAGNOSES
In the course of practice, certain nursing diagnoses emerged as the more frequently
encountered ones in the clinic:
NU
U9ED IN
~
~
COMMONLY
Ol'ION NURSING CLINIC
Impaired health maintenance
F.a.ch client is unique and all encou nters provide exciting challenges for the nurse in
determining assessment parameters and what to do in the domain of independent
nursing practire. There were challenging situations like the one narrated below:
The clients were three middle-aged women whose cause for consultation was
the •feeling of imbalance." They shared the following information:
318
-
''l"la la akong lakas. Para nkon.g nm m pos" (I lnck energy)
~Parang Ttindi ako makapag-isip . Laying nawaumla sa sarili" (l
cannot think clearly. I feel that J am nol myself)
··par-ang may liangin sa aki11g ka tawan " UMC1 i11il ang pakiramdam
ko pero wa/a akong lagnat" (I feel lhat there is 'air· inside my body. I
feel warm b ut I am no t s ick)
Phys ical assessm ent revealed no m edica l problems. No
one m an ifested a n y palhophysiologic co nditiuns, trcalmcnl related
problem~ (ex. immobi lity, pcrioperntivc c.xperi cnce, labor and
delivery) and ma turutiona l fac tors. T hey Wt:!n: all working and c:apahlc
of doi ng their regul ar ac tiviti es and 1rc::portcd no strain in Lbcir fomi ly
a nd pe rs on nl relations hips . All o f them have a low level of work-related
stress.
Eventually, the d iagnosis of Eruirgy Fidel Disturbance was used . Carpenito (2002:
348) calls it ll s t ate of d is ruption of t he flow ore nergy su1Toundi ng a person's being th nl
results in a disharmony o f the body, mind and spiri t. $ini;e the pract itiom:rs were also
tra ined in Reiki (a type of lo ucl1 Lherapy lhal uses sc:nnni ng of the energy fieltl~). Lhe
perceive<l c h,mg\1S in energy flow (sensed as hot, culd) pruvidccl add it ion.11 dat i1 for the
assessm ent. Th is is a particular situa tion where the re was a need to ex pa11d ;1ware ness
on the d iffering viewpoi nts on he human hody . Cnnvcnlional p;1radig rns wo uld refer to
the p hysicaJ body as the basis for assess mc nl. In other tradi ti o ns of healing, th e body is
composed of the physical and the n o n-physical laye rs (also c;JIJed the ;mric fields). The
distortions in the non-p hys ical J.wer can be dc tcc.:ted by a n expe ri enced practitioner
as areas of "hot, cold, tingling". Carpen ito (2002: 349) describes the management of
clients wit h this type of distu rbance by usi ng therapeutic touch.
The nursing-clinic based practice also provided e~-periences oo the use of wellness
diagnoses. A wellness diagnosis is very usefu l fo r healt hy clients who require teachin.g
for health pro m otion and disease preveotion and personal growth (1.Vilkinso n, 2007:
232). lt is commonly stated as "Readine:;s fo r Enhanced, Potential for Enhanced, or
Potential for Growth or Effective Some wellness diagnosis used in the clinic were:
□ Poten tial for Enhanced Pareoting
ft
•
□
E ffective Breastfeedin g
□
Effective Health Management/ Health .Maintenance Pattern
a
H ealth-Seeking ·Beh avior
Consider the case b elow as an example of a client w:itb a wellness diagnosis:
Client A, 35 years old visits the clinic. Assessment reveals no problems. She
verbalizes the desire to have an exercise regimen a o<l a h ealth.ier diet. She
said, "g usto ko na manatiling malusog at malakas (I want to be hea lthy an d
strong)" N utri tional assessment reveals normal findings. There were no signs
and symptoms of problems nor risk factors to her health.
Sioce she needed help in establishing an exercise routine, she was assessed
on readiness for physical fitness acti vity using the Physical Activity Readiness
3 19
---
Q11t.'!<ti1m nt1iN'. PAR Q. ·n1is wr1s d .:,·cfopcd by British Columbia Ministry of
H..-alth tll lk lt>m1in<' a l"'Crson 's n.•ndincss for participntion in a progrmn for
~,,,rcb<'. (Cnrbin '..!lH>O: 46) The nsc of vnrious p hysic.11 fitness tests and
sllmts: r.1rcii1,,·nsrnh1r fitn.-s.-.. fle.,ibil ity, muscular enduran ce, strength,
n.5ility. b:ilan<·c co<1nHn:ition. po" ·er. reaction time and speed also helped in
appn1i,-ing Raqn<'rs st-.11m:.
The w~llness di:l!:nosis that was Ul't.>d fo r Rnq uel was E_{fectiue Health
.\!aiJ11r1m111't' aJl(f ;\fu11ag.-111ent.
ESTABLISHING TH E OUTCOMES OF CARE
'Kllo"-ing the exJX.--cted outcomes of care is critical in independ ent n ursing practice.
This 1,iU make the al:tlinmcnt of goals clear and precise. 'Wben botb the n urse and
client are aware of what needs 10 change. t he expectations become c.lear . The in puts
from other health profesfilonals can be identified.
Consider this client :
Client Bis a 16-year-oldadolescent \\ith obesity a nd hyperglycemia. She is using
insulin and oral hypoglycemics nod verbalizes great d ifficulty i n mai n ta ining
the dfobetic diet and exercise. The mother e.,-pressed her great co ncern for tbe
daughter's oon-compliance. Aft.er the assessment, the nurs e and the client
agreed on these e.,-pected outcomes of Deza:
o
o
lose 1 kg of body weight for the first week
maintain CBG within the normal range
The:e outcomes im·oked acfo,ities that both nurse and the client listed. Monitori ng of
dafly blood gluco..~ level9 ,,,;n be d one and communicated to the nu rse by ph one caJls.
Weighing \1il] be done at the end of the week. There was a need to work closely with her
phys ician to adjust the ins ulin dose, as needed:
't\1hen the outcomes are dear, the nurse will have an estimate of the number of visits
required and the type of monitoring that is needed. Having clear outcomes of care also
makes reimbursement and pa}ment for services easier.
THE N URSING CONSULTATION AND ITS COMPONENTS
The challeoge of independent p ractice is learning the boundaries of nu rsing p ractice.
1bis is based on the legal expectati,Jn among nu rses to develop a plan of care to anain
expected outcome$. Titese expectations are enshrined in the professional standards of
care.
Independent practice enha nces awa reness o f interventions that are independent.
·.rnese .:.re actions smd acthitie.s t hnt a nvrsc L.; licensed l'o prescribe, perform and
deJ1:g;ile ba:.w 1111 knowl:::dgu and :-..kilb. Dependent interventi ons are those p rescribed
hy !he p hrsic-ian and carried out by the nurse. Cofiaborative interventions, also called
intl!rdependcmt, arc carri"d oui "itl1 other members of the health te am. Iney may
include cormlirw tiun of health ca re: scndccs.
320
Jn II clinic-bosed prnctice, the client seeks the services of the nurse for various reasons.
This is a list of the clients' most common causes for consultation:
a
problems on comfo rt: ''mnsakit ang aking likod, balikat, kamay, buong
katmvan. paa. talompak011 {body aches and pains)." [n a Touch Therapy
Cli nic held at the UP College of Nursing in .October 2001 1 there were ninetyone (91) clien ts who came for consultation. Fifty percent reported body pain
(sh oulder, upper and lower back).
a
problems on body composition: "gustong lumiit ang tiya11r, dmataba ako~.
"gusto kong pumayat", "gusto knng twnaba"
□
Perceived high levels of stress: "p1Jno ako ng l'ensiyon", 'hindi na ako
nakakapag-isip ng k/ar·o•·, Jbabagsak ako sa aking kurso", "magulo ang
a king isipr. unawawala aka SQ sarili''
a
Menstrual concerns; "hiridi ako nir-cregla r, "'masakit kapag may reg/a aka~
□
High blood pressure. About 30% of dients who came for the Touch Th erapy
Clinic were diagnosed as having elevated blood pressure readings or reported
being dia,gnosed hy a doctor as having hypertension.
Initially, there was a hypothetical estimate on the duration of a nursing consultation. A
practical measure was to record the du ration of consultations. It became evident that
the time ranged from thirty (30) minu'tes to one (1) hour. This estimate ensured that
the consultation is a focused interaction. Nursing deals with human responses and
there is a need to spend enough time \dth a client while being aware of time constraint.
Also, as a clinic practitioner, becoming aware o[ the time factor is a practical concern
since th-ere are also other clients waiting for their turn.
Establishment of rapport was a very essential step. It was done by greeting the client
with a smile. introducing t he practitioner's name and asking the client what name and
form of address they preferred to be calJed. The preferred name was included in the
client record to re mind the nurse in futllre transactions. Tbev were also asked to fill out
the forms with basic identifying information.
,
Another important component of a nursing consu ltation was the
Mcreation of a liealing space." TI1is is a practice from the teachings
of a spiril-ual leade r and shamanic healer, Gurudevi Ahalya Running
Deer Mahakali •~ who made sure that clients und ergoing ex"t.raction
healing were in a heali ng space. lo the nurs ing cUnic, this was done
in various ways. Clients are asked to sit comfortably. remove shoes
and wear comfortable slippers to hel p release tension. Bags, books,
cellular phones, pagers and other belongings are set aside temporarily.
Relaxing essential oils Like chamomile and lavender we.re also used
in burners t o help create a healing atmosphere. The c:lients' rem arks
that the consultation caused t hem to rest, relaxed and be focused on
t heir goal for the ,isit validated the value of ~creating a healing space.
n When the client is comfortable, it was easier to talk abo ut the cause
for the visit nnd do the interventions.
] • G urudevi Ahnlyn Running Deer Mahakali is a spiritual teacher and shamanic healer
of the 1-lari Om Tat Sat Henn it.age (visit www.hQtshrcmilagc.arg)
321
.Marn , a 42 year old, single client co nsulted clue to 11 '1>a i1!ft1l se11satio11
011 the rigllt breast wrd because th ree relatives haue already ,lied of
cancer." The !>Elin was dull, on and off and with an intens ity of 2 to
. 3 out of 10 on a pain scale. Since Mnnt w:1s vc1y com fo rtable while
discussing her conccr·n, it was also easy to explai n the apprnpriatc
period in doing breusl e.xnmination. She was pr operly draped and
positioned on the examining table. Palpation was done and n o masses
wece noted. She was also taught to do palpation and hQw to ensure
that the appropriate areas were covered .
The nursing cons ultation also made us.reali7£ that clients nre used t o having "something
to bring" after a consultation. This, we l1ypothesized, was a product of a long history
of consulting with the doctor where one brings home a medicine prescrip tion written
on a piece of paper. To address th is concern, nursing prescriptions were written. This
includes reminders, pointers for care and instructions that they need to can-y out as
part of the interventions. The schedule of the ne::-.1: visit was also written down.
As appropriate, client!; were made to experience interventions on a s ensory level
th.rough verbal instructions, aromatherapy, massage, and Reik.i. This worked well for
clients e.'\-periencing various types of problems.
Counseling and sound healing through the use of audio tape recordings were most
useful for those having difficulty in making decisions. These interventions helped
create a state of relaxation which tl1e clients thoroughly enjoyed. T he experience of
relaxation was what they eventually decided to 're-create' on their O\'l'Tl . These sessions
also helped them ach.ieve a state of mind that is devoid of too many tho1)ghts. rt gave
them clarity on decisions that they needed to make. Students would often flock t o the
clinic for so,und healing sessions before taking their examinations.
At the end of the consultation, the practitioner needs to have a review of the plan of
action and agreements on man agement. This gives the client a nm through on what
transpired and prepares for the closure of the visit. A subsequent visit is also p lanned
and its purpose identified.
rt is also very important to record the care given. The client's feedback on the treatment
and care is documented. Proper d ocumentation makes the nurse aware on the progress
of the client and serves as a refer ence for a next visit.
CHARGING CLIENTS A NURSING PROFESSIONAL FEE
Since nursing pi:actice in the countcy is in settings where the nurse works in an
institution for a salary, there was an initial apprehens ion on how to deal ,vi.th clients
who will self-pay for nursing services
A review of literature was done to look into the costs of nursing services in indepen dent
pra.ctice. There was not much information to serve as basis for local costing. Most
countries ha\fog independen t nurse pra<.1.itioners charge the cost o f se1vices through
the national health insurance. This is based on their inclus ion as legitimate providers
of care in the health system and the e.icistence of prnvisions in the ins urance system
that covers their services as part of health care. This was not the case in our cow1try.
The experience of holding a nursing consultation for a fee was something new. Some
viewpoints on this are: people cannot afford to pay services because of the severe
economic situation ; nursing must be done as a service to humanity and must be given
322
freely nnd withou t n cost; nurse practitioner's lnck of readiness to charge a foe; setting
a sliding scale of fees to accommodate the client's capacity to pAy; setting a s tandal'd
fee for some treatments.
The ICN guidelines for ntLrse entrepreneurs encourages actjve participation in the
developme11t of equitable fees for service. The suggested criteria for calculating fees
include: {ICN: 20)
complexity of the task
tbe professional responsibility implied
levelof expc1tise required
time involved
equipment needed
Since the clinic operation was done to demonstrate independent practice, the following
principles served as bas is for professional fees:
There v,,;11 be a standard fee for treatment and follow up consultation (cHent
will b e charged less if th e visit was for monitoring or progress check)
l11e cost of the fee will be openly discussed with the client to give t]1em the
opporlunil-y to make a decision.
No clien t will be deprived of nursing service because of lack of monetary
capability
a
a
a
The experie nce of eKplaini.ng the professional fees was very enlightening. Clients showed
willingness to pay the nursing professional fees. Many would explain that paying a
standard fee for the nursing consultation and treatment makes a good closure for the
transactio n and helps prepare for their next visit The professional fee was commonly
paid after the consultation.
MARKETING THE SERVICES OF THE NURSING CLINIC
Marketing of the services is needed for the viability of the venture. It was done to make
sure that a segment of the population knows about the services. The flyers contained
the nature of lhe services offered, schedule, location of the c;; linic, practi~ioner!;i ~nd the
contact number. They proved to be very helpful. Clients would usually come bringing
the said information material. Allother method that was used was holwng short talks in
the various offices of the 1miversity about the nursing clinic. The talks commonly 1asted
for fifteen minutes and consisted of the giving out of flyers, explanation of services and
an open forum. Common questions include:
Wbat are the services?
a What is the du.ration of a consultation?
a Wbat are tl1en credentials of the practitioner?
a What are the problems that they can c,onsult with the nurse?
a How much does a consultation or treatment cost?
O
One of the best ways in attracting clients were referrals from satisfied friends or
relatives. For the Westhaven Nursing Clinic in the USA, the strategies included doorto-door flyers that listed the clinics services, open houses, mass screenings and home
visits done by students (Heh,;e 1998, p. 387)
ESTABLISHING LINKAGES AND A REFERRAL SYSTEM
The cycle of care will not be complete without the setting up of appropriate linkages.
·323
In managing the client's condition, they would often request for information on the
medical practitioners whom they need to visit. Conversely, when form aJ linkage is
established, referrals from med.ical practitioners will also come in . Helvie (1998: 397)
re.port that they collaborated with other agencies and health providers. The agenci es
and providers were those being u~ed by the clients. The nursing cli nic, with the clients'
consent contacted these pro,; ders with a n offer to work together in serving the patient.
In the end this resulted in referrals from s uch providers a nd increased credibility \\ith
the clients
In the Philippines, establishing linkages include makin_g a presentation o f the services
being offered a ud a discussion oftl1e fees for nursing services. Since ·the clien ts shoulder
much of health care, doctors olso find it important to have an idea on the type and cost
of n ursing senices. This also :helps them explain to their what th e nurse has to offer.
It was a good practice to leave broclmres of the nursing services to the h ealth provider
with whom linkages are established. The brochure include the type o f service offered,
schedule, location of the clinic and in most cases, the name of the person to be
contacted.
In mak; ng referrals, it is very jmportant to have a refen-al form tl1at has data useftil
for the nurse a nd the referring health care provider . This works in bolh ways. The
nurse knows what sen1ice she will provide and the doctor will have information o n
wby the nurse made the referral.
·
REFERENCES
L
Carpenito LJ. (2002) Nursing Diagnosis. Application to Clinical Practice (9tl1
edition). Philadelphia: Lippincott.
2.
Guidelines on the Nurse Entre/Intrapreneur Providing Nursing Ser vices. (2004 )
International Council of Nurses. Geneva, SY..itzerlaud, pp 1-35.
3. Heh~e, C. (1998). Advanced Practice ofNursing in the Communit!J. Thousand
Oaks, California: Sage Publication.
4. J ohns, C. (2004). Becoming a Reflective Practitioner.l31ackwe11 Publishing Ltd.
5. National Objectives for Health Philipplnes 2005-2010. Department of H ealth.
Republic of the Philippines.
I
l
6.
'
l
Philippine Guidelines on Periodic Health Examination (PHEX) Effective
Screening for Diseases among Apparently H ealthy Filipinos. (2004) . The
Publications Program. IPPAO. University of the Phmppines Man ila.
l
I
l
7. Philippine N'ursing Act of 1991 (R .A. 7164) and Implementing Rules and
Regulations. (March 8, 1994). Series No. 1 . Professional Regulation Commission.
Board of Nursing.
8. Standards far the Safe Practice of Mother and Child Nursing in the Philippines.
(October 2001) Maternal and Child Nursing Association of the Philippines
(MCNAP).
9, American Nurses Association. (2004). Nursing: Scope and Standards of Practice,
3"' ed. 2004. American Nurses Publishing. Ameri can Nu rses Association, 600
Maryland Ave. SW, Suite 100W, Washington, DC.
324
C
scbober, M a nd Affara , F._ ( 2 006). Advanc,ed Nursi ng Practice. Blacl-.-well
10• publishing, Ltd. International Council of Nurses.
11-
Wilkinson J . (2007). Nur~ing P~·ocess and Critical Thinking (4th edition). Upper
Saddle River, N ew J ersey: Prentice Hall, lnc.
,z. INTERNET SOURCE http://srdkoninpl1iL blogspot.
325
In managing the client's condition, they would often request for information 011 lhe
medical practitioners whom they need to visi t. Conversely, when formal linkage is
establisbed, referrals from medical practitioners will also come in. Hel vie (1998: 397)
report that they collaboraled 1v:ith other agencies and health providers. The agencies
and providers were those being used hy the clients. The nursi ng clinic, with the clients'
consent contacted these providers with an offer to work together in serving the patient.
In the end this resulted in referrals from such providers and increased credibility with
the clients
In the Philippines, establishing linkages include making a presentation of the services
being offered and a discussion ofthe fees for nursing se rvices. Since the clients shoulder
mucb of health care, doctors also find it important to have an idea on the type an d cost
of nursing services. Tbis also helps them explain to their what the nurse has to offer.
It was a good pract.ice to leave brochures of the nursing services to the hea lth provider
with whom linkages are established. The brochure include the type o f service offered,
schedule, location of tbe clinic and in most cases, the name of the person to be
contacted.
In making referrals, it is very important t o have a referral form that has data useful
for the nurse and the referring healtb care provider. This works in both ways. The
nurse knows what sen-ice she wiD provide and t11e doctor \1.-ill have information on
why the nurse made the referral.
·
REFERENCES
1.
Carpenito LJ. (2002)Nursing Diagnosis.Application to Clinical Practice (9th
edition). Philadelphia : Lippincott.
2.
Guidelines on the Nurse Entre/lntrapreneur Providing Nursing Services. (2004)
International Council of Nurses. Geneva, Switzerland, pp 1-35.
3. Helvie, C. (1998) .Advanced Practice ofNursing in the Community. Thousand
Oaks, California: Sage Publication.
4.
Johns, C. (2004). Becoming a Reflective Practitioner.Blackwell Publishing Ltd.
5.
National Objectives for Healtb Philippi.oes 2005-2010. Department of Health.
Republic of the Pbilippines.
6. Philippine Guidelines on Periodic Health Examination (PHEX) Effective
Screening for Diseases among Apparently Healthy Filipinos. (2004). The
Publications Program. fPPAO. University of the Philippines Manila.
7. Philippine Nursing Act of 1991 (RA. 7164) and {mplementing Rul~ ?nd
Regulations. (March 8, 1994). Series No. 1. Professional Regulation Comnussion.
Board of Nursing.
8 . Standards for the Safe Practice ofMother and Child Nursing in the Philippi~es.
(October 2001) Maternal and Child Nursing Association of the Philipprnes
(MCNAP).
9. American Nurses Association. (2004). Nrrrsing: Scope and Standards of Practice,
3ni ed. 2004. American Nurses Publishing. American Nurses Association, 600
Maryland Ave. SW, Suite 100W,Washington, DC.
324
tO·
11.
J2·
Schober, M andAffara, F._ ( 2 0 06) . A~vanced Nursing Practice. Blackwell
publishing, Ltd. International Council ofiNurses.
w·iJcinson
J . (2007). Nursing Process and Critical Thinking (4th edition). Upper
1
ddle
River,
New Jersey: Prentice Hall, Inc.
Sa
u,rrERNET SOURCE http://srdkoninphil.blogspot.
325
I
,-d
Chapter 13
ENHANCING
COMPETENCIES ON
NUTRITION FOR
WELLNESS
Lucila B. Rabuco
INTRODUCTION
Over the years, there have been significant changes in d ietary patterns of individuals
i;rnd pop\tlations. These chMges are brought about by advances in food tech nologies,
including improvements in prescrvntion, storage, transport and distribution. Changes
in social values, attitudes and lifestyles have also influenced patro nage of convenience
foods as evidenced by the ever increasi ng fast food ind ustry. Dietruy ch anges have
nutritiomil implications which impact on the overall health and well-being. Because
of this, there is a growing concern and interest to achieve good nutrition and wellness
among the public. This ch apter deals with the basic principles of n utrition that will
provide tools to achieve wellness Uuough good nulrilion. As integral part of health
care, adequate nutritional status should be achieved ·with the help of the health care
team ,vhich includes the doctor, nurse, dietitian , social worker, occupational, physical
and speech therapists, and pharmacist .
NUTRITION
Nutrition is the science which deals with food and how the body uses it . Man
needs food to live, to grow, to keep healthy and well, and to get ener gy for work and
play. Several factors affect food consumption an d utilization of an individual. These
include the emiroumenl (natural or man-made), psychosocial, cultural, social and
even philosoph ical. The choice of diet influences long term health with in the range
set by genetics hence some diseases may or may n ot be infl uenced by nutrition. The
lnteragency Committee on Nursing Education (ICNE, 1964 ) en umerated the following
basic concepts of nutrition:
1.
2.
326
Nutrition is t he Food you eat and how the body uses it. We eat to live, to
grow, to ke'e p healthy, and to get energy for work and play.
Food is made up of d ifferent -nutrients needed for growt h a nd heal th.
a. All nutrients needed by the body are available through food.
b. Many kinds and combination of foods can lead to a well-balanced diet.
c. No food by itself, has all the nutrients needed for full growth an d health.
d. Each nutrient has a specific role in th e body.
e. Most nutrients do tlieir best work in t he body when teamed with oilier
nutrients.
3.
All persons thro ughou t life, have need for the same nutrients, but in varying
4.
The way food is handled in fluences tlte amount of nutrients in food , its safety,
appearance, and taste.
amounts.
FOOD
Food is any substance, organic or inorganic, ,,..hicb when ingested or eaten, is used to
provide energy, build and repair tissues and regulate body processes. Food cons ists
of chemicals which are nutrients and non-nutrients in nntu re . Based on the major
nutrient content, foods have been grouped into three namely: (11) Energy-giving
foods, (b) body-building foods and, (c) body-regulating foods.
(a) Energy-giving foods
The energy-giving foods consist of foods rich in ca rhohydrntes and fats and oil.
l•oods rich in carbohydrates include cereals (rice, wheat, corn or maize). starchy
roots and tubers (sweet potatoes, yams, taro, potatoes cassava and others). Fats
and o ils include butter, cooki ng oil, coconut milk and margarine, and animal fat.
(b) Body-building foods
The body-building foods are sources of protein and include: animal foods like
meat, fish, poultry and milk and vegetabl e sources like legumes, pulses (soybeans,
mungbeans, red and white kidney beans and other dried beans) and nuts.
(c) Body-regulating and prot ective f oods
Body-regulating foods are sources of vitamins and minerals. These include fruits
and vegetables. Th ey are further grouped into either Vitamin C-rich fruits and
vegetables and other fruits and vegetables.
NUTRIENTS
A nutrient is a chemical sub stance present in food and is needed by the body for proper
fun ctioning. The nutrients are classified into macronutrients and micronutrients. The
macronutrients include carbohydrates, fats and proteins which contribute to the total
energy requirement of the body. l 'he micronutrients include the vitamins (fat-soluble
and water-soluble) and minerals (macro-minerals and trace minerals).
Macronutrients
Carbohydrates
Carbohydrates are the cheap and chief sources of energy in the body. It has been
recommended that carbohydrates provide 55-70% of the total energy requirement
(TER) of an individual (RF..NI, 2002). Carbobydrates spare protein from being used as
energy source. In the form of glucose, it is the sole source of energy for the brain and
nervous tissues. It is stored as glycogen in liver and muscles. Complex carbohydrate
like dietary fiber pro\lides bulk that promotes normal functioning of the intestines and
helps prevent many chronic illnesses. As the chief source of energy in the body, one
gram of carb ohydrate is easily converted to 4 kcal of energy.
The types of carbohydrates include monosaccharides or simple sugars (glucose,
fructose a nd galactose); dissacharides or double sugars (sucrose, lactose and maltose)
327
:md the polysaccharides or starch, comple.x c~rbohydrates . Glucose is found in fruits,
certain roots. honey and corn whi le fructose is fou nd in fruits, honey and vegetables.
Ga.lactose in nature is fou.nd olll~• in mamma lia n m ilk. Sucrose o r tabl e sugar is
fow1d in s ugar cane, 111o ln~scs, s ug.n r b eets . natl sy ru ps. Lnc tose i.c: fo und in milk nnd
milk prod ucts while ma ltose is fvu11u in 111<1lt .md malt produc ts. Star c h or complex
carbohydrntes are found iu g rains an d gTain prod ucts, seeds roots, tuben;, potatoes
nnd other rootcrops. Diet.1ry fihcs (in d ige:;tihle) is found in s kins and seeds of fru its,
vegetables and grains. Larie .1mo u n1s of so luble filler are found in legumes, greens,
citn .1 s fruits, oat meal :ind barley.
Excessive intake of carbohyd r:1te may contribute to ove n.veight a nd ohesity }ls well as
incrcascd risk o f chronic illncs~es like di:ibctes ,md hea rt d isease. Also, high inta ke of
sugars like s ucrose bas l,eeo associated with dental caries.
Proteins
Protei ns are esst:ntiul to all life. I I consists of clrni11s of 20 amino acids helcl together
by pcptidc bonds. These ami110 acids arc classified int o essen tia l (cannot be synthcsi;1,cd
by lhc body nnd should be s upplied in lhc diet) und non-essential amino acic.l!l w h ich can
be synthcsi.zcd by the body. Protein ~ have seve ral r11111.:1ions: fur building 11 nd repairi ng
oftissu Ci!'i; to n1.1i11tai n important c:ompountls suc:h as c11;1,ymcs . ho nn o11es, :111tibo d ics,
other 5(;.>t:n:tion:-; ): maintain vascular os motic prc,;:m~. It al:;o prnvidcs 10- 15% of the
c11crp,y rt~1u irc rnc-n l :Ind suppli es 4 Ja::11 pe r gra m . The• protei n req uirem e nts nn• greater
d uri ng periods of growth as in infoncy, enrly childhood , udo lcscence nnd prcgnuncy
and hii.:tatio11.
Depending 011 whi.: ther aU the essen tial ami no ucids nre present in t he right amou nts,
1>rott>ins art• cl.L~sifit"d into complete protein 0 1· im:omplete protein . Com p le te proLeins
contain all the essent ial amino ndds in the right amou nts wh ile incomplete protei ns
nmy Le lucking i 11 one or more ess<:nti al atilino acids. Anim al so urces li ke mea t fish ,
poultr:v. mi lk ,rntl milk products are sources of com plele prote ins. Incom ple te pro teins
arc from n :gc.tablc ~ou rccs like legumes, dried beans as well ,1s who le gra ins and seeds.
J-lo wcYe r, a combination of incomplcle protei.n foods that would complement what is
lucking in one or the oilier ca n increase the biologic value of lhe protein in the d iet.
Prolonged lack of dictnry p rotein can le.ad to undern ut rition o r protein-en e rgy
malnutri tion (PEM). '!'be severe forms of PEM nre marasmus and kwaslliorkor. On
the other hand , mccessive intake of protein will b e stored as fat in the body.
Fats
Fals are found in many foods an d provide concentrated sou rce of en ergy. P::its a lso
supp ly the essential fatty acids whid1 have s pecific functions in t he body. In ridditjon
to its role in providing essen tial fairy acids. fat ha s othe r fu ucliuns. Fa t is s tored m ainly
in the adipose tissul' and Ullls maintains body te mperature. JI al so serves as p rotective
pad nnd s upport to va rio us o rgans. Pat in creasc.s tlie satiety value of foods a nd add
flavor and palat.1bility to food. fl promotes absorpt ion of fat-soluble vitami ns . Fa t also
provides s tructuml com po nent of cell membrnncs, ho nnones and other secre tions. As
source of energy, fat should contribute 30-35% of the TER of an individual.
Dietary fat c,111 be ohlai ned from anima l so urces like m ea t, milk, butter and a re ma inly
satura ted fat.s. Unsaturated fots on th e other hm1d can be obtained from vcgetnble and
seeds s uch as com, safflower, cott onseed, sesa m e and so}•bean oils. Polyunsaturated
fats stay in liquid form wh ile saturated fats are solid in cold temperature. Fish fr om
cold regions are high in polyunsaturated fatty acids called omega-3 fa tty acids.
I
!l .
328
~ - - - - - - - - - - - - - - - - - - - -.-:rt
E,xcessive intake of fat can lead to overweight and obesity
MJCRONUTRIENTS
VITAMINS
Vitamins are organic compounds which are found in small amounts in food. TI1ey
cannot be synthesized (except vitamin D) in the body and have specific and vital
functions in cells irncJ tissues. Vitamins function in regulating the synthesis of many
body tissues, participate in cellular metabolis m as coenzymes and cofactors, involved
synthesis of gene-cnn taining 1m1terials a.nd may function its antioxicJan1s. Vitamins are
classified into lwo groups according to their solubility in c.ither organic solvents (fatsoluble) or water (waler-soluble). Fat soluble vitamins are stored i11 lhe body wh il.e
wate r solulJle vitamins are generally not stored in significant amounts and are readily
e,xcreled.
Fat-soluble Vitamins
Vitamin A
111ere arc two main forms or vitamin A. iu food: the prefonne<l vitamin A (retinol)
or the vita min itse lf :i nd the precursor 0 1· pro-viti1min A (carotenes and simila.r
s ubstances). The nrnin function of vit amin A is iLs ro le in vision since it is an essential
component o f rhodopsi.n (visual purple). It is also needed to mainta in the integrity
of epithelial tissues. Vitamin A is also needed for hone growth, immune system and
reproduction. Prcformecl vitamin A is found in animal soun:es such as liver, mi lk, and
eggs. Precursors (carotenes) nre found in dark green leafy vegetables and deep orange
fruits and vegetables.
Vitamin A deficiency is the main causeofprevenlable nutritioual blindnessamongyoung
children. Clinical signs associated with the deficiency range from nightblinclness to
keratomalacia (severe lesion}. Vitamin A deficiency is also associated with keratinfaation
of the epitl1elial cells, depressed immune response, poor dental health and growth. On
tl1e other hand, because it can be stored iu th e body chronic excessive intakes can cause
hypervitaminosis A or toxicity.
Vitam in D
The two most important forms of vitamin D in man are: vitamin D~!2 (ergocalciferol)
found i.n plants and vitamin D-3(cholecalciferol) found in animal tissues. Both vitamins
are formed by ultraviolet irradiation. Cholecalciferol is found in eggs, butter, liver and
cheese. A cholesterol-related vitamin D found in the sldn is converted to the active
form of Lh e vitamin when exposed to sm:ilight. Vitamin D is needed int.he absorption
of calcium and phosphorus, it is needed in l>one formation, cellufar differentiation and
modulates immune function.
Deficiency of vitamin D can lead t bone ,deformities called rickets, malabsorption
syndrome, d iseases of the liver and l..~dney. These can be prevented by exposure to
sunlight, consumption of fortified foods and fish including its liver.
Vitamin E
Vitamin E exists in at least eight tocopherol and tocotrienol forms of which d-alpha
tocopherol is t he most widely distributed and has the highest biological activity. The
richest dietary sources of vitamin E are the polyunsaturated vegetable oils an d nuts.
Vitamin E functions in the body as tissue antioxidant protecting liquid membrane of
cells from oxidant damage. In food, it acts as an antioxidant by preventing the oxidation
and breakdown of polyunsaturated fats.
329
---
\"1trtmin E dc6dency I:; 11:-sociah:<I tu po:-sihlo h c mo lyt k uncmin in lvw hirth wc i1d1t
infant-s ond in m:.ilabsorption!>tote.<-. E.xce..ssiw intnkc•s of viu1min E mny luwc i111plic111io ns
in pnlicnts tnkii,g nntico~ulant mccl ic.otions :i i> it inhihils vitnmi n K 11ction in clo tting.
Vitm11i11 A:
Then• nn:- two nnh1rnlly =11rnng fonn~ of ,·itamin K: yil tm1in K-1 (phyll oq11inonc)
formed from pl:mts and vitmnin K-~ ~yntht•sized hr intc..,tinnl bncte rin and found also
io s mall nmoun1 ~ of nnimnl tissue. Diclory w urre..'l of vit ami n K a rc dark ~rccn leafy
wgc tablc-;,. The ma111 function 0£\'itomin K is for blood clotting uncJ <lcficicncy o f the
,;1nmi n h•ntl~ to hcmorrh~c.
Water Soluble Vitamins
'f11inmi11 (Yi1umi11 81)
Th iamin is a ('()fnrtor thu l piny~ n n.~lc in r:, rhoh~·drnte metabolism . II also hel ps in
Lhc pmpcr funrtioui 11g of lhf.' ,wn't)u,: s~-stc m, henrl muscles a nd digcsliv~· t r:u.: t. Food
source.~ IIH'htd,• lt·an m ....11. li,·<·r 1(11umes nnd l'Crcnls. Ddicicncy o f thiamin includes
ht•ri· bt•ri. "--~" of appetitt'. Mt:::tric tlistrc.-.s. fati gue, ht:nrt failun· . c<lcmn of th e legs mid
men tnl pruhlcms RequJr,mh?nt for intake is relnted lo C':t.lori c requ irements.
R i /)(:,jhwiri (l i tnmin 8 :J}
Kil>t•tlm,n i$ .,lso import a nt in m a ny em~1ne rc:.1cti on s. It is ncccs.-.c,ry lo mn intai n
h,•.:tltliv .skin . lir• und ton):lu:' . Food sources uf thc viLamin ,ire milk. m ,'nt, po ult ry.
fuch. ~n>,•n . lf.'il lY \'\.'Jw1atih.... Ot>ficie nc;y s1·nh: i< chnrncteriied by wo und aggrnvntion,
s to rnntit1 ~. swoll,m n!<i ton~ue. cyl' irritati ons , i-ki n cnt~ltioni: nnd dcr11111ti li:,,.
Rt'Q11in·mt>nl fur in1akt' dc~m.ls on energy n.'qu ireml•n Ls. physical activity. 111l! labolic
rate , _r.-;mw1h r.ll l' :rn<l h<.>c.ly s i7c.
Niacin (Viramin B3)
Ninci n. also lmm,n as nicotrn ic acid is also fou nd in menl , l~um cs nn cl cn riclwd cereal
wnin-< ll.l.t' th inmin nnd ribofln,.in. nlndn is r1l~o liwo h ·1:cl in enCT)t)' mf'tnhn lii.111. 1'11 n
ofnin<"rn i, clt•ri\ n l from tryptnph an. :rn amino ad d, nbtained from pm1,•lt1 conta ini nl(
foodc .-,c:,·p1 t·on1. ·n1e cla<.~ical d cfiri,•nt-:,· ~11dr11111c :l:.!«>cintc<l wi th nin.:111 dcli<:1cn<.;·
i-. 1wllai.r.i rh:1rn.-tt>ri1C"fl hy dia rrh r11. dnrnrn iii~ (('a,.,;11',, n1·ckl;1rl') wltl'.11 t' '<p<N:u 10
sunliih1. d,•m,, ntrn Cronfu,1011, lo!-'\ (>f m<'m<J I)'), :rnd dro lh. Rc.'<1u 1rc-r11<•111 fo r 111nc1n
i~ C'tf)n-<-«l in ni;idn equh-;ilen~ , inc-c it is der ived from prcforrn, "(I nincin 1111d
tryptopl11111
Py rid, u-i11t>
\llumin IV. includt' pyridmc1n e (1lr•rin~d fmm :mim ol MJt1rce_q), pyn dox:i l :rnd
pyridoum111c (fmm pl.lnt /itl u~) piny impon:m t roles in hcmoi;lobi n ,'iy11lh •sli, :ind
in thr t'Om t'l' tnr1 ,,r I 1:1111,phrin t n nia<"in. Ocfi cir•m·y of nincin b, mnnl fcstcd by J:C• ncml
•ymp1 o m, ,,1, h ""lei,~"' ~tn mina, 1m1nhility, conv1.1 l•,lonq and 1111t•t11i:t. l'ru td n-rich
foods surh a~ nwa t. fi.'1.h and poultry. as .,-ell 11~ r.n.:cn h·n fy Vl'jtclu!Jl t·.s, 1:cn•al itmins ,
n nd SC>lll•' fruit<; are good c:.o111·c<''"
r olatr
11,is ,,1,,min i,; al sio rdMTrd l·o a., foliC' 11rid , fol;icin or p l t'l'llYIAl utnm k ncid. "l11c
main function 1s a, ran o ( 3 COo'n,:,-me neNW in n,•w r.t'II "}'nthr s i~. A-: th e nnmc
,m,, li,~, thi' m:lm '-'\111\"{'C of folntl' ~ n' <l11rk 11.rN•n l<-o fr Vl'Jtl'tnhl<•q, hut it ii; nl:iu fmrnd
m In, 1. 1,,.n,m,·, imd wl"d.• Fol a te dl'hnenq c':ll uq,~ nne type rif 11111 ri1io n al 1111t; m.in.
m,~o lohlo,t1<' i1n,•m 111 l1t11'l(I' 1mm11turt C\'ll ~I but It h a11 n(,"' ~•11 t•!-tn hlis h l'd t hn t fol til e
prf"·~nl:, neun.l htlX' ddect (NTD).
330
cn/m/0111ir1 ( Vi1r1111i11 IJ1 2 )
Co hnl:1111in is a lso par1 or cn<Jn,:yme s ys t«: m m,cd in cell synthesis a nd he lps to mainta in
ne rve c e ll)-;. Th e s nurn is of cobalnmin ii re a n ima l products (meat. fis h. poultry, milk
und cgw,) . S t ric:I vcg t:tari;111s arc likely ttJ d eve lo p deficie m.')' s ympt o m s if th ere are
110 0 1hc r :;ot ircc of th e vita min is 1akP.n. Vita min defici1mcy is als o charact e rized by
111 cgn lohlast ic ;,ncmia. l'aticnts wh o had partfo l or totnl gas trec:to my a rc at risk o f
the dc f-idcncy becm1sc of loss of the inlrins ic factor neede d in th e metabolism of the
vitamin.
Pa11tn thenic l\cic/
panlOt he ui c aci cl is pa rt of a coen1.yme syste m used in energy metabolism. lt occurs
ahundnnlly i11 animal foods, whole g rain cereals and legumes. Deficie ncy syndromes
;,re un li kely.
Jiiorin
Biot in is a s 11lf11r-con t:1ining vitam in and is essentia l in co enzyme used in e nergy
me tnlmlism . fa t. Hrnino acid a nd glycogen synthesis. It is widely found in foods.
Dd 1cioi1cy sy m pto ms inc lud e loss c,f appetite , nausea, d e pressio n, weakness, fatigue,
ha ir loss a nd dci-nrnl itis .
Asw,·l, ic Acid ( Vil o mi11 C)
Vit a mi n C is .:-.sscntia I in a wide range offuncti o ns. Vitamin C is needed in th e forma tion
c>f cnlln)!.cn. th<.: base fo r 1111 co n ncctivc tissues in the body s uch as bo nes, teeth, skin
llnd wndnn.4 11 i11 c- rc;is1•.s resis ta nce tO infectio n , e nh:rnces the absorptio n o f iron. and
functions :is m1 :rn tinxidnnl. Vitam in C is found in ci trns fru its, d ark gre e n vegetables,
s trnwl wr ril!s, p,·rrwro;. pota to es. p:1payas. Deficiency nf in la kc ma y e vcntu,11ly leatl lo
sc u rvy- s wo llen . hlccd ini:; )!,t1m s, nncl loose teeth. Other s ym pto m s a re roug h s kin, poor
w() und h c;tlini.;. bruise easily. increased risk to infectio n u nd a nemia . Megacl.oses of
vit.u min C .sup plem ents can res ult in rebound scu rvy.
MINERALS
M in c ral.s ha" c ,·ario us fun ctio ns: ( 1) ass tn1ctured compo nen ts of bones; (2) ns central
atoms in t11')')!,i' n •c•11 rrying pro teins : (3) :u; con stiI11en1s of numerous e n-zymes: and (4)
as d ec trnlyt e rt' .sponsihle for the move m ent of wnter through t issues. Requi rements
,·nl)' frw n r,•w micrni:rams (trace minerals) lo hundreds or mi.lugrams (major mine ra ls)
n d11y. M inera ls nrc widely but unevenly dis tributed in nature.
Major Minerals
C<1/d111t1
C11lci111n is thl! most 11h unda111 m ineral in the body with 99% found in bones and teeth
nncl ahout 1Y<, in body fluids . Cnlciu m is needed to keep s trong bo nes nnd tee th . Other
muj c11· roll':-: or1.:ald u m arc rc1sulnti on of transport o f ion anoss membranes particularly
ne rvt' tr:111): n1issin n. It is eSSl'ntial in muscle contrnction :md bloocl clo tting, helps
mai11111i11 bk l$1d pres.sure . a nd (11111.:tioning nf :so me cn7.ym cs. Fuod so urcc::s include
mi lk, clri,•d s mall lis h with ho1ws e:11,•n. some green vegc::ta blcs. to fu, can ned fis h. and
fortifo•d 1m ,d 111·t:<. Dl'ficiL·ncy lea d to poL1r h o ne growth a nd tooth d e ve l<>pmc n t, poor
blCJod cl11tt i111,t. i111·rr•n:-1·d risk of n.s tenmalacia and os tt.'Oporosis in adul1i;. Toxicity may
lea d tu tctany o r fo rmal in n of rt!11al s to nes.
l'lws{'htw11s
M.tjo rlty o f 1hc phosphoru · in the body is combined with calcium in the bo nes and
tf'c th. Ph1)>-f)honis helps rnn in ro in a cid-bas·e bolnnce a nd energy m eta bolis m . Primary
fon d su11n·cs nrc foods ric h in protei ns s uch as meat fis h an.d poult ry. De ficie ncy from
pho:- phon i.s i:- p rnct icaUy unknown.
331
Ma51n(!!;i11m
/,fagn e.~ium i~ invoh·ed in numcrou.s cm;ym c .systems and e n e rgy rnct1,lx,l h1rn
prord n ~-ynthe.L, and fot m<!WboHsm. fl also help build s1rnng bon e.~ ;, nrJ 1cc1h :,11,j
regul;i11: h•:anl>eaL Magne<;iu m sou rce..-.; ar<.: S<.:ufoods, wbol r, ~rain.~, le:gu rm:!. :.nd n111• .
Dt'fici~ ncr 'iti,t~ ha ve rccr::ntly been associated Ylith hype ncnsir,n . i.• ,d1tmic lv:;,n
disea."'-', arrhythmia, precelamps-i,'.11 and :i_<;thm a. To;,cicity m ,1y hE: as.'>oci;,1,~d wirh intah,
af magm!Sium-cont.aini ng ant.acids , laxatives and othe r mtdic:stion.~.
Sodwm
Sodium is the main catir)n in the extracellular fluid compa rtment or the bo<ly. Sc,diurn
b!!lp, main Lain th,;2cicl-ba.'i#: balanc:e Mthe br.Jdy anti is important in m u.'>Clc c•intrac1 i,,n
:me r..!,r.·,; transrn.1.!i'ii'ln, The major diet.an· source of sodium is u.bl e ~alt anrl prrJ<.-..=<.v•.;:f
for..<l5. ~,t:ral fr:...-,d~ including ~-c~et,,bl<.-s. mr•aL mill and milk pmd uc:ts cont a in Y,m.-:
.:mr;unt., of s,;,.lium. C,,:1dim<:nt:S lilt!: fish and srJY sauces, monosodium g.lu1;,mat!!
OY...ln1n:t: tn s;;it intake am,,ng man:, Asian coootries. Too much int.ikc ()( s,.x:fiurn
!Il2} cau:;.e h:--penerui.on v:hich c::an It-ad tr) cardiO'-'ascular a n d kidn t."Y d Lc;ea.,;es_
Pm~<:fum
Po:zs~-n is the m::jo-r ~tir,n in the intra~Uular oompa rtment and als,, ph,ys a maj,,r
rc!E ir: i::v•.i:nair:mz fluid a,~d ~1=:...,.,J•,"te balance and cell integrity. Best w u rces cl
P'l"~~-T. !>P: :.7:'.!:-. :r.,-~ lih- m!dnns.· ban.an.a. milk. baked potatoes and fish, l.n-;s (Jf
;x:'~~:r. ir: ca:;s·-uab.= can be fal21 because it .affects rate of heart.bea t. Pali.ems on
-=·L ' · i-'"" ri:.7"ki
intake o f po-..zss:ium from foods. Excess potassi um intake
~.. ;;5"'.J ~ d2 -gert)C£ U> h:~lth-
~=
0-Jr;-,:,:::q mci Si!1fu:,
c.-.;,:r::~ ts t:e ::=.;n ~ of th'!: e._=cellula. component in the body. It is found
~ ~.,.-r.=...at:. .-,:: ·,.j:;:i ~ tnsi..1<> ~ cell it is in association ·with potassium.. it is
f.::::_;,,:-:.<.::: -e.'....:.rJ :n ;:,.-h:1aiaing 2:cid--base .-nd e!ectrol)1.e balance and is part of the
:::,--i._...-..,-J-j;zi,:: ,_,.:.,; b Ge $mn2d1.. lts .source is mainly from table salt and natm:ally
CY----~ i:: :ood::_
5::i:-.:- :.s b!p:):um: b h.dp'.ng protein strands assu me a particular shape. It is also
fu=.d b :f.:ir , &Ir znd :l.2fu.
Trace Minerals
Trori
[nm :s ciTl es--a:,ti;;I ~':Dt needed in the synthesis of hemoglobin. The primary
foor-rico mL"mog!ob:n is to c:2:ny o>:;,gen to the tissues and carbon dioxide from the
celli. iro::i oo.:n'::5 in l:',,o forms: heme iron which is found in red meat, and organ
m.":Z..; l1r;er. ~!sen. ki<l.ne,.· heart) and is \•:ell absorbed in the body. Non-heme irou,
0:1 th<: other ~nd, o:,mt:S from plant sources such as legum es, cereals , dark green leafy
,·ege:12b:e::s and grains an.dis poorty absorbed by the body. To improve absorption of
= -heme iroo, ·,it:amin C-rich foods and meat should be eat.en together ·with iL
Iron dclicienc.-y anemia is the most ,,idespread micronutrient deficiency globally and
affects aJJ peop1e but the most vulnerable groups are infants, preschool children,
adolescent girls, p regnant and lactating women and elderly. It is characte.riz.ed by
small. paJe red blood c.e.l.ls. lron i.s !>tared in the liver and excess intakes can lead to
iron O\"erload.. For e.umple, some .African tnl>es .,..'ho use i.ron cooking pots s uffer from
hemosiderosis due to hi~ intake of iron from these pots.
332
Jadin~
Iodine i_.., an t",.,•· ntial rnmponPnl ,,( th,, ll1;-;-,,it1 br,rm,,n,,. t h:,Tn-un II L• found 111
,;e;1foo<b '> urh :i<. fi-,h :rnd ~.:;,v.,·rih. ,n,j ,,,di,,,..J ~ It. J ►..fi..-j,,n,:y .,, i•,din,. re ,,I in
a Rpt't"lnim uf <'tJntliuon~ ~ud , ;1, p,r,i lf r ( rh:--r11ld ,·nlar;trmrnl /. yo"'1h wYr<iatlrm.
cretini ~m . m,•nt:ll n:t.1rd a tio n, and hyp,,1hyr<1idL~m.
Fluorine
F111nrin1: j-. an cs•,(.-n ual rnini·ral ,d1ich hl"l p, in LhP fonnatirm o (btm.- anrl t,,rtl, It is.
ncc~"ar:,· t,, pre·.·P.nt <lenta.l .-a n ~. 11tf' mr)",t ~·.,mm<1n v,un.·t· 11f flw,nd, ••· ilnnl<inr,i
..-atcr hu1 in plac(::'I "· he re th•! IP.n!l t!t Irr.... 011•Jn1fa t1on 1, n:cnmmr nrJ,.,J. Otlwr «,11n.,~
are fish and tea. \\11P.n Cl') n ,;um r•J m la111,P am" unu.. llunnd,• r-.in ti, 111"11" Ctl11tir, ,.-l-1.).
Dental fiour-o'ii.s is manife:-ted ,,.;lb mr:Jttloo ern:unel of 1hc trrth..
Zinc
Zinc i.c; a n ~v•ntial rdem f'nr in pm1PIM n11d 1•n1ymr'I. Fc.><xl •,oun:1....., q( 7-im· ltrl'
animal proteins pa rt icularl;,· oy er: and crnh rn i:-nl , ~<.'rm or ~min <. nut , . rnill.. :ind
eggs. Z inc:: d.1:diciency h ,J._~,,ciateJ '-Ith J)')Of imrmm11~· ,ind ' "1und lwa lin~. ,:;m.,,,.1 h
retardation , hypogonadism and poor ta'-1..- acun-y ThQ'.C witJ1 rhrnmc di:irrlw:1 and
chronic pancreatiti.s and others ";th mal.ab--,1r-ption ":71dmm~ are :it lugh n-.k of Tine
deficien cy.
Selen ium
ln recent ~·ears, increasi ng int erest in seleni um i.!. brou~ht :ihout by II$ :intioxl<lant
properties . Seleniu m is found ,,,.;dely in foods lil<c meal nnd :;hcllfi,.h anti in VL~t,;t.,blcs
and grains grown in selenium-rich soil. Selenium d<dk1enL·y l1:1, 1>,.,,..n :i~"'1cfa1t'ti ";t.t.1
card.io myop athy, a certain hea rt disca..o;c. This wa.,; first dc,,crihed in China nmon~
people U,ing in a rea.s where the w il is defir:ic.ni of sclenium. .E.-,;cc:..,ivc sclcuium intake
due to intake of supple ments may cause ha ir loss. di:irrhea and dcfocts on fm iernoils
and toenails.
Chromium
Chromium is also in volved iu enzyme systems and is required in c.1 rbohydr.ite a11d lipid
metabolism . It has two forms: Chromium 3-'- (non-to:-cic) and Chro mium (>+ (toxic).
Good food sou.tees of chromium liver. whole grains. mea t, cheese t1 nd nuts. Chromiu m
works \,itb ins ulin receptors io tbe control of blood glu cose. Lack of ch romium may
result in diabetes-like high blood glucose (Alld erson et al, 1991).
t
Copper
Copper is aJso a nd essential part of many enzyme syst em and is involved in the
absorption of iron. It is also needed in the maintenance of the l.trcliova.scular ~\-stem .
Copper deficiency is associated with prot!!in and iron deficiencies. Primary food s~urces
are organ meats like liver, seafoods , nuts and seeds. It is unlikely to get toxici ty from
foods but it is possible th.rough use of S\lpplements.
ASSESSM.ENT OF NUTRITIONAL STATUS
Nutrition is influenced by many factors and th erefore different methods may
be applied in order to assess the overall nutritional status of a n individ ual. group
Or population. There are direct methods which provide direct infom1ation on the
actual nutritional status. These include aulh ropomclric m.:as urc mcnts, biochemical
:md biophysical examinations and clinical assessments. lndin.-ct methods prO\ide
information on factors that can affect the nutritional o::onJ.ition of a po pulation being
Studied. These methods include the dietary assess men t and ecological sunrey. \"/hile
these m ethods do not directly assess nutritio nal status they provide information on the
333
ris k u( r1 1111tritimrnl clcfic.:lcncy a nd therefore arc a lso important 1:1<.ljunctx to t h e m ore
tJirccl 111clhodH.
Indirect m ethods
Ecologlcal
I nformr1tion regard ing existing hea lth statistics in the community, socio -econo mic
foclors, rmd cultural factors and enviro nmen tal condition s give info rm a ti o n which ca n
help in the. assessm ent o f Lhe nut riti ona l sta tus as these woul<l dfrccl ly or ind irectly
influence an individual's health and nutrition. T h e prevailing con<li t io n s in th e
enviro11mc11t a id in a ssessing the risks that th e p opula tion are exposed to and which
can contribute to th e h ealth and nu t ritional status.
Dietary Methods
Food consumption surveys examine dietary in ta ke of individuals, a g r oup or. 11
popula tion. Data obtained from s urveys can be used to provid e bases for m easures
aimed a t improvi ng t h e dietary practices which can th en help in th e improvement of
the nutritiona.l status o f affected people . The basic tools used in di e tary assessmenl
include: the dietary method, the food composition tab1e a nd the recomme nded nutrien t
intakes.
There a.re three revels where dietary evaluation can be done: at the population level,
household level and individual method.
A. Population leuel - the most commonly used method at the population is level
is the Food Balance Sheet which provides information o n the amount of food
available for consumption oftbe whole co untry. rt d oes not give in formation about
djfferences in food consumption patterns between groups in the population.
B. Household l <!Vel - tbrough a food inventory or food list, foods consumed by the
family is obtained but does not take into account food bought and eate n outside
the home.
C. Indiuidual level - information on individual intake is obtained either
quantitatively by recaU or record using actual weigh t measurement of foods,
estimates in h o usehold measures o-r qualitatively by dietary history and food
frequency questionnaire (Gibson 1990).
1.
Twenty-fo ur hour n:call method
In this method, tlie respondent is asked by a nutritionist to r ecall all foods
and drink consumed during the past twenty-four hour. Details of food and
b eve rages including coolcing methods, brands (for processed foods) and
estimates ofamounts in household measures are recorded .. I ntake of vi t am in or
mineral s upp lements should also be noted. To h elp respondents in estimating
amounts or portion sizes, t he inte rviewer may use memory aids like c ups,
spoons, ruler or food models if available. All information s h ould be recorded
in a form . The data is then processed by converting the household measures t o
we ights and then analyzed for nutrient conte nt using the software oftbe Food
Composition Table for use in the Philippines ( FNRI 1997). P e1·cent nutrient
adequacy is calculated b y comparing nutrient int ake with the recommended
intake for the particular nutrient (RENI 2002). To estimate the average food
intake repeated twenty-four hou r recalls can be done.
334
.....
Example of a 24-hour Food Recall
r-iam e : Jua n dcla Cr ~z, Jr.
Age S.O ~ears old
Sex : Male
Address : 1234 Mah irap St ., Lupang T1gang, Manila
15
thi s a typical diet? Yes_ No _
Date : April 1, 2 009
(If no, Interviewer should go back a nother d ay)
TwentY•fo ur hour food recall
.
Descri ption of food and
drink
For processed food, give
brand name if possible
Amount in
household
measures and
portion sizes
Food Code
Pan de sa l
2 pc (5 x 5 cm)
A042
Hot dog, fri ed
1 pc (10 x 4 cm)
F252
Milk, powdered, filled
2 tsp powder
J019
10:00
Bi scuit, Marie
1 pack, 4p cs
A092
12:00
Rice, well m i lled, boiled
1 cup, packed
A020
Chicken leg
broth
1 small leg, (13
½x3cm
F108
Banan a, lacatan
1 p c (9 x3 cm)
EOll
rim e
For Lab Use On ly
Amount
(grams)
AM
7:00
Chicken Tinola with green
papaya and sill l eaves
I
PM
3:30
Pan de limon
1 pc (6 xS x 4
cm)
7:30
Rice, w ell-mil l ed boiled
l cup, packed
A020
Bangus, fried
1 slice (middle)
7x3x2 cm
G076
.
.
A04 0
Vitllmin/mlneral suppl e·
ment - brand and dose
\._
.
.J
335
Sc.:,.., ~ wilh CamScan:11:r
Steps:
1. Col'ect d.ata a:id rerord rn d leia,y eva luation form as shown in rabte above .
2 !'l'eparatton of c!.a~ fa: ar.a-Jysi.s.:
A. Com~:. househ,old m :astires into grams using the Tabl e of Weight and
~•eas,..-es (FNi,I 19771 c : ;'-2 c::,oo & ch ange List, (FNRI, l':?9~)
S. li ~ ~ t cs gr,ce n "' 'A!, P,..--chaseo· (AP ) -,.,eig ht, ch ange to w e ig h t ~Ed• ble
0 o -.'ori· (E" l b,, rrul::c." ;ing \\/Ith~ EP fo r th'! p.;rttCIJlar iood from t he Fooj
C a ~~n To'J:e (FCT).
Exatr. : !e: Ii c-r.e ;-<ea?·oi oa~..a= , lac:a:an has an AD" e ig_h t of EO g a nd its %
i:? f:-:;-m :t<i= KT is fil';,,. then E? -,., ba.:, an1! = 60 x 0 .69 = a 1 g
~~ :! ~ !:iar.:s-..rs.. fried !7x3x2 er.t) - E? COO""--°"ti 1Vei1;ht :: 356
Cc-::1ad 't-ir~:tl X Cln""R5.o:'l fa,rto( = EP rc,•, \atai; .~t
3.5.x ! ~ = ~g
~= •
•
:; ..; ~ :;o.:;4.-.sc ~ rs ~.a-.-..a.b'..e in the 'FCT.. th~re is no ne-ed to
c.c,ven to
ra-•-~~
live .:::c-c-c red:?E is. ix:: ~-72""'-a t ! e .ti U-1.-e FCT~ cato-.,l#tion has to b~ cion-Et
r..s7~
,:z« v,~~~ -~ d-..:S ~ cr.e ca.c=. a.fl: w one- :ea:s-oo~;i of oil for fried
=--~
u ~ ~-~ =-;;i:;S ;;-,::: se..- .-:-.;..
o.. O:h+--e -1.-":?'i~ (O:!::: c;~ ::Y ~ fa-r~ it em ar.C major fooc it£m in
m =' ::o:-i5, t;;S;",g me Kr e:.:.~ rn2 nis!!y e r using the FCT $-0:V,Vcre (FNRJ.
2m2j
-=••
.:-.~ ~ : i' vd , a;
cf 1 S-:-re ni':':! bangus (from CJ
Foe,;; CccE cf~.;-" is.s: G076 from KT
n:....:
Pre.-_g_-. :. g EP/lJJJJ. n:.ttnfu-"!t.ro:i~ fro-::, FCf
= 35/ 3.00 r: 23. 5
"
8.3 i;
d nw~ o f ~ (6¢ g} is usd FCT Code is G074
P!G¢ei(J ,,.g a> n,,w/J.00 'Jf. nutrient CZ>l'J'tefft from fCT
= -64/JJJO i,;19.8
= l2.7
E. C-a!a"3!P Ole total amour¢ of each nl.ltfient from all foods consumed and
,,ita,,.iu /ffl1M.f21 tal:en.
f. To~
adequ;;,cy of l'lll'ttlem lnll!ke, compare the actua I intake with the.
,ew,,woa acfed intalr.e {REHIJ for each m.rment fer particular age and sex.
"lfww:nt A6eqnar:y "' amc,um of nutrient consumed
~ n u t r i e n tintake
336
--
2. Estimatedfood record
ln th is method. the re... pondent is asked 10 record nil fond and drink am«umed
o ver a period of tim~. The recordin,; i!' dnnt' at th•~ lime nf con"'-!mption.
The amo unt con;,-umt.-<l is recorded in hm:1-.:h,ild m<'.a.4 un:--, and dct.'3ileJ
description,, oi prep2rauon and coolani; are not~!. Thi< metliod require<: lhat
I.he ~-ponden1 is li1er:11e and f"eGutre.!' more c,x,pc.rat1nn. D:ila an:ilyri."' i«
similar lo thi'l t of th.,. twenty-four houir n.'call method.
3. 11·eighcdfood rec-ord
Thi!' is the m o..."'1: p reci.'-e method and re:cp,:,nden~ arc a.•kod to wei!1,h 1111 food
and tiri·nk as it happens durin~ a ,;-p,ecifie-d p('nod nf ttm<:. Detail-. of fnod
preparation. cooking methods. brand name,;; arc alw ra--.mkd. In thi~ method.
the actual wei~l.5 of food , ccorded are u,~ m the an..11:,---i!-.
4. Dietary hi.ctory
Th is method a ttempts to estima te the usuaJ m1,1kc of an mdi,,dunl o.-c-r lnn);
periods of time ( Burke. 1947). This consic::c_<; oi :i r.,cn~ -f,,ur hour food n.'C:111.
followed by a frequency o[ mt.Ike of ccrtem fnod it em., ;i< c ~ <hed: and a
three-<lay food record (this is ao ion~cr u..-.uall~· clone). The rn..-thod i.< ,-er)·
t edious an d requires a trained aulritioni.sl w orrr i1 ou t.
5. Food frequency quesrionnai-rc (FFQJ
The FFQ consists of a list of ioo<l!, and a :;et of Fn-qu..-n~ of U."<: ~ose
categories. Depending oo I.he objecti,-e,. of the srudy. the list of foods may
be short o r very long. The FFQ m2:,- b-z adminLru?red fac:e 10 face or it can
be a self-administered questionnaire_ Thi5 i., now ,cz:.· comm only used in
investigations of diet-di_c:ease relationships.
.->.s stated earlier, the dietary method i5 an indin.-ct method of assessing
nutritio nal status since it does no~ define the nutrition.ii deficiency but
only the risk of deficiency o r e:,ccess. Also. one mu.,;i ~Li7..e that there are
limitations in the different methods used. For ec1t2mpl.:, m--:thod:- using re1:all
rely on me:mory and errors may arise ·.-.·hen icx:xi.5 are omittt:d or estimates of
amounts are inaccurate. On the other hand. the food record met.hods h:!,-.:
the advantage of not rci)ing on menlo ry since food intake i:; recordt.-d as it
happens. However. this requires a lot of moc:h-ation and cooperation from the
respondents.
Direct m e thods
Anthrop om etric m ethod
Nutritional anthropometry has been defined as -measurements of the v:manons
of the physical dimensions and the gross composition of the human bod,.. at
different age level and degrees of nutrition- (Jelliffe. 1966). Toere are h,-o ty~ of
anthropometric measurements: growth and body composition measurements. Body
composition measurements mclude two types: body fat and fat-free m ass. This has
se,..eral advantages in that the procedures are simple. non-i nvasive_ and ioe.-..pensive.
Pro\.;ded standardized techniques are used and properly tra ined personneJ do the
measurements, the method is precise and accurate. Ho,,·ever. there are limitations of
the anthropometric method which should be recognized (Gibson. 1990).
337
::J
1. Weight
Wejght is measured using a beam balance that has been calibrated by a standard
weig_ht and following standard procedures (,Jelliffe, 1966). l11c subject s hould
preferahly he naked or if not , s hould wear minimum clothing, barefooted and
asked to sta nd at the center of the platform. head s traight . re laxed and still. Weight
s hou ld be recorded u p to th e te nth of a kilogr11m. For infants and children less than
two years of age, the infant (pediat ric) weigbing scale with a p,in or a s uspended
scale and weighing bowl or sling (e.g. Salter scale) may be used.
2. Length/lleight
Length or height measu res skeleLnl growth particularly of U1e skull, spine an d the
legs. Recumbent length is measure in infants an d ch ild ren less tlian two years of
age us ing a wooden length board or illfanwmeter. The s ubject is placed on the
wooden hoa rd , face up with Lhe head agninst the fixed hoard. Two p e rs ons arc
needed to take the length . one Lo hold the head ~Lr;lig h l ;ind th e o t her to do tl1e
m easure mcnr. ·n1c m easurem e nt is done with the subject's fee t, without shoes or
socks, is held by the exa miner, who makes s ure th a t th e knees arc st r;,ight a n d the
toe.s pointing stmi&)it upw;rrd. The movahle foot p iece is brought firmly ngai nst
the heels a nd the reading taken to the nearest millime te r.
For childre n two ye.ars and above and adul ts, h eight is mcns urcd using a
1m1cJiometcr. If this is not uvai !able, a measuring rod or no n-stretch tape m cas ure
or /i'lec l tape and ;J wcxxlr::n right-angle lwadp iecc ca n be used p:ir1 ieula rly in the
field . ·nw mc11s uri ng lope is :itt;ichcd to a s t rnight vc rtic.al wull, and the fl oor
~hou ld h,1 \'C' rm 1:vi:n s u rface. ·n1c :rnbjecl is lw r cfoo l and asked to s tand s tr.1ight,
fel!I tcJ~•·liler. hern.1 pu~ iliomi d s 1n1igh1 in the Fr;,nkfo rt Hori;,.o nln l Plane, a nd the
l1N·l~. huttr,ck.~ ;ind !.hnu ld cr blad e.<; tou c hing the: wall wh e:rc th e tape is fi xed . 111c
11 rm.~ ;,r1• lmn~ir1g l•H,~c rm the s it!,: :md 1111! s11hjcc1 is asked t·o rake a der-p brea tl1
11ncl m11inlarn ;:, fully urect r10si li1,n. ·n1c headpi ece is lo we red un ti l it t<>11chc11 tl1r:
mo,, 1mp1•rlt>r p<iint of the head and th e m easure m e nt is record ed is recorded to
thr.: n<!;,rc,a 0 . 1 cm.
,"J, Mid•uppPr arm cfrr.11mferrm.ce
'f11,. mld •upp<:r :-.rm circum forr:n<'..e reflcc:t,i muscle rmd :1dipo~e 1i1rnu e rc,;crvc. TI1c
midJ M1i111 I.wt •,v, -r n I hr; tir, a r.rnmion and till; tiJl nr Ilu: oltcroncrn p ro1...1.: ss hy askirri;
thri r,11h;•·•·t to flr:x 1h1: ;,rm (usua ll y tlw left hand unl(•ss imbj cct is lc•l't •h:rndcd) and
:, mark i,, nwd,· ril 1}11; mldpoinl. Wi th :orm lurnKing l"widy on th r; sid e:, 11 no notrf'ld1 1111w rn<•as,urf' i.11 pl:1o•d .iround th e ann whe re lhc, m idpoint is ll'>f.!Hted :ind
fitr. ii ,11111)1.ly. ·nw d rcumfon;n c:a i11 rcc,:irded t" Ihe nearest 0 .1 c m .
1 , Tnr:r•rt1 Sklr,jf!ld 71,ickne.<1.~
'11i-· llkinfold tllicl.m•:<11 pr,,vi!"-: a nlrnplc i,nd nr,n -in v:mivc e.,;tirn:itc o f body fat.
M••a... uri·nwnl nf •,ld nfr,l<l thir-km•"lq in fivi; Nit,~q, tri ccr,R. l1it:cfk'l, ,m bi;ca pular,
i.uprailia,· 1,ncJ ,ni,11,xillary c;;in p rovi,I•; ;, g,•n1: rol ($ timnt c of to tal l!ody fat.
ll uvwwr, ii i.t, 11111 ;1lw;1y,1 f•·a •,ilil•· in th,; field I"<• t,1k1; all thr:.'\C rnem;urcments,
h"n<'•·• tl1•· trlccpn ukinfold thlckne«r:. i11 th,: m fJq t commonly me;is urcd site.
M~ai.1m · n w 111 nf ,ikJnfol1I thlckncs'l n'(1uin:11 a 11kinfold c;;1 fiper . TriccpH Rkfofold
1hkk11,.,.~ i1t mea-'lurtd ;,t tl1r m idpoint of th•· Jp(t 11rm rn:1rkcd :,s i 11 th e mid-upper
nrm nwa• rirr-rnrnl . Aho ut I cm fm,n Ilw run rk, u pinch i1, rnmlc· ln elevat e the
r1khif,,l,J :, ml, withoul r, •l••:.11ir111, llw pi1Jd1, 1lw j :-iw•i 1Jf tile c111iptT i.~ ~•ppli,:<l :ind
1h•·11 th•· prc'.-.u rr [,. r,·Ji.:11,,·d . ·r,,,. n·11di11g i•1 11111d1: fJh1: r 1,b,,111 four i,cc•rnds of
1h r n·Lcll"'"' llf l h1· 1:alif)'·r prt,M un: ;111d th•: th k km!li>1 is rccorcled lo 1he n,•;ircst 0 . 1
mm.
J
iodices of Nutritional Status
1 . Weight for Age (WFA)
Weigh t for age is an indicato r ofpresentacuteundernutrition. Weightmeasurements
for children 0-83 months are comparecl with International Reference Standards
(IRS) adopted for Filipinos (Mendoza, TS, Ocampo, ML and Barba, vc, 2003)
specific for age ancl sex. Children are then classified using the following cut -off
levels. Th e exact age in months must be known.
Norma 1 : with.in :t: 2SD of median IRS
Underwe ight (Below Normal) : < -2SD of median IRS
Overweight (Above Normal) : > + 2SD of med ian IRS
For ch ildre n 9 years - 19 years of age a.nd adults the Body Mass Index is
calculated us ing by dividing the weight in kilograms by the square of the the
height in meters [JJMI = Weight (kg)/ H eigh t (m)~J
Ch1ssmcation of n utritional status for 9-19 years
Normal : P15 - P85
Mild u nderweight : P3 - < P85
Un derweight:< P3
Overweight : > P85
BMI Classification for Adults (WH O, 2000)
Unde rweight : < 18.5
Normal
: J8 .5 - 24.9
Overweight : 25.0-29.9
Obese
: 2: 30
a. Hciyh l for /1.ge (!-! FA)
Height for age indicates past, chronic undernutrition and a good index
of stuntini:;. The hei ght meas ureme nt is also compared wi th the IRS. For
ch ildrcn 0-83 mo nU1s the exad age is should also be calculated. The cut-off
levels for classifica t ion a re the same as that of the weight for age .
Nonna ! : :!: 2SD of median IRS
Short for age : < 2SD of median IRS
Tall for age : > 2SD of median TRS
I,. W eigh/'for l-lci9h t (WFH)
Weigh t for height is a sensitive indicator of current nutritio nal stat us. It
dis tingu ishes stunting (weigh t is height but height is below normal) and
wasti11g (weight is low but height is norma l). A child whose weight and
he ight a re both below normal is considered both wasted and stunted.
Normal : ± 2SD of median IRS for WFH
Wasted : < 2S D of median IRS for WFH
Overweight : > 2S0 of med ian IRS for WFH
2. Diochemical M ethod
Uiochcmical method of nutritional asse.55ment is an obje<.i.ive method of
nutrit iona l assessment however, it is expensive and not all labora tories may
:33.9
be l':l p::ihll' of c-11 r~·ing out U1c s pecific.· test. Moreover, it cou ld be invmd ve und
t fwrt'fon.' 111.iy no t be ;,ok to d k it c-ooper11tion of s ubj ect~. The m o~t co mmo n
biod1cmic;il tcsL~ em ployed in nu tritio nnl assessm ent includ e the followi ng:
Deficiency
8iochcm ic,1I te-~t
Protein defici ency
Se ru m albumin
Urinary urca :crca ti ninc rat io
2. Vi ta min A
Se rum vit nm i n A
3. Iron
H cm o~lobin . He ma tocrit
Serum lro n
4. FolicAcid/ 8 12
Seru m and RBC Folate
Se rum and RBC vi tnmin 8 1.2
5. Iodine
Urinary iodin e excretio n ( Ul E)
TSH , T3 , T4
6. Vitam in C
Senim Vitamin C
7. Thi:imin, Riboftwin, Niaci n Urln:i ry Excretion
8. vit:imin B6
Tr:vp topha n load test
J.
:2. Biophysicul Tc..~ts
Biophysical usscssm ent includes t ests of functional ability s uch as nightb li ndness ,
and e nl:!rgy expenditure. delayed h ypersensitivi ty. It also includes exam in at io n of
clin ic.ally ac=sible tiss ues s uch as ha rdness of nails, t e nsile st rength of hai r .ind
radiogra phic e.~a rn inatio ns . Dc, iations from th e normal fun ctions m ay be associated
"~th nu trit iona l defi ciency.
3. Cli11ical Examination
Clinic.'tl exami nation is relative.ly simple, in expensive, and non-invasive. It is
practicnl ;rnd use ful when the deficiency is endemic. It assesses cha nges in the skin,
h:ii r, mou th. and thyroid. TI1e cJJnica.l s igns are suggestive o f nutri tio nal deflclcncy
include the following:
Deficiency
Suggesti ve signs
Anem ia
Pale conju nctiva , in ner Ups and
Palm of hands
Bi to t's S pol
S torna ti tis
Casal's necklace
Bleed ing gums
1l1yroid e nl argement
Edema/m oon focc
E piphysea l enla rge ment
Vita m in A
R.il>ofl avin
Niacin
VilJlmin C
Iodine
l'rotei u
Vitamin D
COMMON NUTRmONAL PROBLEMS OF PUBLIC HEALTH IMPORTANCE
1. PROTEIN-ENERGY MA LNUTRITION (PEM)
Pro tein-ene rgy ma lnutri ti on remains to be a public hea lth proble m in m a ny
de velo pi n~ count ri es includin11 th e Philipp in es. ft is us w 1ll y m an ifcs1cd as g ro wth
failure. PEM r~ ults mainly fro m lock offood and frequent infcct irm.G thot c:w se lnck of
a ppetite while: incn•a:,ini; tht: body's llt.'l.--ds fo r n utrie nts. l nodt.-q ua te in take is hrough l
about by t he inte rplay of scvernl fa ctors inc.l uding political, i;oc-ia l, c ult ural , econo mic
3.C O
and enviro nmenta l factors. Pnorfeccling practiccssuch as not exclusively breastfeed ing
for s ix m oths , r <11,r reed ing 1>rnctices (giving foods too early or 100 lalc) and g iving
food s whjch lack in <:ncrgy, protein and other essential nutrients from varied foocls
are cnuscs o f un<lcrnutrili<Jn. This is aggravated by frr.quenl infections because o r
poor cnvironnumt, inadcqu:1te access to health services, poor maternal and child care
practices. The severe forms of malnutrilion a re marasmus and kwashiorkor.
,
Marasmus
Marasmus results from p rolonged starvation and is associated with severe wasting
with classical signs of "old man's facie" because ofloss of fats in the cheeks. A child
vii th maras rn us appears apathetic, with ilhfo, sparse an d easily plucked hair. The
child us ually has good appetite.
Kwashirokor
The main s ign of 1.-washiorkor is the presence of pitting edema in the legs and
feet a nd can also affect the hands and face. The face is characterized as~rnoon
face" likely rlne to edema, hair is described as flag-sign, because ·of alternating
dcpcgme ntation, the skin lesion called M{laky paint dermatosis". Children with
kwas hio rkor are also apathetkand irritable.
Marasmic- Kwashiokor
Th is is a. m ixed form of PEM and manifests with edema b nt do not have the 0th.er
signs o f kvvasbiorkor.
Manage ment of PEM
Children with severe PEM are at risk of hypoglycemia, hypothermia, dehydration,
electrolyte in1balance, micronutrient deficiencies and infection. Thus, management of
cases requ ires first, an initial stabilization for acute and medical conditions followed by
a rehabili tation ph ase (WHO, 2000).
1.
2.
3.
4.
5.
6.
Treatment of dehydration, hypoglycemia, hypothermia and electrolyte
imbalance
Treatment of infection
Vitnm.i n and m ineral supplements t o treat micronutrient deficiencies
T reat mcnt of other conditions
Initial feeding
Assess ment of recovery
To preven t and control malnutrition, ilie following are recommended: ensure tl1at
food that is adequate in quantity and quality, control infection th rough public health
measures and p roper nutri tion education of mothers and car egivers (encourage
breastfeeding, knowledge on appropriate foods for the young).
2. IRON DEFICIENCY ANEM IA
Anemia is defi ned as low hemoglobin level. Nutritional anemia results when there
is an inadequate store of a specific nutrient needed for hemoglobin synthesis. The
most commo n causes of nutritional anemia are: iron deficiency, folate deficiency and
vitamin B 12 deficiency. Iron deficiency is the most prevalenl micronub:ient deficiency
wo rldwide a nd the most com mon cause ofnutrit:ionaJ anemia.
Iron de ficiency anemia is of major concern because it can affect various stages o f life
a nd have serious effects. Iron defkiency anemia results in decreased work perform ance
sin ce low h e moglobin level means low supply of oxygen needed by tiss ues to perform
341
.L
work. Anemia 11nd iron deficiency also increases comp lications dllring pregnancy
including premature delivery and low birtlnveight -babies. Jt has been suggested that
iron deficiency increases susceptibility to infections. Among children, iron deficiency
subnormal cognitive performance.
Causes of iron deficiency
1.
Decreased absorption of iron whicl1 may be due to decreased intake or poor
bioavailability ori ron depending on whether source in the diet is heme or nonheme iron. Absorption of iron from heme sources is higher than fron nonheme fron. In addition, µresence of inhibitors s uch as oxalates (from leafy
vegetabes) and phytates (from cereals) and tannin (from tea) form insoluble
complex with iron and thu,c; it is not available for absorption. On t h e other
hand, vi tamin C and meat, fish, poultry can enhance absorption of iron.
2.
Increased blood loss due to h ookworm and m alaria an d to a limited extent
tricburis; excessil,-e menstrual flow and bleeding from the gastrointeslinal
tract due to ulcers.
3.
lncreased requirements irn infancy, p regnancy adolescence.
Clinical features of iron deficiency anemia are non-specific. Pallor should be examined
at three :;ites: conjuncq\·a, the inner lips and nail beds and palm of h ands. Other
clinical features are respiratory distress, sleeplessness and easy fatigabiHty, reduced
power of concentration.
·
Diagnosis
Diagnosis of anemia is based on determination of hemoglobin an d then specific-tests
may be request ed (refer to the bioc]1emical method section)
Treatment
For immediate al leviation of anemia, iron.su pplementat ion is necessary. The dosage
will depend the age and p hysiological status of the patient.
Prevention and Control
Approaches to the prevention and control of anemia include the following:
1.
2.
3.
4.
5.
6.
Iron supplementation
Control of infections
Forti.fication offood
Nutrition education
Public health meas ures
Combination of approaches
3. Vitamin A Deficiency Disorders
Vitamin a deficiency is defined as the condition that results when the level of total
body stores of re.tinol nod of the a ctive metabolites is depleted such that n ormal
physiologic function is impaired. Vita m in A deficiency d isorders (VAD D) describes
the spectrum of conditions associated with Vit am in A deficiency from ch ronie d.ietary
deficit, tissue depiction, systemic effects, xeroph thal mi~ and finally corneal blindness.
Vitamin A deficiency is pri marily d u e to Jack of intake of the good sou rces: n amely:
an imal sources, liver, eggs, meat, milk and dairy products. Dietary lack o f fat, protein
342
and vitamin E which are needed in the metabolism of vitamin A can also lead to the
deficiency. Frequent infoction increases the requirement for the nutrients includi ng
vitamin A h ence increases risk of deficiency.
clinical features
The clinical signs associated with Vitamin A deficiency depends on the stage or
severity of the deficiency.
t.
2.
3.
4.
5.
6.
Nightblindness, a functional sign characterized by difficulty in seeing in
dim light
Conjunctiva! xerosis or drying of the conjunctiva
Bitot's spot - a cheesy, foamy whitish deposit usually in the temporal
quadrant of the eye
Corneal xerosis (corneal crying)
Corneal ulceration
Keratomalacia - the most sever lesion characterized by the softening of the
cornea
Biochemical FeatL1re
1. Serum retinal determination by high pressure liquid chromatography:
Normal 2:20 µg/dL or 2: 0 .70 µmol/L
Low
10- < 20 µg/dL or 0.35 - <0.70 µmol/ L
Deficient <10 µg/dL or< 0.35 µmol/L
Treatment
Treatment Schedule (WHO 1988):
Inf-ants and ch1ldren-<8.0 kg.
Presd:loolers
Immediately on diagnosis
100,000IU
200.000IU
Followlng day
100,000IU
4 weeks .tater
100,0001U
200;0001U
Prevention and control
There are several approaches to prevent and control vitamin A deficiency.
1.
2.
3.
4.
5.
6.
Prophylactic doses given every slx months
Infants 6 months to <l year of age- 100,000 IU
1-5 years - 200,000 IlJ
Mother upon delivery - 200 ,ooo IU
Give fortified foods
Health educati.o n and horticulture
Nutrition educ;ition
Public health m ea::.-ures to prevent infections
Combination of interventions
4. Iodine Deficiency Disorders
Iodine deficiency dfaorders (IDD) refer to a spectrum of conditions associated
with lack of iodine. These include goiter, ment,.land growth retardation, cretinism,
abortion, stillbirths, thyroid enlargement and slow decision m~ng in adults.
343
causes of IDD
IDD is due to inndcquote intake of iodine-rich foods s uch as seafoods, seaweeds and
jocfu,ed ~a lt. in cre:isccl l'l'(Jllirement-s duri ng periods of rap id growth (adolescence,
pregmmcy :md lactation). nnd consumption o f J)laots grown in iodine dep leted soil and
waler. Consumption of foods containi11g goilroge ns like cassava. cabbage a nd li ma
be:ins mny interfere ,dth th e metabolism of iodine by the body.
Const-quence.~ oflD D
l odinc defiriency l111i; serious conseq uences. The m ost commo nly recogni1,ed
con~ uence is goiter o r enlargement of the thyToicl gland. This can affect man al
nU s1age;; of life. Crt'tini$m results when there is iodine defici e ncy d uri ng fetal life:
ncu rologic-;i l crl'tinism (dc-fidl'cnl'y in early p rci:n11ncy) nnd h~1,o t.hyro id cretinism
(drfirienry in ln lt'r pn·g n.i111.:~·). Mnnifl·:-tat ion:- of ende mic crct in i~m a re cle ;1f- rnu tis m,
squi nt. ntt'nta l ret:ird~ tio n. ,;rowth rvtnrdatic,n. Child ren i;u ffo ring fro m I DD ha\·e poor
school p('rfo rn1ru1 <.'c dm· to low [Qin child r<'n a ntl ofl en drop ou t or sehool while adults
wo uld not able to perfnm1 we_ll :11~0 at \\'Ork ,md o th er tasks. Amo ng p ri:-gnan t women
with lDD, the co nseq ue11ces include nbortions, still births, and miscarriages.
Diagnosis of IDD
Iodine deficiency di~orders can be diagnosed through clinical mctliods by e:mmining
the tht mid gla nd and ide ntifying cretins in the eornmunity. 13ioch e mjcal methods
include dt>termin:ition of urin:1~· iodfoc excretion nmong school age children, serum
len:li- of 111~-roid hormones. T3 and T4 nod thyroid stimulatin g hormone (TSH).
IodiuP len?I of d rinking may also be detcm1inecl.
Prevention and Control
The implementation nf the Salt lodizntion L.1w in the PhiHppines cnn be rega rded as
imtnunental to the- d mmatic effect sct:n in reducing the proportion of schoolchildren
\\ith deficient ll',·el;; of 11rinn1:· iodine e.-:cretion. Also consumption of iodine-rich
foods l'bould be contirn11>11:<l_1· c11eo urni;ed nnd in nreas whe re IDD is endemic, ghingof
iodized oil should continue as pn rt of the nutrition progr:1m.
5. Overweight and obesity
It hmi no"· been recognized that oven,·eig ht and obesity are e m e rging problems
that need to be addressed. lt has been observed that over the years, th e prevalence of
o,·erwr ight i~ constantly incxcnsing (FNRJ, 2007) :md is seen in all ages, thus efforts to
preve nt furth er increases are in order.
0\'1!1wdght nnd <1be.sity result from nn imbala11ce in ene rgy intake·a n d energy output
(Seidell :ind Vi~scher. :.ioo4). Tl\is is du e to ch ro nic excess energy int ake a nd reduced
phys ical arti,;t)•(decreni-ed ene r~· expe nditure). Obesity is now well- recognized to be
a risk factor of rar<litl\'ascul:1r disenses, hr pertensio n , type 2 d i11betes m ellitus. It has
also bi!i!n assoc-i.ated "ith cert·ai n types o f cance r, nnd conditions l ike osteoarthritis,
and respirato ry diso rders.
Pn·vention nncl control of overweight aud obesity, sh ould includ e m o dificntion of
lifestyle habits, prom otio n o f h ealthy eating lmbits and regular p hysical acti vity.
SUMMARY
Nutrition pla}'S nn impo rtant role in nchleYing overall health of an in dividual. A
person cannot achieve healtJ1 and well-being at the highest level unless U1at person
is or good nutritional status. Th e refore, henllh workers, whetl1er in th e community
344
or the clinical setting s hould haYe a b.-isic undemanding of how to achil.?\-c optimum
nutrition. th.: factor.; d1a1 can affect it. and the solutions wh icl1 cnuld be the basis for
appropriate ad,;ce.
RE FEREN CES AND READINGS
1.
Food and KutTition Rese;ircl, lnstill1tc. Food Excha11oe l,i!lt:5 Fo r M 1c'Ol
Pla1111ing . R-Rl P\1bl. No. 57-ND 8(3) 1994. FNRt. DOST.
2.
Food and Nutritio n Research Ln~itu te, Tnbl.: of Weights 1111d Mcam11"1:$. and
Table uf Conversion Fl1ct nrs. 19,. FNRI-DOSr.
3.
Food and Nutrition Research lnstih:ile. Re·rorw11t"tl(led F.r1crpy and N11trit·n l
Intakes. Pltilippin~, 200:.1 Editio n. FNRl-11OST.
4.
Gibson , R.S. 1990. Pr-inc:iplcs q[N1r.cririorml Assrssmt"nt. O."rfonl Unhcrsily
Press, New York.
5.
lnte rnge m:y Com m it tee o n Nutritio11 Educution (lCN E). llgn'cult um/
Research Service. USDA. Nutrition Proi::mm News. Scpt.: mbcr-Octoocr
1964.
6.
,felliffe, D. B. 1966. Assess ment of N 11triticmnl Status of tlw Commu nity .
'Nl'fO M onogr. Series No. 53, Gt•nc.,,-:1.
7,
M e ndoza. T .S., Ocampo. M>L>. ond Onrhn. C. V.C.. 2003. U:::rT·s Manual
011 the l11ter11ational Reference Standard (]RS) (;rp1NII Ta/Jlci: and Cltarrs
Adop ted fo r Field Use in the Philippir1c$. FNRl, 0057'
8.
Pecken paugh, N >J >, 2007. Nl1tritiorr lisscn rials a11d Diet 111crc1py,1oth Ed.
Sau nde.r s, Elsc\"ie r, S t. Louis. Missou.ri.
9.
Seidell, J .C. a nd Visschcl',T. L S. 2004. Public 1-fralrli .-\!'peers n/
Overnutririon in: Public Health N u.tririan, eds. Gibney, ~LI.. Mnii;ctts.
B.M .• Kearney, J .M., a nd Arnb, L nlnckwcJl, Scicnc:.t, UK.
10 . World Health O rganiza tio n, 1988. Vitamin II Su pp/cnrnn tntion: .A g uide
to their- use i n the treatment and pnwention of vitamin A defi-c:ioni:tJ a_nd
.'\'.e rophtha lrnia . \-VHO/UNlCEF/ IVACG Task ForC\!. Geneva
11. Wo rld Health Orga niw.tion. 2000. Mcmagcmcrit of the cltild w ith a serious
i nf ection or severe m a.lnutrition Gu idelines / or-care an: tl11:J irst n:ferrol
level in developing co1m tries.WH O/ FCH/CAH / oo.1
12 .
W o rld Henltl1 Org:m izatio n. ::?Ooo. Obesity: prt'irt'nting and m anaging the
g lo l>a l epidem ic:. A rep ort of IVHO Cons11 /tation. Te<. Rep. Seri~s No. 894 ,
Geneva
34S
Chapter 14
APPROPRIATE
TECHNOLOGY FOR
THE PREVENTION
AND CONTROL OF
MALNUTRITION IN EAR LY
CHILDHOOD
A1'aceli S. Maglaya
NU T RI T IO NAL STATU S OF FILIPINO CHILDREN :
CON SEQU EN CES AND IMPLICATIONS
In Ilic 11p a n of fift een ycors from 19 8 9 -90 to :,mos, there Ji on been a r c <.lu ctio n in
111c p rr•vttl e ncw r,( 11nrl crwci;;ht ( from :~,1-5 p c r c<: 11 1 , ,, 24.6 p e ret: nl ) 1111d un der h e ight
(fr,,m '.l'J .<J pr·n·•·n t , ., :.1r1. :i rwrc r:n1) among J/i liri n,, c:hi l<l r cn a gr;s :1.cr0 ' " fi ve years
(FN H l - l><JST, :.,11117, p . 14 J. 11,,w,•v1•r. acr·1,rd i11 Y, 1,, t h e l'h ili r>r>in •~ N ut rit iun l(uport o f
l hc fl<1<1rl ;ind N 11 tri1 i,,11 Jnr,1i1111•: . /)1:1mrt m 1:nl
S c it:m .:•: ,m d T•:d 111o l•J~Y, 1h r; ,,vcn,11
l r•·n d >< i 11 rJ.,.:,1r· 1/i;,1 ru:o l n11 1r, 1i,,11 r1..:11i:,i rn, Ir, lw 1111; , ,v,; rridi n).\ prr,b l1: n1 H111r1r11~ th e
v••ry y ,;1111,1, ;i mf ·,11II 111:•·d .<i 1,, t,,, tl11• prit.1ril y ,.,,,,,.(: n 1 (J'N IU - f)OST, :;,, r 1<17, p . 15 ). To
r•l u nd::.1,-. liir,d11•mi r~; J ;u, ..,-,,.,n,, nr d ,, 111: i ri 'l-<ir,:s n :w: nlcd 11,:,t lr,w hr•rJJ<J)<,lohin l1:vcl11
(l n<l lr:11i11Vi 1r,,n dl"firi•·nr·y il n<! mi;, •1r I D.I\) ;unrmg i11f,. nt :<1, '7· ! 1 ,n, ,n t h !< (()(,. ::.! '½,) nnd
onr• y ,·ar• o,l rl c l11l rl rr·n lr,:f¼> w•·re ,,( liiv,h rrw1~,11 i l ud1 : , wit h , ,v c r - a ll r11·cv al1: n , :r; o f
r1111·n1ia :1111•,n~ 6 rrirm l h 11 tr, !'i y,,;, r,, ,,Id h1:i11 K ::2.,f ½. . ' llH! p rr:v:i lc n c ,, of v itru11 i n A
,1 ,-fw l ,· rwy (VAl)J :,rri,, ris~ i11fan1'1 hM, h •·r• 11 in1•r,•:rnl 11~ frorn '.{7,:,% in 199 '.$ t r, '17'X, in
~ri,,:1, w ,1 11 ,,w·r-:il l r,r,-v1tl1•n<:•· , ,( 40. 1% am ,, n v. c:hildr<:n fi ve y,;a m <1( us;1: un d nclr,w,
i rw r,·:11,i n1~ , J.,.ir ri<ik 1,, ,,,.,, ,, rr·<,i;.; t;,111·1: 1,, di ~,<::rn,:, r,11ir J~r r,wth , i11al1i lit y 1,, •,,;r• i n di m
Jli:,lt t , ,,,.,, .,,, ,v,1 y ,,( t lw r-y•·'> tr, hri?,hl llithl , dry111:w, ,,( th•: 1:y1! , a nd l,l in c.l11 rm11 i11 ncvc n :
1•:J1>1•', ( VI~ H f f >( J~T . .,,, 111(,, p . 7.-;J. ·11,,, pr••v;t1 ,,n 1·,! (If zi n c d trfid , :111:y H m, ,n J~ i, 1(:i11 1H w 1-111
9 1% wi t h 1h1• f1,11r y1•:,r-t1 ltl , t1il rlr1•n ti:,v lu ;~ t h,, h i;~l11:.111 p n:v:1l1:n <:•~ of ;d11(: di:fi<.:i•~n cy
al 1:~:7'x.. ·11,,, , ,vr•r-all p , ,,v:, 1,·rw•· r,{ 1.iur rlr·fidc• n•:y :1111m1g i11fa111J., a 11d cl1ild n : 11 u p lo
f1v1, y 1,11 r11 ,,f ns:.•· vm t ,•,,r,,,irl•·r•·•l 111 r,•l1•,:, 1,, a t 'J.H'.I(. in :.i 1J<>:1. Zi11 t: (l, ,fii; ir: 11 ~:y r:• n1 t ri l>u t <.:tJ
to l m-r••r,•,•·d rai n, rr( inf,., ., ,,mr. li,I,,. di:1rrl1,,;, ;11ul pnc•11rnr,ni;, , :,.I n c· h <:ins•, :, n i1n por1.a nt
frH'l<, r in 1,,,.,1 iin m11r w rl••f• ·m.•·., / I l<1f t:, ;.r1t·J l~r, ,vrn , 2 1,04 ). <; Jl11I a ! II prrJd 11c:l i1m nnd
11,;,11·•, rml n 111( r:,1 l, ,rr . ,.,,,,n t<l 111vrolv•·d in rapid aynap li•· cr,n,w<:tir,n;, ;in cl wi r ins~ i n b r:1in
d• -v•·l•,p111••111 il 11r111;~ f, •t:r l 1,/r• Jill r-:;rly r-1, ilrllir,r,d , arr· ;,ff1•t•Jr·d l,y 111 :tl1111i r i1 ion . Iro n
cJ, ·f1 ,•trrn-; 11r1•· 1rt i;i , :;11J 'l1••" in,pnl ,.-.d l 1r;u 11 •J••v•·· l,,pn,,:rit dur· t,, d,-cr1· r1}!J• d r,11:n rn i ne wh ile.
fr,I,, , ti 111 rld 1r "''"'>' ,·;11,,,, •. _ IJl'1tr.1I '"'"' r1,-r, -,·1 fr tJn d •· fl<'i <•JH')' i n Hlrl fJrt;t, t ltc nr·ona l e R
i" r •·h , 1,,,1 Ir, anti;, ,.,,,,.,..q,1•·ttr·•· ,,I pr,-v:1l •·nr·1• ,,f r11 w r11l a :11 11r,n 1~ rh,·ir p rr·g 11; ,11t rn o l h (;n;
( -1;V / K ) i t11d IJ><1.a1 tr1K nr nl hn>1 (-1 :.i .:/K, ) . llli ,, m p irira ll y ,w p pr, r1 •·d by I I I r : :.ioo:3 P l Ii Iip pi rl C
N11 t ri t l11n Rr•pmi ur llw l•:-..' HJ , 1>0/iT (:.tC> tl 6, p. 7 1).
,,r
3 116
Protein-c al o ric malnutril itm ranked numhc r JO ;1s ca use o f child mort:11i ty amon g
J'lilipino c hildre n one lo four years o f a~c: ( Nati,mal Epidemiology Cent e r, 11epartment
of J·Jc alt h , :.ioo2). I II the snmc year, Lh c tnr tl, rec causes or murtn lity in early chilc.lb nod
\'/Crc p 11c11 ni o 11ia, d iilrrl u;:, ;, nd m,,,,slc:,;, ;111d ,,ftc11 a ('r,mhim,t ion of thcqc fa ctnrs with
unc.lcrlyin~ m al1111t.rit inn. Th ns<, who ~,, rvivc d ea th will ca rry the residual e ffect.,; of
cliild h nocl 1111dcr n ut ritio n, as le.'l'i fit :,dulls wi th low prod uctivity potential.
Accordi ng t<J the f-'N l{f 200s Phil i pr,inc Nutriti11n l«:port, the triplin g uf the preva le nce
of c,vcr·wcight e hildrcn frorn 1998 111 11005 ( fr om o.o'¼i t.<i 2.0%) s h!Juld not he taken
fo r grn nt cd , p u r1i c 11larly hcca11sc of the r.:me r-i-:ing lifostylr! -rcla lc<l nrm•commu nica hle
diseases u nd risk fo,:1r1n: :;uch m, di uhc t1:s rncllitus , r.:mJi,,vascuh,r rfo,e.ise and
hypert e ns ion in 1.itcr li fe am.I e ve n am<in)c\ childn:n in s <irnc cases ( j!fJ07, p.:30).
community he alth m1rHcs play :i c:n,t:i;, I mle in the prev<:ntic,n 1J nd co n trol of
mnlnutriti<m i111:,1rly d1iklh111,<l, IIy fr1cus ing (m the rcas<m !. why m;ilnutrition per~; sts
nn d w1,rsc11H in t l,i,; :i;;c: ;;mup, they 0111 ma;,cinii~.e 1lw ful l p,, rticipation of familic.-i
and c.:11n:-;;ivcrs 11n tl,c Ullt: of nppmp riatt: tcchn ,,l,~gy t,J cnh:inc.:c family cnmp<:t c nc,i es
,m food Hclec: tirrn , prcp,,rntion a ncl feeding using 11,c;,lly ,,w1ilahlc ancl affo rcl ubl.c food
sources ;ind ,,pt ifJn~.
CAUSES OF MALNUTRITION RELATED TO FEEDING PRACTICES
Stu dies a nd expe rience s how that the ca us e.~ o f mi,lnut rition, particu larly
11 ncJ c; rnut rili on, in c;,rly <:hil<l ll'1o d rc:latml tn fcccli n ~ prnc:ticcs inc lud e: (a) non
hrc;, s t fc:titl ing or •!:srly wc:rn ing; Ch) absence IJ r tir in ad11q1i:.1t,~ r.-o mp lemcntary feeding
during cxtcntl1:tl p<~riods ,,f hre:is tfectli ng or dcpcncl<'ntt 11n :, r1ificial feed in g; and, (c)
J;1ck of ri r i11:1clc1p,a t1: 9kill in n11rnu1~in~ d ia rrh r:u :it hornc. d iarrh<,a be ing the second
:imnn~ t h e l!.!tidini.: c,1uf.Cs r,f child m,, r1ulity and ,1m,;ng 1h1; Hlf> 3 m ost commc,n causes
of infn nl clc:ut hs ( Nu tion;.d l~pidc m io lo~y <.:enter, Department of l lcalth, :wo2).
NON-BREAST-FEEDING OR EARLY WEANING
In a study o n con lcm pornry pattcrn11 ofhrem;t-fccding involving countries like India,
Chile. Ethiopi;1 , Nh;c ria, G 11ntcma l:1, llun~ary, Sweden, Ph ilip pines :ind 'l...ain:, it was
1lli n w11 th a t the l' hili ppiru:s ha.~ the lrJ wcst p1:rr.:1:nta g1; of mo lht:rs h masl-fced ing the ir
ch ild1 •·11 at birl h :,c rn,s so<:i,,-c:cnnomir: lcv<:ls ( W 110 19fl1, p ,:M)- 1\1:ycmd 1h ree m onths
o f c:hild's llJ!,'', th•· l' hi Iippirn.:s r:rnkr:t.l lhi rd lri l:hflc a nd Gu:,t ,am:ila :inwn~ the countries
wi t h th;• low•"-l l 1ti: r1,r,11 ta)(< ' of urban poo r um 1l11.:rs br,:ai;t -fl:ccli11g. II rank,:cl v ;cnnd to
Chlh; u m,111i.; 1l11; c<>ttr1triw; with th e l<iwes t percc ntogc o fnirul rnrithf:rn h rcnst-fc:cding.
'l11 c sa111c Ht111ly s h,,wcd t.h:,t ;,111n11g ti,<: u rh;,n pc,or, th e nccr,nd i; h,,rtcsl tlu rnlion of
l,.-c ,L1o11-fct:d i11~ is in I he l'hiHppinei; wh C!rC 2/~1 of all infontJ; h:11] been wc:mcd h y th e age
of Rix mont lis (p.:1:J).
Eitpc r ic m.:c flh1Jws that urhri n poo r mothers ,ire lcsi, likely tti h ri::;1stfce d their habics at
r1 lo ng1:r pe riod (if th,!y arc :1bk tu brc:.a s t.focd at :ill) because they join th e l:1hor force to
aui-rncnl the rnrnily im;om•~. In s11mc arc:rn amr,n~ th e urhan s lums , these mo thers are
thl! Ho le hm:i d,...,.i11n c rs , wilh hush;1nds he co rning lcsii able tc> c,,rn for tJ, e:ir famili c.,;.
Am ong poo r famili es, hahtcs who urc n ot brc:;1s1-fed fire likely to s uffe r from
mu lnutrition c:onr;ic.lc ri ng the unava ilability of low cos t, high ly nutritious aml easily
d lgcstih lc rc pl.iccm cnt for breast milk.
347
ABSENCE OF OR INADEQUATE COMPLEMENTARY FEEDING
DURING EXTENDED PERIODS OF BREASTFEEDING OR
DEPENDENCE ON ARTIFICIAL FEEDING
M:rn y infanL-. a nd to ddlers s uffer from malnutriLion becaw,e inudcquate mi l k
int:-ih.: i, 110 1 auzm e nled by ot h er foo<.I so urces to m ee t t he bod y 's r cq ui rcmenL.., f,,r
c alc, nr,,, p rr ,ti,,in , iron , o tl ciu m , ,;inc, vi ta min,\ and o the r nu t ricnt.,;. T h ey;, n .: 11 ,,1 J!,ivr=n
c 0 >mple mcnt;;i l")' f,,,xJ in t h!: a m ou nt ancJ kind n eed ed fo r v,rowth and d r:vc:1,,p rr u: n t.
.:",l o rr•1 ,vc• r , non h reastfeedin~ o r e a rly wea ning encourages de rend enc:c on :,M ifi<;i;,J r, r
h<1ttl~ fr•,ding. \\'ith t he inc reas ing cost o f comrn erciaJ mi l k formu la , p,,,,r fom ili,.:s
re• ,,rt Ir> )!.1·.·ing hi~hl), diluted mil.k form ula lo th ei r babies. AmrJng ud;a n pr ,r, r f;, mi liC!.'i
.,, 1,,, n·ly 1,n h<,ttlt- fc:.-rc<l ing, condensed mi l k is wide ly u st, d bec:,usr: ii i s c:h <::,rer and
last'< 1<,ng<-r h; lho ut refrige ratio n co mpared to o the r types of m i lk in li quid form .
Con."id!!ring t ha t co n densed milk contain s mo re sugar than pro t·c in , babic,s r C!cx : ivl:
inadequa te nutrien t'> ...._;th the absence of o r inadequate cornpl e m en t,11]1 feed ing.
LA CK OF OR I N ADEQUATE SKILL IN MANAGING DIARRHEA AT
HOME
:.fill, and c,•her cnmple:m.entary fec<ling are often disco ntinued w h en babies a n d
trxlcl!:'r-; ha·-~ dia rrhea. ~l ath ers a nd othe r care takers are afrajd to give mi lk ,md i.o lids
.,, 1.h~1r id· chll-1.:.,n ~use the !an e r p ass m ore stools ..,,;th fo<xl int:Jke. ·1111.: lo ,-., rif
fluid- :md au,r.~m... du~ tr.> diarrhea i!; aggravated by the v,·i thd r.awal o f m ilk and food .
Th1;~ rbarTn•~ n'!!p<; t<, c;,o...--e m aJmu.nt ion ,,,,,hich, in turn . leads to a m;i l:, h<;orption
r,~r,t; ..... ~a· =···•=:s di.-.:Thea ,,·o~S'!- S tudies have sha.....-n that ma ln <,uris h e d chi ldren
M··'" d~a:.n,::,: m";n, ,,ft.en t:.hat ·.-.·ell -noiuished ones (Cutting a n d Savagc 198 1, pp.
13-1,1J. y,.;,. L"- uvi ·.-ierr~"-C-/ d!, uf malnutrition and diarrhea. They eac h make the other
. . . . ,..,J~..
INTERVENTIO·NS USING APPROPRIATE TECHNOLOGY
rr-•f!r.~.i•,::.rtt> ~ e-;1:nt o n::ontrol malnutrition in earlychfldhoo<l using appropriat.e
eri-.r;r;m-. i:1d::,:,e: <a1 Increase f.a:mit;· comv.aencies on how· w m r,nitrJr nulriti,:mal
..:.,. · •1• ~:-~
-.: :,,.u;::. u.ru·e 1~ or<lel- w ace d ress nutrient inadequacies thru pro p(!, fr>Od
-e. ..- , •. ,....._~ ;......,-,..r::,·..,-,-:. ba.~
r:n ..,pecific nutrient functions and foo d <;rJLJrcr~: ( bJ
re;;a:,;, ,: v,.:.-:- .. :c-.,,;t:.u:-· ~~m i tJf t,:.tj}:,· ciigest:ible, locally availab le prr,te in s,,ure<;S;
«:.1 ,. •-~~... - ~ -,,~~!: ~"-; th1: : =mmend!!d energy and nutri ent intake( R.E~I ) fur
r.r.·· r· an-:::-~- pe:- &:.-: a;;tl. <c>appropriate home management for diarrhea.
FAMILY COMPETENCY-BUILDING ON NUTRITIONAL
STAT U S OF CH I LDREN AND OPTIONS TO ENHANCE PROPER
NU TRITI ON
:: hel-.:::1: fami~ u a c ~d the irec:lities o f undernutrition among th e young.
2 · - r I a~ ·-,;;-,;e::-...b!e r:;~mber<,. the CH}.: c;m us,, experiential l earning
a pproaches
w ~.h,!' ~ ·J,.. f.a::nil.'!' ;,:Ow!:} t<.1 kn~ .rt thei r lived experiences o n food selection.
ttr-d ~·~.:~ p~;;,i:-ic-.,.... u~in g thei r ~~ nutri ti r,n;d a ~~es.smcnt d ,a ta o n
Th r'7UJµl p ra('tlCP - - ; ,on<: on t aki n g v.·eighL
J-.,-~h • c-.c-:.-~.n~ ;:;d c=roir:2 dieta..";, in.take usin~ lhc dai ly food rPcord ( Sec ch a p tc.r
13 r..c:),...:,, .,.:-. .: <f1>:r fa::iil:, c--c.r.:-t2ke!r'S can a ppreciate earl~- an d r egu la r m o nito rin g
of n.i: :.u•~ ~:t.,n..~ r.,f ,h.'?ireuldn:n. The au.rse-catal) st pa nner can use these da ta as
WI.L"-tr.Tt .ion, 1.n ba: :::.rapn p:.e chan o r pictograph to help fami lies visualize I.he nature
a:-.-! e:w:1e.;:;: o ~ rr;2!r;.;rrTTtit1a i n oroer t o address its specific causes. For ex.am ple, based
p;-~:-2-.._1, n
. . . - ~. :
34B
!-i,- zm ,:>1 <121ly f,,.-~ 1:1wt:.
d ie t a ry intake C0llut1:,J from U11.: di,i ly food n:C(,ro, the families 1;,1n ,111;,fy,.r;
s pecific nu tric.: nl c.lc ficirJncic!'I f mm the n11n-,; 'r, explici t ilf 11sw,tion s, pict 11n:.~ :,nrl '> imp!•:
explanations mi nut ritional a~sl,s,,;me:n1 d:,tu , their imr,lir:atious u11d crin,;,:,Ju<:nc,,,- c,r
proloni4!.!<l nut ricn t <lcficif;!ncics. Using th e "fnr1k-thin k-a1;'1 ,;1clr: rif 1111: p:1r1i,:ip:J1r1ry
approach, th e fo 111 ilics arc mr,t iv:i tcc.l to ;;dc.lrc.% the ide11t ifi1:d prril,l,:111. Sp<:1·ilif·-.t•:r,s 1,i
(:[lrry n u t ti 11.: r,plior1:, <:Hn he: ,Jc.n<: thmugh i,d,; qUJJI<; p rac;I i<:t: M:s~ ir,m, •;n fo,,d !.<:l•:ct irm ,
pre parat irm a nd fcc:din i l<:chniques. The cr.imp,,t,mcir:.<, Ir, c;,r,y 0111 1hr• inlr:rw:ntion
options can l,c s u~lai 111.:d t hro ugh e nhancin g tJH, w1Jrkabi li ty CJf nut riti(,n optir,m; (Sc:c
chapter 13) :rnd affirmation of fomilic:.r;' sense CJf cffiC<J<='J in handlin i; lmpli:mcrllalic,n
problems and la pses .
011 the
REGULAR COMPLEMENTARY FEEDING USING PROTE IN
POWDERS
Low cos l, easily digestihlc and highly nut rit ious food sou rces nf prr,tein (:.,n be a tided
to th e diet or i nfonls ,rnd trx:ld lcrs who are usually ~iven ,,nly pl,11 n ri c,;, ,,th1:r cerr.,.,J:,; nr
root cmp, for (;(,1-nplc:nicnlary feeding. Ho m !:rna<le prot,.:in p<,wdr:rs c:in b•· prt:pa rc:d
using lor:;tl ly ,ivailahlc: for,d sw:h :as s mi.111 s h rimps (1: .g. "1, l;,man.( :md ·u.guntr,n"},
small fish (r:.g. "d ilis'·, "hiy:,- , ·ayungin") and dried h<,ans ( c . f!,. m1m!!,Wl, ,,:hile, black
and red hc:snsJ. Prntcin a nalyi,is r,f specific type.s <if )()<:ally i,va ilablc fr,Qd wa;; d<Jnl! by
the Philippine: I nstitute of Pu re and Applied Chemistry. Table 14.1 s hows tJ-11: proLC::i n
co ntent of lh c:se lir, rn i:maclc p rotein p0wdc r.s..
Protein powders ,:an be woked for at least 5 minute!; with boi h:d rice ond sa nll'-e<l c,r
stewed vegctabl<:..c;. Sugar a.nd tJ il t:a n be added in the mi zturc. PO\,:derr:d hcans e;.,11 l:x:
given to in fants a~ ea rly a<; th ree or four months in case.'> when they are n <Jl br1.:as tfc:d
or are suffering from m a lnut rition. Powde red shrirnpr. a n d fis h can ~,,, giv,:n at age
six mrmths and older. 'Jbe amoun t to b<: givc:n dfapends upon the. protein crml{:nl of
the locall y a\'a ilable food and the recomm ended nutrient intake (Rl\'IJ for infonL,; 11nd
toe.Idlers pe r day (see T a b les l4.1 and 14.2).
TABLE 14 .1 ANAI.VSIS Of ~flllOiidN CONll!Nr GI s,,a;a. r,,'ifs
OF LOCAU.V IN/IAAINEJOOD SOURCES
Smail Shrimp
Small fbh ("'dffls"}
Monao
WhiteBeans
BlacklleilllS
RedBeans
349
Toddlers
.:1.-3 years
2'l/3 cups
(cooked)
1.small piece
5 level tsp.
6Tbsp,
4Tbs p,
81/2 Tbsp.
101/2 Tbsp.
10Tbs.j::,.
11 Tbsp.
:lkup, cooked
'4 Tbsp .
sp.
P•
The following section of this chapter describes the procedure.in the prepar ation of
specific types of protein powders .
Powdered Small Shrimps
1.
350
Clean the s hrimps. Rem ove tl1e d irt and let water pour down the shrimps in
a strainer. Be sure to remove the antennae of the ''tagunton" (shrimps bigger
than the "alamang").
2.
Steam the shrimps.
3.
Sun dry in an alumin um ware or flat basket ("bilao") placed under intense
sunlight. Cover tl1e container \\ith clean cloth to keep away mes or dust . If the
s unlight is not enough to dry the shrimps thoroughly, toast them in low fire
while stirring constantly.
4.
Grind oi: pulver ize tJ1e dried shrimps.
5.
Store in a clean, d ry, ai1·tight bottle.
powdered Sm all Fish
1.
Clean t he fish. Remove tJ1e seawc1.-ds o r other dirt and let Wtltcr pour down the
fish in a s trainer.
·
2•
sun dry or toast u ntil thoroughly dried . Follow the prowdure (above) on how
to su n dry or toast the stu-imps
3.
Grind or pulve rize the dried fish.
4.
Store in a clenn, dry and airtii;lit container.
Fish and shrimp powders must be prepared using fresh ingredients. Otherwise,
dried fish and shrimps available ill the market may contain allergens., or may have
b een frozen too long b efore drying. 1bese can cause problems to the infants and
toddlers. The advuntage of sun drying can be maximized by preparing the protein
powders in the summer months or during. sunny days.
Powdered Dried Beans
1.
Soak the beans for two hours.
2.
Boil the bean s in t he water used for soaking. Make sure tllat the amount of
water is just enough to m.ike the beans soft. ·
3.
Mash the c.o oked beans.
· 4.
Sun dry or toast until thoroughly dried. Follow the above procedure on how to
sun dry o.r toast shrimps.
5.
Grind or pound into a fine flour.
6.
Store in a clean, dry a nd airtighr con tainer.
INCREASE KNOWLEDGE ON THE DAI LY RECOMMENDED
ENERGY AND NUTRIENT INTAKES (RENI) FOR INFANTS AND
TODDLERS
.
Bodybuilding food sources are critical for growth and development during late
infancy a nd early childhood especially after the weaning period. Infants (6 mont.hs
to less than 1 year old) need 14 grams of p rotein and 720 K calories per day while
toddlers need 28 grams of protein and 1070 K calories per day (FNRI, 2002). Table
3S1
8 shows the daily RDA based on the RENI for babies and toddler s. Note t hat p roteia
powders are recomm e nded in place of whole milk, m eat and poultry as bodyb uilding
foods. Meat and poultry a re \Jsu al ly more costly a n d not a s easily che wed as p rote in
powders by infants and toddle rs . Considering the p ri ce of commercia1faed w hole milk,
protein powders made from less expensive, locally available food sources o f prote in a r e
considered as a pprop riat e technology option.
The daily RENl from protei n powders a nd other foods can be divid ed into sever al
feedi ngs . Infants ant.I todd lers may need to be fed m o r e frequen tly than o lder ch ildren
an d adu lts considering th e ca pacity of their stomach. Certain beh aviora l characteristics
such as s hort attention spa n and preoccupation with n e w found freedom d ue to
increasing locomotor develo pment among older in fants a n d todd lers m ay decrease
their interest lo finish a se rving full of foocl in one meal t ime.
APPROPRIATE HOME MANAGEMENT OF DIARRHEA
Many families belie ve that it is wro ng to feed their children suffering from diar rhea.
They h ave noticed that th e diarrhea seem s to stop sooner if t heir children are n ot given
food. As ex-plained earl ier, starving a chi ld with dia r r h ea makes his nu tritional state
worse a nd h e will h ave m ore attacks of di arrhea lat er. Families need to know that the
two-part oral therapy of fluids and food can prevent many hospital adnussions and
many deaths from b_oth dehydration and mulnutrition.
Adequate fluids must b e given as soon as the child first begins to pass diarrhea stools.
At this time, extra fluids such as water, fruit j uices, s oups, m ilk or w hatever the child
drinks can re place the ones lost du e Lo diarr hea. When rehydration is not sta rt ed before
the child begins lo sh ow vis ible signs of dehydration , the amount of o r al rehydration
solutio n (ORS) containing sugar and salts that must be given is d etermined b y the
degree o f dehydration and the weight of the child. The guidelines a re describe d below
(Cutting and Savage 198 1, pp. 4-16):
Mild dehydration (5%) - characterized by thirst , dry mouth, less urine, weigh t loss:
Give 50 mJ. ORS/kg. body weight in 4 -6 hour~. ·
Moderate dehydration (5-9%) - characterized by s unken fonta nelle (for babies less
than 1 year old), sunken eyes, rapid deep breathin g, Joss of skin elasticity: Give 75
ml. ORS/kg. in 4 -6 hours.
Severe dehydration (10% or more) characterized by weak pulse, cya.ilosis, cold
limbs and/or com a: Give 100 ml. ORS/leg. in 4-6 hours. May need rv fluids and
hosp ita1i7.ation. If a child needs to go to the hospit al give him oral fluids on the
way if h e is conscious. With ORS be will not be so seriously ill when he gets to the
hospital.
·
While diarrhea continues ORS must be given i n the same volume as the fluid lost in
the stools. If the eyelids become puffy, s top giving the ORS and continue giving other
fluids. Start ORS again when puffiness is gone and if diarrhea continu es. If rehydration
is slowed up by some vomiti ng, additional r eplacement fluid must be given.
Diarrhea due to infection is the body's reaction to ge t rid of the toxins p r oduced b y
microorganism s. With d iarrhea the toxins are washed awa y from the body. Drugs that
aim to stop diarrhea are n ot e ncouraged becau se these result in the absorption of the
toxins. ORS does not stop the diarrhea, w hich may continue for some days. However,
ORS reduces the danger of diarrhea (deh ydration) beca use it replaces the essential
352
water and salts lost \\ilh each d iarrhea episode.
some h enlth centers in th e ,; llagcs or "barangays· supply patients "ith prepacked
oral r ehydration saJts. Each pac:kel is d issolved in one liler of the cleanest dri nking
"·ater availab le , ,~ith ius tru cti ons to d isc:ird t he solution if not ta ken within 24 hours
aft er mi:-.ing . If the or al r ehydratio n packets are not avai lable. home-made ORS can
be prepared . lfased on the Reduced Osmol.iritv Formu la (WHO/UN ICEF, 2004) of
13.5 Gm/ L Glucose and 75 mEq/L Sodium, home-made ORS c:m he rn ixe<I using 3
level huusehold teaspoons ( 15 grams) of suga r and i/3 level lea!-poon of in<li1.ed salt
dissolve<l in 1 liter o f the clea11es1 drinking water nvailablc (prefcrnhly cooled boiled
,-,ater). 1f rock salt is used. 1/., level of hous<Chold tca$poo n will give app roxima tely
th e sam e amount of sodiu m. The reduced·osmolanty OR.S addressed the concern for
occasional hy pe m at remia from the standard ORS formula . Howf.'Vcr, the new ORS
showed increased risk of hyponatremi;i (odds ratio 2.1 ) (AJ am & otJ1cr.:. 1999). SbouJd
there be earl y cl in ical indica bon of hyponatremia, such as lethargy or wcakne.,;s, the
child must b e brou):\ht immediately to tbc nearest health facility . ln the interim. the
child sh ould be given foo<l sources o f sodium.
Juice from citms fmits such as o range and ca\amansi can be added to each cup or serving
of ORS to improve its taste. These fniits arc rich sources of potassium, an important
saJt needed by t11 c body. Another liquid source of_potassium is coconut· warer.
Wboever m ixes and gives t he ORS must ta...<:te it before making the sick child drink it. It
must not taste more salty Lh an tears. Too much sall cnn res ult in hypematraemia (high
]eve] ofsodium in the blood) which can cause fits and brai n damage. W11en the solution
js very sweet the diarrhea may continue longer and the child may lose more wate.r.
The ORS must not be contaminated "ith dirty hands, teaspoons, cup and storage
vessel. Once mixed the ORS must not b e used after 24 hours.
The ORS must b e given frequently and in smnll drinks . Following the guidelines on
the amount to b e given, the fluids must not be given more tha.n 1 teaspoonful (s ml.)
every minute. IfORS is given too fast. the child mnyvomitor refuse to take ony more. If
vomiting occurs, give drinks of about 5 -10 ml. (1-2 teaspoonfuls) every 5-10 minutes.
Tlris allows more time for the fluid i.n the stomach to pas.s into the intestines to be
absorbed before the next drink is given.
Milk and soHds comprise the second part of the oral therapy for diarrhea. Mothers
need not stop breast-feeding their children suffering from diarrhea. Infants and
toddlers taking solids can go back to normaJ diet after 4 or 6 hours of oral rehydration.
Mothers or other care t akers can give easily digestible food such as soft-cooked rice
with protein powders and stewed, mashed vegetables. Ripe bananas ("latundan") can
provide additional potassium. Fats or oil can be added to the diet only when the child
has recovered from diarrhea. Solids can make the child pass larger stools but that does
not matter. Uthe child vomits food, give ORS for a few more hours and tty to give food
again la ter. [fa baby vomits breast milk, let the mother express her milk for one or two
feedings. Start food again as soon as possible. Food is a very important par1 of oral
treabnent. After the diarrhea bas stopped, the child can be given one extra meal each
day for one week. This will help him make up what has been Jost .
Diarrhea due to infection can be prevented by making sure that the food and water
taken by-the. child are clean. The t hings used for eating and drinking mu!it, likC\\ise,
b e clean. Hygiene and sanitation are important aspects to be emphasized to p revent
diarrhea and parasitism, two diseases highly :related with malnutrition.
353
SUMMARY
This chapter presented Philippine nutrition data related with the nature, extent,
consequences and implications of maJnutrition in early childhoocL
Causes of
mal nutrition among infants and toddlers related to feeding practices and famiJy-b ased
intexvention options are described. Emphasis is gi.ven on appropriate technology
to ensure ad equate complementary feeding a.od accura te home management of
diarrhea.
REFERENCES
1.
Alam, NH, Majumder RN, and Fuchs, GJ. (1999). CHOICE Study Group:
Efficacy and s afety of oral rehydration ontl solution with reduced osmolarity
in adults with cholera: a randomized doubl e-blind clinical trial. Lancet, 354,
296-299.
2.
Cerdena, CM and otbers. (2002). 2001 ,Updating of Nutrition.al Status of
Filipino Children at the Regional Level. Bicutan: Food and. N u trition Research
Institute, Department of Science and Tech nology.
3.
Clauclio, VS. and Dirige, OV. (2002) . Basic Nutrition for Filipinos (5lh Ed.).
Manila: Merriam &Webster Bookstore, Inc.
4.
Corra, MN and others. (1985). Malnutrition in the P hilippi nes: A Task Force
Report. In Iglesias GU a nd others (Eds.) Severe Malnutrition of Filipino Preschool Children: A Policy Review_ UP College of Public Adroioistration and
UNICEF.
5.
6.
Cutting, W . and Savage, F. (1981). Diarrhea Management. London: Institute
of Child Health/Foundation for Teachin g Aids at Low Cost (TALC).
Department of Health. (1999). National Objectives for Health. Philippines
i999-2004. HSRA Monograph Series No.1
7.
Department of Health. (2005). Nation al Objectives for Health 2005- 2010.
PMlippines: DOH.
8.
D ian7..on, B D . and ViUamejor, M F. ( 1985). Philippine Malnutrition Update:
Focus on Pre-schoolers. In Iglesias GU and others (Eds.) S evere Malnutrition
of Filipino Pre-school Children: A Policy Review. UP C<;Jllege o f Pub lic
Administration and UNICEF.
·
9.
Food an d N u trition Rese;i.rch Institute (FNRl), Department of Science and
Tech nology (DOST). (2007). Philippine nutrition facts & figures 2005.
Tnguig City: FNRJ-DOST.
10. Food and Nutrition Research Institute (FNRI), Department of Science a nd
Technology (DOST). (2006). Philippine nutrition facts & figures 2003.
Taguig City: FNRI-DOST.
11.
354
Food a nd Nutrition Research I nstitute - Department of Science and
Technology. (2002). Recommended En ergy and Nutrient Intakes Philippines,
2002 Edition .
12.
Holz, C. and Brnwn, KH. IntemationaJ Zinc Nutrition Consultative Group
(IZiNCG) Technical Document #1 . Assessment of the risk of zinc deficiency
in population and options fo r its control. Food and Nutri tion Bulletin: 25:i
(Supplement 2) S94-S200.
13. KelJy, DG and Nadeau, J. (2004) Oral Rehydration Solution: A aLow Tech"
Oft Neglected Therapy. Prat.tical Gastroentorology. pp 51-63.
14. Maglaya, AS. (1989). Factors Affecting Weight Change among Ch ildren
Below Six Years Old enrolled at the Nutrition Program of a Selected Social
Action Center in Metro Manila, TheAnphi Papers, 24 ( l and 2), pp..5-4.
1.5. National Epidemiology Center- Department of Health. 2002 Philippine
Health Statistics.
16. Singer, HW. (1985). Priority Problems Pertaining lo Infant Mortality,
Malnutrition and Pre-school Child Development. In Iglesias-GU and others
(Eds) Seuere Malnutrition of Filipino Pre-school Children: A Policy Reuiew.
UP College of Public Administration a nd UNICEF.
17. WHO. (198.1). Contemporary Patterns of Breast-feeding: Report on the
WHO Collaborative Study on Breast-feeding. Geneva: Wor ld Health
Organization.
18.
World Health Organization Report: Reduced osmolarity oral rehydration
salts (ORS) formulation. Available at h ttp://www.who.int/child-adolescenthealth/New_ Publications/NEWS/Statement.htm Accessed 8/30/2004.
355
Chapter 15
PARASITOLOGY IN
NURSING PRACTICE
Winifreda 0. Ubas-de Leon
INTRODUCTION
Nurses perform important roles in the delivery of basic health services, both in the
rural and urban settings. They conduct health promotion, health maintenance and
disease prevention activities as health team members with U1cse designated bealth
education functions. They are challenged to help improve h ealt b and living conditions
through family and comm.unity empowerment. Recent studies have docume nted the
importance of political advocacy and client empowerment to prevent and control
communicable diseases in the community (Maglaya 1999; de las Llagas 1-999).
Apart from the nurses· major role on health promotion and maintenance, anotl1er
criticaJ area of concern is related with managing health 1,Jroblems/diseases in many
parts of the Philippines, especiaJJy in doctor-less rural villages wh ere comm unicable
diseases are prevalent. Competencies on accurate diagnosis for prompt and appropriate
treatment are necessary for client care.
lbischapterwilldealbasicaJlywithparasitesascausativeagentsofselectedcom~uunicable
diseases encountered in commu nity nursing practice. Some of the diseases, like
malaria, filariasis and scbistosomiasis. are endemic in specific communities because
of the presence of vectors or intermediate hosts in the locality. Others are prevalent
among population groups and marginalized cultural/ethnic communities where unsafe
drinking water supply, unsan itary waste disposa l and unhygienic practices are still lhe
prevailing conditions. Sections of this chapter \,ill discuss the life cycle of each parasite
to illustrate lhe foci of prevention and control measures. Appropriate Iaboratoryt ests for
diagnosis and management options for the communicable diseases are also specified.
Discussion on the laboratory procedures can be uti lized either as requL,;ite competency
for appropriate referral lo laboratory facilities or as additional diagnostic skill that L11e
oun-e practiti oner can learn for prompt and appropriate treatment. This competency
is especially u seful in areas where laboratory tech nicians are not accessible and drug
resistance is becoming a big problem as a consequence of use of r adical treatm ent
without laboratory confinnation of presenting signs and ~-ymptoms.
THE PARASITES
Parasites are organisms that live in or on the body of a nother organism for survival
The primary needs of the parasite such as food and shelter are provided by that otller
org;misrn technically know11 as the host. This relationship can be best exemplified by
man as the host and hook-worm as the parasite.
Parasitic organisms are found practically everywhere: air, food, water, soil, inanimate
objects like linen and clothing. Some are carried by insects like bugs, flies and
mosquitoes, while some sunrive in some animals like swine, cow and cattle. While
majorit:y of the parasites are found within or inside the body of a host , there are those
that are found outside tl1e body of the host like skin miles and head Hee.
356
fhey are able to invade the host using different portals of entry, but the most common
is still through the mouth. A few are able to actively penetrate the skin or are passively
introduced into the host by some insects. lnfected individuals may or may not show
signs a nd symptoms of infection. Those who d o not show the signs and symptoms may
however serve as carriers and extra source of infection.
Most parasites live in h umal) a nd animal intestines, and are usually passed out with
the feces. Howeve r, parasites ha.ve also been recovered from other organs like the liver,
lungs, brain, m e ninges, lymph nodes, lymph vessels, subcutaneous tissues, muscles,
reproductive organs, blood vessels, blood cells and even the eyes.
Parasites may be s ingle celled culled tbe proto zoa or may be multicellular call "worms~
or "helminthes." T he collective term applied to wonns found in the human intestines
is hi ntestinal heliminths" and infection is "intestinal helminthiases" which is one of the
top causes of morbidi ty worldwide. The most vulnerable sector of the population.are
the children .
There are few parasitic infections which can cause death like malaria and capillariasis.
A few may cause p ermanent disability like elephantiasis due to filariasis. There are
increasing evidences today that associate parasitic infections with malnutrition, poor
. learning ability and growth retardation. Infected individuals oftenmanifost abdominal
discomfort, lack of appetite, hunger pangs and loss of weight. As a whole, parasitic
infections can affect the economic productivity and quality of life of an infected
individual in particular. If t he parasitic infection is present among a big segment of the
population, then the effect of this parasitic infection is magnified.
The following sections will discuss the parasites according to the different modes of
transmission. The life cycle of each parasite show the points where spread of infection
can be prevented or controlled. Illustrations of the life cycles were adapted from
l1andouts given to students of the course on parasitology at the Uniformed Services
University of Health Sciences in Maryland, USA.
DIRECTLY-TRA NSMITT ED PARAS'I TE
Enterobius (Oxyuris) vermicularis
This parasite is also known as the human pinworm or seatwonn.. It causes an
intestinal infection with worldwide disl-ribution. Jnfected individuals usuallysufferfrom
intense perianal itching whlch mayb e complicated w1th secondary bacterial infection.
Because of itching, most patients have disturbed sleep resulting to nervousness and
irritability.
Enterobiasis or o:-.')'U.riasis is observed in places where there is overcrowding and water
supply is inadequate for personal hygiene. Eggs of the parasite have been found in
fingernail clippings, door knobs, faucet tops. and even from the keys of the piano and
keys of typewriter s.
Eggs are deposited in the perianal region causing contamination of underwear and
bed linens. Outside the host, eggs become infective in four to sh: hours. Transmission
takes place either through ingestion or inhalation of the eggs (See Illus. 15.1). Infection
is easily transmitted to the othe.r members o f a family or a group. Adult worms may
be found crawling out of the anus but the choice of diagnosis is recovery of eggs using
the Scotch tape method in S\Vabbing the perianal region (See 11lus. 15.2). Specimen
357
collection is best done in the morning prior to a bath and/ or washing the p erianaJ
region like in defecation.
Specific drugs must be administered. Personal hygiene like proper hand washing and
keeping finger nails short must be advocated. Contaminated linens and clothing of the
patient must be properly sterilized tJ,rough boiling.
SOIL-TRANSMITTED PARASITES
Some para.sites .ire p11ssed out into tl1e soil, where they undergo further development
until they become inf~tive. These parasites r emain as major public health problem not
only in the Philippines but in many tropical and subtropical countries as well. Children
who live in areas where there is unsanitary human fecal disposal are often infected by
soil-transmitted parasites.
Ascaris lumbricoides
This is also known as the giant intestinal roundworm. Adult roundworms live in the
small intestines. Fe rtilized and unfertilized eggs are passed out by tbe female ascaris.
ln about two weeks, fertilized eggs develop in the soil into embryonated stage which is
the infective stage. Soil is commonly contaminated in areas where there ax-e no sanitary
toilet facilites or where human fe:ces is used as fertilizer in vegetable gardens.
Man acquires infection when these infectiveeg.gsareswallowed mainly via con tamin ated
food. Upon ingestion, the larva is released from the eggs and then undergoes lung
migration. During this larval migration, the patient will usually manifest pulmonary
symptoms like chest pain, cough and fever. Toe parasite will then settle in the small
intestines to develop into the adult stage (See Illus. 15.3). With the presence of adult'
ascaris, the most common SYffiptom is vague abdominal pain.
At times patients may harbor a high number ofwormsresulting to intestinal obstruction.
Some vomit out these :1dult wom1s as well. There are reported cases when adult worms
undergo em:itic migration to other organs like the liver and even the common bile
duct.
Ascariasis is established ·when adult wonns are expelled by the patient. However,
expulsion of the adults does not happen all the time, so in the laboratory, stool
e.-:amination is done to determine the presence of fertilized or unfertilized eggs.
Techniques recom mended include the d.irect fee.al smear and the Kato thick smear
preparation. To determine the intensity of infection, tbe Kato-Katz (which is n
quantitative metl1od) is recommended.
Tho patient must be properly treated periodically with broad spectrum anthelmintic,
because rapid re-infection bas been reported. Stools should be properly disposed and
sbou Id not be used !IS fertilizer. Proper hand washing must also beencou raged. Vegetables
that are usually eaten raw must be thoroughly washed before consumption.
358
Ponovato and do-nlop
In mu.co,a
/
Adu~ In lumtn
of cecum
,rvae
...-J
lla!Ch
:-:;nlHtine
~-~ I
M A N
___ llfil,...,...~ ...
w•
(lnf<!Cllve Sbg,>)
Egg on
Perlanal rclds
(dlagno1Uc i t.age)
EXTERNAL ENVIRONMENT
lllust,ration 15.1 Life Cycle of Enterobius vermlcuiarls
359
9-
1 - ~po .,_, ..,d of dop,.._.
-
.......- ...11 ....
t.o
•· Jtepl&.e,re taP4 cm .ud.• a.nd a moolb 1,
oUt w ith th• tl:nunb.
Illustration 15.2 How To Use the Scotch-tape Swab (Modified from Brooke, Donaldson
and Mltchelle, 1949)
M A N
Eggs In f«a
-f111'§~~~;------___;
)tll._~
Eoo
•1>9•)
Emb,yonatfd
with 2nd s~g• l.1rv;l
(lnfe<:tlvc stag•)
(dL>gno,rc
EXTERNAL ENVIRONMENT
Advane<>d
c;lea11ag c
Illustration 15.3 The Life Cycle of ,o.scarls lumbrlcoides
361
r
Trichuris trichiura
Tliis worm is also knowu as the whipworm because the anterior end is highly
atlenua tl'<l and the posterior e nd i.s thicker and more fleshy. 1t is another co mmon
intestinal worm nnd is usuaUy found together "ith Asca.ris.
Trichuris eg_i:s that are passed Ollt by the female wonn embryonate in the soil in two
to three we.-ks. " ·hen these infecti\'e eggs are ingested, larvae are released. They then
m igrate to the large intestine$ partic ularly the caecum. whe re they de,·elop i1lto the
adult worm:; (See lUus. 15.4). The attenuated anterior end penetrates th e intestinal
mucosa.
In light infection, the patient i~ usually asymptomatic. lo cases ofhea\'y worn, burden,
the patkul may suffer from abdominal discomfort and blood-streaked diarrheal
:;tools. Bleeding sites h:n·e been observed at tl1 e site of attachment. There are available
e,idences in the cases ofhea\'y worm infection, anemia may develop . Heavy infection
may, likewise, re,,- ult to rectal prolapse.
The d irect fecal smear, Kato thick and Kato-Katz techniques a re very useful in the
reco,-ery ofTrichuris eggs during stool examination in the laboratory.
Like J\scaris, Trichuriasis can be controlled and prevented through periodic treatment,
use of sanitary toilet facilities and proper hygienic practices.
Hookworms
These are blood sucking roundworms, because they can get attached into the intestinal
mucosa of the small intestines through their b11ccal capsule. This buccal capsule
ii; provided 1dth a definite dental pattern, which can heJp is species identification.
The two common species of hookworm are Necator ame.rica.nus and Ancylostoma
duo<lenale. lo the Philippines, Necator americanus has a wider distribution compared
to Ancylostoma duodenale. Animal hook,vonns are also existent namely: Ancylostoma
brazilie11se of cats and A11cylostoma ca11inum of dogs.
The eggs of these two parasites are very difficult to diffcreatinte. When these eggs reach
the soil through indiscriminate defecation, they rapidly embryonate and after 24 - 48
hours, the rhabditifrom larva is released. In about 7-10 days, the rhabditiform larva
develops into the infective filariform larva.
Human infection occurs when the filariform larvae penetrate the sk-in. After skin
penetration, the patient develops some form of dermatitis commonly called ground
or dew itch. The larvae then migrate to the lungs and the patient manifests pulmonary
symptoms like coughing and v.ihee7.lllg. Then the parasites proceed to the small
intestines where tl1ey develop into the adult worms (See Illus. 15.5).
The presence of adult worms in the intestines may result to abdominal pain. Because
of the buccal capsule, the parasite is able to bite into the intestinal m ucosa and while
biting is able to suck out blood fro m the hosL For as long as the worm is attached, the
patient suffei-s from a conslilnt blood loss which may resolt to microcytic bypochromic
anemia. Development of anemia, however, is determined by the·worm burden and the
iron status of the patient.
362
~In~'""
develop In muco.•
LlNOC h.!t<h In
lnt~tint
I
M A N
lngcsWI
Egg lnloce>
w
(dlagno;stlo sb9•)
- -- ~ Embryonated Egg
(lnfe<UVO •13ge)
1-cell
EXTERNAL ENVIRONMENT
/
Advanced cleav~o•
Illu stration 15,4 Li fe Cycl.e ofTri churls trich iura
3 63
• I •
I•
I '\
\\1\,\
\\
.
\
\I \ \
•I
1~
I
I
\
,_,,,- 5willowed...._
Pt,arynl
\\
\
/
I
\
Atuitbtd to
1m.tlllnletllne'
1m:Ml
I
\
Lunas
I
Circulation
I
hr1elnln o\ln
f
. \
\
MA N
(dlagnosllo >l•g•i
EXTERNAL ENVIRONMENT
\
'
I
/
Rh>bdltttonn la111a
\
----:/
\· .
IOcculonllly In old ftcu)
11\u,stra\to~ 15.S life Cycle of Hookw orm
364
hateltos
. ,,,,,---t\,fl
ff
Adult In s111al
Intestine
...,,, ,,,.,._.,
®
~~·~ge;~~~ln.
oyo, connective
!Issue
t
ClrcUladon
.
♦
G
Scolex ettachos
to lnloslino
MAN
/
Ingested
~ (Infective sta,go)
Oncosphero
hotches
pon etratos
tntel'tinal wan
g
Embfyonated eggs
or progloctids
.
·
occasslonally
ingested
- ~ Cystio?'"us In muscle
\
Circulation
\
©
sWINE
Oncosphere hatches
penetrates intestinal
wall
in feces
tdiagnostio stages)
Embryvnated eggs or
proglottlds ingect6d
Illustration 15.6 life Cycle of Taenla sollum
365
'
\\
l
1•
Adult In small Intestine
MA N
Gravid proglottfd
1nges11!d
Egg
_
f f i r \ •c•ys•tie
-. •..•eus
- 1n• m
• u•s·e1•e- - -- - - •(-dl.ag· n•o-,tk-s•~•c•s)
~ (Infective >lage)
\
In feces
In feces or ciwlronment
Clrcu~tlon
\
CATTLE
~
hatches
\J. Onco>i>'b~e
~IJaJeslntnsUn.!IWall
Embryonated egg, or
proglottids Ingested
I
I
Illustration 1s:1 life Cvtle cf Taenla saginala
\
366
•
-'
•·
Abdoml11al
.,;;;-ty
~
P•n•lr>lu dloJ)hrogm
Pe7e'5 /
"I
"'
lnttstin.,I wall
Pll'\11'21 c.,vlty
Excysb In SIOm.ith
Adulllncystlc
cavi!its In luno•
(and 01hor sllc,s)
•
.·
MA N
Ingested
Unembry<>n•lcd egg In
sputllm
\
(dlagno,Hc st>ge)
Metacerc.111• In crustact.an
(lnfecUve stage)
fece~ 11,w1oawed
I
SN AILS
CRUSTACEA
E9~ embryooale:s~
CercanA In crustacean
lnwa~r
Sporocysl In >naU
tissue
Rec!la In snail
liuu•
"'-i
e-· /
./
~
..
Mlracldlum halches
penelnles snall
Illustration 15.8 Life Cycle of Parogonimus westermani
367
AutolnfC>(;tlon
Illustration 15.9 Proposed life Cycle of CaplUarla phlllppfnensls
368
rr1
Hookworm infection (nccatoriasis or ancyclosomiasis) is often found in areas where
people nre not protected from skin contachvit h the infected soil like in most agricultural
areas. Jt might be good to add that for Ancylostoma duodenale, ingestion of filariform
lnrva from contaminated food mainly vegetaiblcs has been found to cause infection ain
some countries like Papua New Guinea and Africa.
Fina I di agnosis of hookworm infection is dependent on the recover,• of book·worm ova
from the stool. Species iden tification howeve·r, cannot be establisl1ed through the eggs.
Studies show that a clirect fecal smear and/or the Kato thick smear is not very efficient
compared to the for malin ether concentration (FECT) procedure.
Use ofbroad spectrum anthelmintics have been effective in the treatment of infected
individuals. Iron supplementation and proper diet are useful in patients with anemia.
On the other h and, if man is exposed to the nlaforrn larvi'te of the a nimal hook-worms,
the skin lesions arc more serious, because the flariform larvae remain on the skin
resulting in what is known as creeping eruption or cutacnous larva migrans. They do
not reach the circulation and therefore do not develop into the adult hook,vorms in
man.
Health education must be strong]y advocated in relation lo use of sanitary toilet
facilities and wearing of appropriate footwear like slippers, shoes and/ or boots.
FOOD TRAN SMITTED PARASITES
Man mey acquire parasitic infectionsthrougb the consumption of improperly cooked
or raw food like meat, crustaceans like crabs and crayfish, fish, snail and vegetables.
These infections are generally related to the eating habits of the population and to a
lesser extent to the beliefs that eating raw food is actually a healthy practice. In some
areas, however, lack of fuel for cooking purposes or lack of food in general contribute
to the occurrence of food-transmitted parasi loses.
Taenia solium and Taenia saginata
The ndult stages of both parasites are found in the intestines of man and l11eir eggs
are indistinguishable. The eggs ofTaenia solium may be ingested by the pigs while the
e.g gs o fTaenia saginata may be ingested either by the cow or the cattle. The eggs, when
ingesteu. will d evelop into encysted larvae called cysticerci: Cysticercm; cellulosae in
pigs and Cysticercus hovis in cows/(;}1tlle. Man acqllires the adult infection when pork
and/ or beef are ingested raw or improperly cooked (See lllus. 15.6 and lllw;. 15. 7).
Gravid segments can be properly speciatcd by counting the number of lateral branches
arising from tl1e main uterus stretched at the center of the segment. Taenia solium
branches number 8 - 12 while Taenia saginata has m0t·e than 13. Eggs can be recovered
from the stool or the perinnal swab.
Manifestations of the adult infection range from nervousness, insomnia, poor appetite,
to ahdominal pains with digestive disorders. Many cases are, however, asYlT.!ptomatic.
But the majority of patients complain of ann oyance due to the emergence of tapeworm
segm ents per anus.
L
Prope.r treatment of Taeniasis must be given to the patient. Recovery of the scolex
from the patient after fuerapy is the gauge of successful lTeatment. Health education
must emphasize thorough cooking of meat. Freezing of meat at l_ess than s 0 c can kill
369
_[
the ('_v~tirerc-i n, wpll. l'rupc r di:-posol o f h11m;u1 feel!." wi ll prcvc11t :1cccss (I f a11 i n, uls tCJ
!111111:111 free_.;.
ror Adlll'd infor111111io11. thcr,• i-s n larrnl inf,-ction uf 1111111 1.h1c lo 1111· an: i.lr.: 11 1,;I
in"1'~""" 11fTt1t.>11ia .!-t>liu111 <'~!,.. Like in p ip,. ra1.: 11i11 ~oli11111 q~;; wi ll 11 1,o dc• vdup
intn 1h,· ,•1-:lir,•n; I ,•,H"'""t•'<l in lh•· di ffrn•11t li!>,;m•,: 11f rn:111, ·t11l' 1·y:-.1in·11· i h:tVI' hcc n
ll.'J""•r1t.Jl_1 f111md in th,• .su ll<.'uUtrR>(.)Ui, tissues, ,--iri ntn l 11111:-.t:h•s, c.:ye ,:, lt c.•;11 I and ,,vc11
1hr r1•111rnl n<"n\111s 1'')"'l<: m o f ma n . I11,·vlvl'nll'11 t of t he: central n e rvous :;ystc m is ea llcd
ni:11rv\:,tkf'~i.;. Mnn)' ca:.es :,,dn1rcs of unknown origin hnvc been a ssocia lctl with
tlus ro ndil ion.
,f
FurthL'rmnrt!. llwn• ;1nz -:t11d ies to s how th:ll in Asia, :m o th er species of T:.icnin c:i ll cd
Tr1rri10 1L<mti1•u i, i11 e,i, tt•nc1:. Lt. presence in th e Philippines ha:; h ccn c.·s tahlish c:d
when ,-.:y.nw11ts fmm pulic nt,- al lhc Dcp nr1 mcn t o f l'a rns itology. Coll c14e c,f Public
lk ai tl1Cnl\en.1ly vf tlw l'h ilippinc.s ~l;mila were bro ught to ,Japan and were esu m in cd
for the 111Rl\,\ ~1x•dfic for T,1eu ia n::intic:i.
Parogonimus westermoni
Thi, trematode. known ,,.,._ Llw Orient.ti lung fluke. is us ua lly found in pai r,. ins irlc
C~'-l" 10 lht lun1,t parcnchr1na o rthe fin a l h osl. " "hiclt co11lcl be man or a n imal r ..~<:crvoir
ho>'l hkP c.at,; nm.I dr,p. ~ of lhc p:ims ite tha t 4-!-~ca p c from these cysts an· e ither
e<mi.ht~ nu t "i th thi?sputum or~wullowed bnck, :ind then pas.<:i;:u 0 111 w itlt th e :;tools.
Th~ !'",/,It-~ nre im111:11un: ;-ind 1?mhrvon alc 10 deve lo p th e mi mcidiu m in wntc:r. ·111c
miracidin "Ill<. \. rcl1·-™.'tl. enter tJ1c ; nail intermed ia te h osl whcn.' dcvclopnwn t into
spor°'"-..,t~. rn li,h! ,wd ccn:a ria c rx.-cuJ~. "n1c rerca ri:ie go o u t of t h e sn:ail tn pc nc tr:ilc
tilP "t'<'<,nJ 1ntcnn ...'<lullc tmst wh ich is a fre~ h 1,·:iter m o un t;iin n:-ah. ·nw r,·n·.1 riac
develrip inru t Ja,, , nf,•L"tJve metac•en.::i riue in Ihe fiills. IH':in , lr)!.S ii ml 11111:,de:s uf t ltc cr,1 b.
Man ,·.m. Lll!.'rcf,m!. :1('QUirc UH.! infectio n 1h rnup,h tlw ingc.~tion vf rn w vr im p roperly
nY.J~1.-<l nah" r.',,•,• lllu ~ 15.R) . .'\duh "~1rn1:, tit c11 :.ettl<- in th e lun1c: purcnd1ym;a, There
are c.1"<--. "lwn th t• adu lt wum1., h,wc hccn rmrnd in cxtro-intcs t in:il s it e.", like the
:1bcl<lmcn. the diaph raJ.!Jll and r:1 rcly even in the brn in.
Durins. th e early :;ta11,r of the infe<.1fon, the patie lll mny be ai-ym p to m tt t ic hul later o n,
tllt' p,11ient will ~uffor from dry tough producing hlood-ti ngrid p11ntle11l sputum. There
1'.:!Jnld iil<:r> rn! few:r. ch t:cat pain. dy,;pnea, c.1•,y (;ui,:uabil ily and gc11('r:t li1.cd myu lgi11.
lk'f'.au-.., uf thew ~i~H ;rnd ,ym ptmn~. the co nditi o n ca n be misd iiJJc;IIOSCd 1111d wron11ly
tn·at N.l :i, pulmona n· tubrrru lo'>i". In some instance.<;, p11 rngonimi:a s i,; rn,1y co-exist
\,11J1 tul.wrcu lo"i'-.
·
Definitive dia,µi osi~ i,; cstablii-hed thro ugh 1.hc recovery of Par.1go11 im us eggs eith er
from th(' spu tum c,r the s tool<,. Serologlc tests a rc useful i( the wo rrn1, arc loca li.1.ed in
the t'.\'.t ra-i at e«ti nn I nrg;m.c;.
l';irngonimia~i, il' p ri marily found in the Pa r Eas t ,vhi ch includ e.-. lh c l'hili p pincs. In
tlw Philipptn!'<;, llw p ar.isit~ has been ide nt ifi ed in lhc followin g p rovin ces: Mindoro,
Sor!.<1,g1,n, C.imannc,. S.. mar. 1..c~e. Da.,.-no, Aft'UM n , Cotohn to and 1/..n mbon n gn. Ra is,
caL, and J og., --e n 1• a< rc.~l"\·oir fJfiofoctioo in th~ endemi c foci. In ,In pa n, wild boar:;
ca n M'r. ca:, parutcn ic ho~tf', .
Pn,ziquntcl ts nvailable for the 1rea tmcnt of Par:i,grmimiasis. Recently. :1 r esearch
group imm tJ1e College of Public lie:il1J1 d id a d rug t rial for parogo nimi osis us ing
T'riclat,end.a7,0Je. 111e l!fficac:y wa found to be abou t 1hr sn ml! as Prm:iqunntcl. Tbcre
370
11111s t b e a s troni; ;idvncm..-y on thornugh c:oo king of crabs ~nd safe food pre paration.
\'\' hil c 11:-;c nf sanitmy toil ets can cr.rntributc in r,revcnting eggs from reaching th e
in te r rncdic1tc s rmil ho:-;t. the re ;,re othcT aniima l reservoir hrists tha t can continue this
chain of trnr1.smissio n.
Capillaria philippinensis
111is is an<>lhcr inlc:,linal roundworm tha t was first described among humans in the
Philippines wa y back in 19<>~3- Egg,, o f the paras ite tha t apparcntlycmbryonate in water
a.re inges ted by fresh or hrackish wa ter fi sh, where th ey develop into infective larvae.
Man acquires the infection upon ingestion o f raw or imp roperly coo ked fish (See Illus.
15.9).
Capillaria infection or capillariasis causes abdominal pain, gurgling of I.be stomach
called b orbv rygm i .i n<l ch ronic diarrhea. The intractable diarrhea caus es remarkable
Joss or weigh t , los s of appetite, body ma laise, the n edema.
I nfoclion is cslahlis hcd tJuough the recovery of eggs, larvae and ad ul t5 from th e stools.
Ln areas where epidemic outbreaks have occurrerl, one of th e main _problems identified
was the inabil ity o f lhc loboratory microsc.opist to d ifferentiate CapiTiaria eggs from
Trichuris eggs.
Early diagnosis is esse ntial for early treatmenl. If the problem is not immediately
diagnosed, the pa tient usually dies due to loss of protein, low electrolyte level and
mafabsorptio n of fats a.nd s ugars.
The infect ion was p ri rna rily thought to be present only in the Northern Luzon pro-..inces
of llocos Sur , Ilocos No rte. La Union, Cagayan, lsabela, Pangasinan and Zambales.
Late r on. it was found also in the Visayan province of Southern Leyte and in Mindanao
(mainly in the provinces of Davao, Basilan, Agusan, Zamboanga d el Sur, Zomboanga
dcl Norte, :i nd Compos tela \'alley).
All infected ind h;duals must be properly treated. Health education must be focused
on th(' risk nf ea ting rnw or improperly cooked fish. Use of sanitary toilet facilities
must, likewise, he cmphasi1.ed . 1.aborntory workers must be properly tra ined on the
idc.ntilica tion or th e parasite as well. It was found that laboratory cliagnosticians may
rnist;ik.; eruw o f Cap illari a for the eggs ofTrkhuris.
Heterophyid Flukes
This is a group l)f flukes that live in the small intestines of man and other fisheati ng irnimals like rats, cats and rlogs. They are composed of several species. The ones
commonly idc.nti fied from man are: Heterophyes hctcrophyes, Hapfo,·chis taichui and
M etago11imus yokogawai.
·
They are cons ider ed the s malles t among the trematodes because they measure only 2
mm. or less in length. The eggs produced a:re also very small but they are already with
mi r;iciuia when Ll1cy arc passed Lhmugh tE1e feces. The miracidia hatch out onee the
eggs arc inJ!,ested by the appropriate snail in1em1ed ia te hnst . The cercariae released
frnm Lhc snail will th en cnerst as metacercariae in tish which is th e second i.nte rmediate
hosl. Man ;ic;quircs the infection upon ingestion of raw or improperly cooked fish
caught from fres h wn tcr , brackish water (rivers or lakes ) or eve n salt water (oceans).
IL wn.~ a comm on observation that patients with heterophyidiasis are concom.itantly
infected with ca p illariasis, since the same sp ecies offish were were found to harbor the
371
infectiw stage of hoth pa r11si1es.
. ,, 1iormnllr suffer from epigastric pain a nd arc cli ni"'· 11 .
I
mfoctcc
· nt the site
• may resu1l lo t:o11c
• k·v pnins ·ind
,.a Yd1•,1gnoscct
. 1palll'.'.ll.S
1nllanun-ition
""PIie
u
cers.
•
.
.
'b'I"
r
·
'
· us
,,_
.
. t'ons .ahow 1b11l lh o.: rc 1s a puss, 1 11,, u 11eteropln-icl mucus, .,.
u1arrh
Enrlyl _m,·~th~llglii \ 1 ,;; the dr.:ulati on which may even tually result ·, 0 n•cggd•." 1111 d udu~ats.
reac 1111& e 1cll
•
-..I r Iac fail
I Ute.
.
.
f hctcroplwdiasis is done tltrough s tool cxamin a tio11 ·'.i nd .
Omgnos1s o
•
'•
. •
characteristic eggs oftbe paraSJtc.
'
1 ecnvcry
or the
A previous natiom,idc survey in 1967 ~evealed a _1% pre,•alence for hctcroph , . .
but o rccently com:luded survey (::woo) LO C?mpostclu \/alley, a province in Mi.n~d1~s1s
btained a prrvalencc of more than 30% m the general p opulation. Occ
anao,
~eteroplwdiasis is related to the eating habits and the level o f e nviro1uneniatrre.nce_of
•
.
san11rttto
facilities in the community.
11
Drugs effective against tl1e other trematodes a re also effe~tive agninst th e hcteroph 'd
There must be a strong advoca~' ll1rough health education 011 eating only th
)1 s.
cooked fish. Pro,ision of sanitary toilets will definitely be useful bul it sh ouJ;~~~h~
forgotten that there are rese rvoir animals th;it can continuously seed the environment
"'ilh heterophyid eggs.
WATER-BORNE PROTOZ.OA
Water is a very essential compound for th~ snnival of .living th ings. It is also relalcd
to proper sanitation be it for personal hygiene or enV1ronmeotal sanitation. Wntcr
however, when unsafe and inadequ ate, may be associated with nn cnomwus number of
dise.,se agents. Parasites related t o unsafe water are mostly protozoan. For the parasitic
infections induclcd here, clrinking water serves a s a passive vehicle for transmission.
Entomoeba histolytica
TI1is is the only pathogenic species of amoeba that can produce lytic substances that
allows the parnsite to invade tissues. The infective stage of this parasite is call eel C}'St,
which can ht> ingested from con ta mi n3ted water nod to some c,.1cnt from co ntaminated
food. Upon ingestion, tl1l! cysts go down into the digestive tract and in the lower part
oftl1c small intestines where the pH is slightly alkaline. Four new parusitcs called the
m etacysts ,vi ii emerge. These metacysts will the□ m ove to the colon where they "ill
develo p into the trophozoi tc stag-e (See Illus. 1s.10).
l
l
I
The tropboznites may develop back into the cystic s tage w hen U1ere is proper
reabso rption al lhc descending colon or may remain astrophozoitcs if there is no proper
water rcabsorption. As tmphozoite.~. they become capable of intestinal coloni?.ation
resulting eitl1cr in mucoid.al stool, with or \'lithou t b loocl s trc;1ks. Sometimes, tissue
iJwasion may be e:...-tc nded to th e deeper layers of the inlcsti ncs ghing rise to u.tceration
of 1he mucosu, submucosu, muscle layer .ind even the scrosa. The trophor.oites are able
to rea0 extra-i n_testinal organs like the liver, lungs and brain, where the parasites can
~tabhsb amoeb,_c abscess for~1ation. As a maltcr of fact, tro phow iles have been fouo d
mother organs hkesplcen, skin, :peri-cardium 11nd even the genitals.
Infected individuals harboring c:yi.1s are asymptomatic. However, they .ire cyst passers
and can, themfore, be the eAtra source of infoction In the com mu nily. T h is is wl1ere the
problems 011 food-ha ndlers come in.
372
Sc.:,.., ~ wilh CamScan:11:r
Diagnosis is confirmed through th e recovery of cysts from Cormedstoolsand trophozoites
from d iarrbeic or watery stools. The consistency of stools dictates how soon the stools
are to be examined in the laboratory. If-what we expect to .recove r from the stools
are t.rophozoiles, th e stools must be examined immediately because trnphozoi tes are
fragile and they die with in 30 to 60 minutes outside the host.
Cysts and tropho:wites can be detected th rougb the direct fecalsmea.r preparation. Nuclei
of the cysts are best stain ed with iodine solution while nuclei of the lropbozoites with
metl1ylene blue solution. Coucent.ratioo tech niques like formalin el.}1er concentration
(FECT), merthiolate iodine formaldehyde concentration (MIFC) and ZnS04 are very
useful in the recovery o f the cysts.
Skill in the identification of pathogenic amebae from non pathogenic ones can be
acqu ired through proper training. Jt";n he worth while to realiietliatusing microscopic
examin ation the cysts ofEntameba histolytica have morphological chnracteristics very
similar to tvvo other amebae namely: Entam,eba dispar and 611tameba hartmanni, the
latter however happened to be a lot smaller than E. histolytica and E . dispar.
Transmission of amoebiasis is related to contaminated water supply, use of nigh t soil
as fertilizer and infected food handlers. Moreover, si:uclies have sh own that flies and
cockroaches carry amoebic cysts as well. Boili~g of dri nking water from questionable
source is a very good practice to avoid infection.
Specific drugs must be given to the patients. Health education emphasizing
environmental sanitation must be done. Drinking water and food must be safe for
human consump tion. There must be regular examination of food h andlers, which
is now mandated by the provisions in th e new Code of Sanitation approved by th e
Department of H ealth.
Idenlification of cyst passers ~\;II reduce tr:ansmission. In a recent study a mong food
h an dlers in school canteens in the City of Manila, a high percentage was found to be
positive to non -pathogenic amobae by stool examination. Even if the identified cysts
were non-pathoge nic, their presence indicat es a possible danger of transmission to the
food cons u mers once personal hygiene is not strictly praclic.ed. Another indication is
that, ch;nking water has been contaminated with humnn excreta.
Giardia lamblia
This i s a flagellated protozoan which lives in the duodenum, jejunum and upper
ileum o f h u m ans. It is also known as Giardia duodenalis, G. d uoduenalis, Lamblia
<l uodenalis or L intestinalis. Th e clisease caused by this protozoan is called giardiasis
or 1ambliasis which has an incubation period of one to fourwecks, averaging nine days.
While it is asyrnptomnlic in approximately 50% of infected individuals, itis manifested
in m ild cases as moderate and protracted diarrihen followed by spontaneous recovery
in six weeks. In acute cases symptoms usually.include cramping, abdominal bloating,
nausea, anorexia, diarrheal stools, often with excessiv.e flatu s with a n odor similar
to that of rotten eggs. Chronic infection is characterized by passage of greasy, frothy
stools.
Transmission of th e. Giardia liamblia parasite results from ingestion of mature
cysts (infective stage) from feces oi h umans or an imals (e.g. dogs, rats, horses) via
contamin ated b:u1<ls, food or water. Ingested cysts pas.,; through the stomach and excyst
in the duoden um in abou t th irty minutes. developing into trophozoites which rap idly
multip ly and a t tach to the intestinal villi (Illustration 15.u). They cause pathological
373
changes like flattened vi.Di tips,shaUow c,ypts, inOammation of mucosa and h yperplacia
oflymphoid follicles. The trophozoit,es may then be found in t he jejunum. As the feces
enters the colon and dehydrates, the parasite then en cysts. Newly formed cysts have
two nuclei while ma tu re ones have four. After encystation, mature cysts a re passed out
in the feces ancl are ll1cn infective (Beli.?.ario and Solo n 1998, p p. 38-4J).
Lllbora tory diagnosis is made by demon~tration o f tropbowitcs and/or cysts in stool
specimen or duodenal aspiration or biopsy. Doud en al aspirat es can be collec1cd Uwough
the so-called Entero-tcst or tl1c Strin g Test method. Prompt in terven tion red uces cyst
pass;1ge und possible transmission particularly when food handlers , chi ld ren in daycare centers, inst itulionalized patien ts and hom!Jsexuals are involved.
The prevalence of giardiasis is associated with p oor envi ronm ental san itation. Poor
hygiene, overcrowding, immu nod eficiency, bacterial and fungal overgrowth in the
small intestines are impc)rtant ris k factors . Sanitary disposal of h uman excreta, proper
management of reservoir :mimals, regular cxamina1ioa of food ha ndlers and i;anitary
practices on food prepanllion and s tor.ige ;ire cnici.il in the preven ti o n an d con trol
of disease transmission. lloiling of drinking water may be required when potability is
questionable.
Cryptosporidium hominis
'11iis is an intes tinal protozoan falling under Class Coccidia. There a rc about eigh t
recognized species, of which only C. hominis is th e only one kn ovm to ca use infection
in humans. A wide range of an.imals ]rnve been found to harbor the parasite as well.
II has been commonly isob1tecl from both tbe small and 1.irge intestines. Howeve1·, it
has also hccn identi fied from other organs like the esophagus, s tom ach and appendix.
Among the immuno-compromiscd 11.nd immuno-deficie nt patients, like AIDS victims,
infection of the bile duct, gallbladdet·, liver, pancrens, an d lungs have been reported.
This was ini tially thought to be an oppor tunistic parasite among AIDS pati ents but
eventually it was found even amo ng immuno-competcnt individ ua ls . Among the
immuno-compctcnt individuals, diarrheal episodes are sci( limiting but among
the immuno-eompromiscd and immuno-suppressed. individ1111.ls, diarrh ea crui be
prolongcd and m::iy therefore rcsuhs in more serious condi tions_
Like any of the toccid ian , the parasite undergoes the process of sch i:zogony that results
in 1110 production of merozoites and sporogony whielt in turn develops oocysts. Both
processes of multiplication occur in the extra-cytoplas m of the intestinal cells. When
oocysts a rc passed out with the feces, they arc already sporulated and are therefore
readily infective.
Data show that ingestion of even a few ooeysts can already estal>lish infe ction in man_
Patients with crytosporidiosis often develop acute gastroenteritis possibly due to the
ability of the orgnni!;1n as an enterotox in. With prolonged symptoms, patien ts mny
eventu ally suffer from malabsorpti,on resulting from villous atroJ>hy and cellular
infiltration of the lamina p ropria.
From the inteslines, the infection may go up to the bile duct and the pancreatic d uct ,
which would lead to cholangitis and panereatitis. In some occasions, lung infections
may be involved, causi.ng the patients to suffer from respiratory symptoms like cough
and shortness ofbrcatl1.
374
Trophozoite-...t,.,u.
In lumen
of ,:;olon
MAN
EXTERNAL
ENVIRONMENT
Trophowlte
I
Oisiltegratos
Illustration 15.10 Life Cycle of Entamoeba hlstolytica
375
Mul1pl!fs by lcngltu<IIMI
l:lna,y nu1on
Elcysls In duodenum
h
M A N
rrcpho1olte
EXTERNAL ENVIRONMENT
I
Dlslntegral6
Illustration 15.11 Life Cycle of Glardla lamblia
376
:1
sources of the oocysts of C. hominis are variable, although the most common source is
believed to be fecally contaminated d rinking water. It is noteworthy lo remember that
00 cysts in ice remain viable once it thaws. Accidental ingestion of pool o r lake water
contaminated with oocysts can also lead to infection.
High-risk exposure has also been associated to direct contact with feces positive for
cryptosporidium hominis while caring for infected patients. This includes bathing,
changing of diapers, changing of soiled bed linens or simple emptying of bedpans in
caregiving institutions.
Infected food h andlers with poor personal hygiene can accidentally transfer the oocysts
to food and beverages. Raw fruits and vegetables may, likewise., be contaminated.
Contact with infected calves in veterinary hospitals, in dairy farms o r zoos have also
been implicated as sources of human infection.
Diagnosis is established witlt the recovery of the oocysts from the stools. Oocysts are
acid-fast and are identified best from stained stool samples with the modified acid-fast
stain known as the Kinyoun's techii.ique. Before staining, stools may be concentrated
using Formalin Ether Concentration Technique (FECT) or with Sheather's flotation.
Since n o chemotherapeutic agent bas been found to be safe and high1y effective for this
pa.-asite, the objective of treatment is to reduce the frequency of diarrhea. Rehydration
is highly recommended.
To control and p revent infection, people mustbe strongly advised on personal hygiene
and environmental sanitation. Sources of drinking water must be properly protected.
Contact with infected individuals and animals must be avoided. Fruits and vegetables
that are eaten raw must be properly and thoroughly washed.
Cyclospora cayatensis
This is another coccidian that has been isolated from patients with chronic and
intermittent watery diarrhea. The diarrhea together with lack of appetite, loss of weight
and bloating may last for weeks. However, the disease is generally self-limiting among
patients who are immuno-competent. Like in cryptosporidiosis, prolonged diarrhea
has been observed if the patients are· immuno-compromised like the very young and
the very old. Infection b as been associated with consumption of contaminated food
and water.
Like the Cryptosporidium, Cyclospora oocysts are also acid fast in nature and therefore
can be s tained with Kinyoun's technique. When viewed under an UV microscope, the
oocysts emit a bluish fluorescence.
Blastocysts hominis
This is another protozoan parasite whose taxonomic classification is uncertain. It is
usual]y mistaken for an amoeb a and was formerly classified with the fungi. Association
of this parasite with gastrointestinal pathology is still controversial, however, if this
parasite is present in large numbers, a variety of intestinal disorders was observed,
especially among children and the immu.no-cornpromised. These include abdominal
cramps, mild. to moderate diarrhea, flatulen.ce, nausea, and vomitting.
The life cycle and the modes of transmission are still unknown, although it is believed
that transmission occurs through the fe.cal-oral route. Occurrence of blastocystosis
·
3n
wai; associntcd \\i tl1 history of drinking untreated ,vate.r a nd exposure to crowded,
unsanit ary co nditions.
Diagnosis is based 011 lhc dctcclio n o fthe organism fro m the s tools. It has bee n o bserved
from dirccl fr:ca l s mea r but sensitivity of llic laho ratory prncecl urc is im proved through
U1e Formalin Eth er Conrcntrntion Tcd1 nique (FECT). The b lastocysts v;i ry in si:r.c with
a dlametr•r rang.ing from about 6 to 40 pm. '111cy arn gen erally sphe ri cal provided with
a centrol hody tlrnl occllpics about 90% of the cell. Because of U1e la rge cen traJ body,
nuclei of th e pa rasite are almost always pushed to Ille periphe ry cell .
I:rom a i;tudy of foodl1andlers in a tertiary hospital located in MetTo Manila and
canleens operating in the University belt of the City of Ma nila, 40% and 24 % of the
studen ts examined were fou nd posi tive for Blastocystis cysts respectively .
VECTOR-BORNE PARASITES
There are certai n groups of living things that carry and transntit in fective agents
to man. Some mechanically transmit the patJ10gen s like the m es and cockroaches,
while in some vectors, like mosquitoes, these infective agents undergo develop ment
anc.J mtlltiplication. To.is St.>ction covers parasites that are transmitted lJ1rough these
vectors.
Plasmodia
There are four species of Pl.asmodia causing malaria in man, n amely: Plasmodium
falcipnn1m , Plasmodium vivax, Plas modium malaria e and Plasmodfom ovale. All
of these $pecies are transmitted through the bite of the infected fem ale mosquitoes
belonging lo the Genus Anopheles. lo the Philippines, the major m osquito vector is the
female Anopheles minimusjlavirostris.
TI1e most common catLc;e of malaria in the PhiJjppines is Plasmodium falciparum.
About 70% of all malaria cases are due to P. falciparum, 30% are du e to P. vivax and
less than 1% is due to P. malariae. P/asmodium ouale,however, is believed to be absent
in the Philippin~. On the other hand, a monkey malarial parasite ai llad Pla1;modium
k'llowlo>si was identifi ed from indigenous people in Mindanao by the Resea rch Institute
for Tropic Medicin e.
\
\
\
Among Lhe Plasmod ia species, P. falciparum is considered to be the most dangerous
because it causes severe complications such as cerebral involve.meat. Amo ng children in
endemic areas, chronic infection with malaria can lead to ch ildhood anemia. Pregnant
women whe.n infected wilh malaria may suffer from stillbirths and abortion.
Plasmodia undergo an ase>mal method of multiplication in man called sd1izogony and
g,ametogony. This makes mao as the in tennediale hos1. The ase,mal multiplication is
periodic am! lhe lens:th of schi2.ogony differs from one species to another 111e sexual
m ethod of multiplication called sporogony occurs in the mosq uito, the d efi ni tive host.
ln man tbe malarial parasites undergo sdli:1.ogony in the red blood cells and for this
reason, these parasites mey be1Tansmitted throu &h jndiscr etc hlood tran sfusion . Stages
that di-vdop during i;chi~ony are trophozoiK-s which "ilJ th en become schizonts,
inside (lf which are merowiles. Schi1.ogo ny was sh orte..:;t in P. fa lcj parum bu t lon&est
in P. malariac. 111e highest number of me r01.oitcs :ire produced by P. fa lciparnm. while
the fowe;.1 are p roducl'd by P. malariae_ Wh en the sd,izonts arc mature, tJ1 c host red
I •
\ \
\ \\
~~■-•---37•8•c-el s•ru-p•t•u•r-e•a-.J1d•th-e•m•e•'r•o•w•i•tes•'
~
•ar
- e•re•l•e•a sed
- •i•n•t o•t•h•c•c•ir-cii•ln• t•j •o n_ . l•t•is- a•l
•th•i•s•p•o•i•nl■w■·■h■c■n-•ia!·
-
rnan us u ally s uffe rs from the ma fa rial paroxysm accompanied by chills, fever, profuse
51,\leating h eodoche 11nd prostration. l11e mero'I.Oites wi ll enter n ew red blood cells to
repeat the schizogonic cycle. Some merozoites wi ll, however, develop into ga.metocytes
that are taken up by t he female Ano pheles during feeding time.
ln the mosquito gut, the gametocytes become sexua lly mature gametes. The male
gamete fertilizes the fem a le gamete to procluce a fertilized cell called a zygote. The zygote
develops into an ookin ette then in to an oocyst . Insid e the oocysts are sporozoites which
are released into lhc salivary glands of the mosquito and are even tua1ly introduced
to a ne w h ost when Lhe mos4uito vector tak.es another blood meal (See Illus. 15.12).
Sporo7.ites introdu ced by the mosquito bite undergo exo-erythrocytic sch izogony in
the liver cells. The m ero7,oites re leased from the liver cells will eventually invade the
red blood cells.
The interval betv,1een malarial attacks is determined by the length of asexual phase:
36-40 h o u rs for P lasmodium falciparum, 48 hours for Plasmodium vivax and
Plasm odi u m ova le, 72 hours for Plasmodiu m malariae.
Thick a n d thin blood films a-re prepared from a finger prick on the patient. The blood
films a re stained with Giemsa and are read under the oil immersion lens. The thick
blood sm ea r is usefu l for rapid diagnosis while the thin blood film is used for species
identification. l n Plasmodium fa lciparum infection, what can be seen from the blood
films are mainly rings and gametocytes because the late tropho1.oites and schizonts
ar e seq uestered in the deep vasculature of so me internal organs. Wh ile for the other
three species, all ase,--.,:ml stages can be recovered from the peripheral blood.
If the blood film s are negative, serological tes.ts like IFA(lndirect fluorescent anb"body)
and ELISA (Enzyme linked immuno sorbent assay) are available to detect anb°bodies.
Recent adva n ces in the diagnosis of malaria include antigen detection from the blood
usin g monoclo nal ant ibodies agai nst enzymes produced by th e parasites like histidinerich protein [HRP) and lactic dcbydrogenase (LDH).
Treatm ent is available for both uncomplicated and comp licated forms of malaria.
Chernoprophylaxis is a lso s ugg~ ted to pr otect man from malaria infection. For
the control of the mosquito vectors, ex-perts recommend the integrated vector
con trol strategies ,vhich include stream modification and/or other environmental
manipuh1ti on, biological control, a nd chemical control. To prevent man-vector contact,
use o f c he mically treated bednets and proper screening of houses are advocated. Long
las ting insecticide treatment nets (LLlTN) a re now•avanable. Families are advised to
use adequate p rotective clothing dur ing outdoor activities at night when the b iting
period of the mosqu ito vect or is expected. until early morning (de las Llagas, 1999: 23)
Community-based family empowerment in terventions for malaria prevenb°on and
control h ave been documented in 1999 by Maglaya, de las l..\gas, Ancheta and Belizario
(See Chapter 18).
Babesia spp
TI1is parasite b elon gs to a group of proto:i;oans called piroplasm s. Human infection
with Babesia mic.-oti has been identified mainJy in the United States and to a lesser
exten t in Eu rope. In the Un ited States prob lem on Babesia is compoun d by the fact
th at the s pi rochaete called Borrelia burgdvrferi causing Lyme diseases is transmitted
b y the same tick Jxodes spp which transmits Babes.ia. Just like the Plasmodia spp,
this parasi te is intra-e rthrocytic in habitat. [tis, therefore, transmjssible through blood
379
transfusion. fn babesiosis, howev-er. the invasion of the red b lood cells will eventually
lead to hemolytic anemin.
Babesia microti is biologically transmitted through the bite of hard-bodied ticks call.ed
lxodcsscapularis, wh ich usually feeclon white-tailed deer. The tick a lso feet.ls on smaller
mammals like lhe white-footed mouse which is the major reservoi.- host of Babesia
spp. Incident·ally the tick is also t he v(.-ctor of Lyme disease cause<l by a s pirochaete
named Borrelia burgdorferi. In endemic places, ii is common tJmt an individual is
simultaneously infected with both Lyme disease and babesiosis.
Diagnosis of babesiosis is established when Giemsa-stained blood films reveal the
presence of the parasites. The ring forms of Babesiaspp are very difficult to differentiate
from the ring fonns of Plasmodium falciparurn. The tetrads called the Maltese cross
are however diagnostic, while Polymerase Chain Reaction (PCR) is very useful in low
parasitemia. Detection of antibodies by serology is aJso u seful.
Clindamycin is an effective antibiotic against babesiosis. Use of protective clothing like
the wearing of long pants and sleeves arc also recommended. Clothing can even be
impregnated with insecticide.
Wucherer/a boncroft; and Brugia malayi
These parasites cause lymphatic filariasis and are transmitted by female mosquitoes.
Wuchereria bancroft is transmitted by mosquitoes falling under genera Aedes,
Anopheles and Calex. ln the Philippines, however , the parasite is trans mitted by Aedes
poeciJus whkb bree ds pretty well in the axils of the abaca and bana.na plants. In some
areas, Anopheles mjnimus is the mosquito vector iden tified in the M o untain province.
Culex mosquitoes have been incriminated but they are more important vectors in
other countries. On the other band, Mansonia mosquitoes are responsible for the
transmission of Brugia malayi.
Adults of Lhe above paras ites habitate the lymph vessels and/ or lymph nodes. The
progeny called mkrofilariaeare found in the peripheral ci rculation. The presence of the
microfilnriae in the circulation exhibits a rhythmical pattern called periodi city. Wbeo
the mosquitoes lake a blood meal and they pick up the microfilariae, the microfilariae
will develop into first (LI), seco nd (L2) and third (L3) stage larvae in the muscles of
the mosquitoes. When the mosquitoes bite a susceptible bosl, t he 3rd stage larvae a re
deposited oo the skin and the larvae actively enter the skin through the s ite of the bite.
They will eventually reach the lymphatic system and the worms ½ill d evelop into the
aduJt fila rial worms (See mus. 15.13 and lllus. 15. 14).
In the ea rly stage of trmphatic fiJariasis, the infected individuaJ suffers from fever with
inflammation of the lym ph gland.'I. There is recurrent retrograde lymphangitis with
localiu.-d swelling and redness of tbe arms and legs. This is believed to coincide with
the release of microfilariae by the female worms. When the adult worms d ie, there will
be an immunological reaction resulting in lymphatic obstn1ctioo which in tum can
lead to elephantiasis or hydrocoele.
Jt is worth mentioning that there are microfilariae positive individuals who are
asymptomatic. A few. however, manifests the characteristic tropical pulmonary
eosinophilia where patients do not manifest microfilaremia because the microfilariae
are in the tissues. They have hypereosinophilia and usually suffer from pulmonary
symptoms like paroxysmal coughing.
380
. Malarla
·um vivall causing
d
Fig 15.1 2 .Life Cycle of Plasmo '
St.~ nr ~<l w,'L'II l";,m1Sca11mff
..,
"\
Mlcrofllarlae
Cl.rculaUon
\
M A N
Ent.n skin llm,ugh
mo,qut\11 bl1a woul!d
Mlcrolllarla In blood
(dlagnostk stage)
3rd StJilt larva
Qnle<:llvt slageJ
\
:';!:'.!:.":"
,.,,
,...-!'111•3-:::""- ....
-
7
~
......
MOSQUITOES
·,.._,.__/
:
-;-····
~ l e musclH
Illustration 15.13 life cvcte of Wuchererla ban croft I
382
"' \
Mlcrofll•rt••
Lymphatic$
I
Clrcul1Uoo
MA N
\
Ent<>rc skin rhrouo h
mo•qulto blle wound
Mlcrofflam In blood
(dlagno11tc sta11•l
\
MOSQUITOES
Ml11~tes lo head
ar>:lpro,
cls
,
...__,,........
3rd stage larva
S~s sha.ath;
penelfa!M slomach wan
/
Tltor..,lc m~cl•~
~
st s l a g e l a r n ~
Illu stration 15.14 life Cycle of Brugla malavl
.
383
f
Diagnosis of {i]ariasis is established "itl1 the recovery of microfilariae from staioed
thick blood films. Wucbereria bancrofti microfilariae exhibit noctu rnal periodicity while
Bnigia mala~i microfilariae exhib it aocturnaJ bu t s ubperiodic periodicity . Beca use of
these char.1Ctl'ristic periodicity, blood samples must be collected fro m 8:oo pm to 4:00
am. To increase the chance of fin ding rnicroftlariae, concentration techniques called
Knotts's technique and nucleopore filtration are recommended.
Filarial antigens can also be detected from the blood using a monoclonal based card
test, called the ICT card test.
fu the Philippines, \.Vuchereria bancrofti bas a wider geographic distribution compared
10 Brugia mala)1. Bancroftian filariasis bas been reported in Cam a rin es Non e,
Ca.marines Sur. Albay, Sor:sogon , Mindoro, Marinduqne, Masbate, l'ala wan, Sarnar,
Leyte, Bohol, Mountain Province, all of Mindanao especially Sulu, Tm~; tfmi , Basilan
and Zamboanga. On the other h and, Malayan filariasis is present in Palawan , Eastern
Samar, Agusan and SuJu.
Effective dn1gs arc available for the treatment of filariasis. A combination of d.ieiliyl
carbamazine and albendazole is bei ng utilized for the so called mnss dnig administration
(!\•IDA) toeliminte lymphatic filariasis . Healili education should focus on the prevention
of man-mosquito contact lLke the use of bed nets, repellants and chemical spraying.
The use of Bacillus thuringien.,is as biological co ntroll1as also been tried.
Schistosoma japonicum
This is a Ouke. Among tbe Oukes, this is the only species provided with separate
sexes. Adult worms live in the portal and mesenteric veins of man and a wide range of
reservoir animals like rats, mon ke)'S, pigs, dogs, carabaos and cows .
Schistosoma eggs are deposited in the mucosa) capillaries where they undergo
maturatiou and are eventually able to enter the intestinal lumen via ulcerations. Upon
reaching a body of water. the embryo called miracidium is released. The miracidium
then enters the snail intermediate h ost which is scientifically called 0ncomelania
hupensis quadrasi. Within the snail host, tl1e miracidium develops into t\vo generations
of spor~ysts tl1ep into cercariae. Tiie cercaria is the Wective st.ige and it can actively
penetrate Lbe bumao skin. After skin penetration , the cercaria develops into juvenile
adult called schistsomula. Jt will enter the circulation, undergo tissue migration until it
reaches the portal veins where it wilJ develop into adult sch istosome (Sec Illus. 15.15).
Entry of the cercariae into the skin may or may not result in d ermatitis . At the time
of egg deposition in the intestines, patient starts to manifest diarrhea with blood. The
deposition of eggs in the tissues, mainly the liver, results in granuloma formation.
This usually leads to portal hypertension with hepato-splenomegaly , ascites and
emaciation. Many reported cases of death due to schistosomiasis wer e caused by
rupture of esophageal varices.
Diagnosis of schistosomiasis is confirmed with the recovery of the eggs from the stool
through Acid-Ether Concentration (AECT) or Kato-Katz technique. Eggs embedded in
tissues can be seen from rectal biopsy material A serological test t o detect antibodies
called Circumoval Precipitin Test (COPT) is usually r equested together with stool
examin ation.
·
Schistosomiasis is found in the Luzon provinces of Mindoro Oriental , Sorsogon , Visayas
provinces of Samar, Leyte, Bohol and in all provinces of Mindanao, except Misamis
384
Oriental. New foci of infection have bee n formd in Goni.aga, C.'lgay:m Valley in Luzon
and Calalrava. Neg ros Occide ntal in the Vlsay:is.
Drog for treatment is a,·ailablc. Ad,·ocacy for the prope r dis posal of human feces.
control o f reservoir animals nnd snail control help in the control and prevention of th e
infection.
CONC LU S ION
}Cnowledge of U1e life cycle of each par.i:-itc helps dct.em, inc nppropri:i tc nu rs ing
interventions t o p revent or control iti; tmnsmission. i\lost of the parasite.~ dC$crllX!d
in this chapter a r e excreta-relat('d and arc m::ii11l1· ahlc to leave the ho.~1 \ ;:l the fccc.~.
Therefore. unsanita ry waste disposal is a \'Cry ,·mpon:1111 factor llmt n , ntribu tcs to
the co ntinuo us transmiss ion of thes•• pnrnsi h~$. Snmc h:t\'P animal rc.~cn ·oir hosts or
intcnnedia te h osts which co m p lic,tle prevention a nJ con trol strategics. Uns.'ln itary
garbage/r efu se and waste disposal ca n also c nco urngc mechanical transmission of
these pathogens through arthropods like flies ;ind cockroach es.
community h ealth nurses are challenged to be creative and innovative in dcsii;n in~
and implementing preve ntion and control intc n·cntions which require pannership
and empower ment processes (Nlaglaya 1999). Examples of these st rategi~ to pre,..e.nt
or control parasitic infections include:
1.
Client-ce n tered nursing interventions to fucilitnte develop ment of healthy
lifesty le, motivating clie nts nnd su pporting their learning throui;h each stage
o f the behavioral change process (Refer 10 Appendix E): Em ptu1sis rm perso nal
hygiene, sanit:.1ry food preparation, safe eating a ncJ drinking habits/ pmctice$.
use of sanitary toilet facility and lisc of self-p rotection measu res such as
wearing o f appropriate footwear or sleeping under insecticide treated bed nets
especially in endemic areas.
2.
Advocacy, partnership and collaboration with the community, the locaJ
government unit and the partner agencies to ensure the provision of safe
water supply (specially from public sou rces) and nppTopriate facili ties for
garbage/refuse and waste disposal. Refer to Chnpters 5. 6 and 9 for l;trnt@gil:'.5
and interventions.
3.
Community-ba.s ed and family-centered empowerment strategies (see Chapter
18) to eliminate breeding and resting sites of mosqni.toes (de las Llagas, 1999) .
snails, other vectors, intermedi ate hosts and mechanical carriers (e.g., flies,
cockroaches, rats) of parasites.
38 5
M A N
"'"'"'
SNAILS
Illustration 15.15 life Cycle of Schistosom es
~----------- - - - .....
\ ',· i
386
REFERE N CES
1
Belizario Jr. V.Y., aud de Leon, \V.U. (Eds.). (2004). Philippine Texibook of
J'1edical Parasitology. Ma nila: Information, Publication a nd Public Affairs Office
·
_ IJni\·e rsit y of the Phili ppines Manila.
2
3
·
de las lJagas. L.A. (1999). l.\laloria Vectors and Vector Con trol. In M.D.G.
Bustos and oth ers. State-of-the-Art: Malaria Resea,-ch in the Philippines (pp.
21 • 3 2). Philippines : Pltili ppine Council for Health Research and Develop m en t Departm e.n t o f Science a nd Technology.
_ Henry J .B. ( 1998). Clinical diagnosis and ma11ageme11t 1.,y labo rntory methods.
(19th ed.) Philippines: W.B. Saunders Co.
4 . 11.faglaya, A.S., d e las Uagas, L.A.. Ancheta., C.A., a nd Beli1.ado, V.Y. ( 1999).
A/amity health empowerment interventio n m odel towards prevention and
control of malaria in th e Philippines: The local govern m ent 1mit/ n1ral health
unit perspective. Manila: Department of Health - Essential National Health
Research.
5. Marquardt, W.C .. and Demarce, R.S. (1985). Parasitology. New York: Mncmillian
Publishing Co.
6 . Strickland, G.T. (2000) . Tropical Afedicine and Em erging Infectious Diseases.
Phlladelphia: W.B. Saunders.
7.
University of the Philippines Manila, College of Public Health, Department of
Paras itology . (1997). A Study Guide in Medical Pa rasitology . Manila: College of
Public H ealth - U n iversity of.the Ph ilippin es Man il;i.
387
Chapter 16
LOGIC TREES FOR
COMMON ADULT HEALTH
PROBLEMS
1.Vfa. Cor azon S. Mag laya and A r a celi S . Mag l aya
INTRODUCTION
Fo r m ore tha n a decade. there has b een a rapid increase i n tl1e p r evale n ce o f
non-communicab le diseases. particul arly lifestyle-related h ealth p roblems. W11 elhc r
in d octor-lesi- communities or in areas w h e re prom pt and effective e ntry inl ~> l h c
h ealth care dclin•ry i-ystero is a prirua.r_v objec-t h ·e. lbe nurse h as e ve ry a v,i ilable
oppo rtunity to e n sure I.hat adul l clients "ilh lifestyle-related h c;:ilth needs. con ce rns
or proble m s ca n be promptly gu id ed to s ou r ces of infor m ation. a d v ice a nd
m anagement appro pria te to their particular compla ints o r s ituatio n s .
Sta.otlnrds of heaJt h a nd / or nursing care specillc d in assess m en t a n d m ana gem e nt
protocol,- c..111 e nha nce th e nurse·s competence and confide.nee for indepe nden t practice
and case m;;i n a~e me.nt. These are effective. efficient a n d c r ea tive o p t ions fo r im p r oving
access t o quality c:1re "ith the increasing mmiber o f patients in va ri o us prac l ice setti n gs
in the Phili ppines a nd th e weste rn world l.ike the U .S.A. and Europe .
THE LOGIC TREES
The use o f t he. Logic Trees \\-:1S in troduced in Ch a pter 10. Va ri ed sets of assess m ent
nod manage m e n t pro tocols h ave bee.n developed by th e authors based o n a long
experi ence in J!<meral medical and e11isod.ic nursing prnctice in th e community. Each
pro tocol focU."-CS o n a s pecific med ical com p lai nt or a set o f s ign s and sympto m s.
A set o f l.ogic Tn.•cs fo r commo n s igns an d S)nlp torns or co m p laints ,ire included i n this
ch apt e r ai< examples for ours<: p ractitioner.s ha nd ling adul t c.l ien t.5 w ith li festy le - re lat ed
h ealth n eed!-. et,nccni.-. o r proble m,;_
388
ASSESSMENT PROTOCOL FOR PROBLEM ON COUGH, COLDS
OR DIFFI CULTY O F BREATHING
NOT A SSOC IATED WITH FEVER: ADU LT PATIENT
(Logic Tree No. 7)
o IRECTION: Determine/identify which of the following symptoms/signs (S/S) or
history dat:1 ( lh:D) are present and follow the flowchart for the appropriate plan of
management.
RED
YELLOW
GREEN
S/S or HxO
5/S or HxD
S/S or HxD
• Difficulty of breathing
when tying down for
several m i nutes but
relieved when he i s
propped up
• Pati en t has coughed
out large amount of
b lood (at least two
teaspoons)
• Systolic blood
pressure of 160 mm
m ercury or above
and/or diastolic
blood pressure of
100 mm mercury or
above
• Altered consciousness
(very sleepy or
disoriented)
• Labored fast bre ath i ng
• Nostri ls spread i ng out
• Patient is 65 years old
or older
• Respiratory Rate is at
least 30/min
• Symptoms have been
present for more
than 3 weeks
• Cough productive of
yellowish phlegm
(the whole day)
• Presence of blood in
the sputum (even if
blood-streaked only)
• Difficul ty of breathing
when doing his usual
physical activities
like sw eepirig the
floor or taking a
• Patient has been
exposed to chemical
dusts like silicon or
asbestos for several
years (like the patient
u_sed to be or is
currently working as a
min er)
• Change in the quality of
the patient's voice
• M ild or tolerable pain
at the epigastric area
described as burning
or gnawing pain
• History of intake of
medicine for ulcer
like those containing
omepraz?ie,
laz_oprazole,
esomeprazole, or
those containing
aluminum/
magnesium hydroxide
• Recent history of
intake of medicines
causing gastric
irritation, such as
Aspirin, anti-arthritic
medicines (ibuprofen,
diclofenac.
meloxicam,
piroxicam, celecoxib,
etc.) or antibiotics
belong Ing to t he
Macro lide group
(erythromycin or
azythromyclnl
with eGch breathe
.
• Swelling of th e face
and/or both lower
ex tremities
• Bluish tips and nail beds
• Prominent veins over
th e upper chest
• Skin behin d the
coll arb ones and
b et w een th e ribs
sucked In when
Inhaling
• Neck veins that
pulsate well above
the coli::irbone wit h
the pati ent In a
recl ining position
bath
• Sharp chest pain
whenever he coughs
or breathes de.eply
• Difficulty of swallowing •
• Marked weight toss
• P.ro longed period of
lmmobllity like
patient stayed in
bed for several
days with almost no
movement due to
illness
• History of Tuberculosis
or intake of antiTB medicines like
those containing
IN H , rifampicln,
ethambutol,
pyrazinamlde and/
or streptomycin
Injection.
389
I ti l t i
j
I
REO
YELLOW
S/S or Hx0
5/S or HxD
• Patie nt is hypertensive
or Is taking
anti hypertensive
medicine belongin g
to t he ACE Inhibitor
o r ARB group (e.g .
captopril, ena lapril,
perin dopril,
losartan, ibesar t an,
Telmis-a rtan)
• Patient Is a smoke r
(especially if he/she
is a heavy smoker,
i.e . smokes at least
o ne pack per day)
or has just stopped
smoki n_g
• Systolic blood pressure
of 140 to 1S9 and/
o r d iastolic blood
pressu re of 90 to 99
• Enlarged cervical or
a><il lary lymph no.des
GREEN
S/S or Hl<O
• Previous histor y of
Asthma or u~e
or anti •asthrna
medicines like
salbu t amol,
te rbutaline, etc.
• Chest is big "li ke a
barre l"
• Wh eezing sound
esp eci ally when
patient brea t hes out
.
.! : ...
~
I,
..
J
.:.
··-
")
390
.
---~
LOGIC TREE FLOW CHART NO.
7
cough, colds,
difficulty o f
breathin g; adult
patient
With
fever
RelC?r to logic
TreC? No . l
No
at least one
Yes
RED
s/ s or HxD
Proceed with
Plan C
'--l-No
at least one
YELLOW
s/s o r HxO
No
t
at least one
GR EEN
s/s or HxD
Yes
Yes
Proceed w ith
Plan 8
No
at least one RED s/s or
Proceed w ith •-'IIJI►, HxD developed since
Plan A
last visit
•
391
,-:: '
MANAGEMENT PROTOCOL FOR PROBLEM ON
COUGH, COLDS OR DIFFICULTY OF BREATHING
NOT ASSOCIATED WITH FEVER : ADULT PATIENT
(Flow Chart No. 7)
PLANA:
1.0
Determine patient's knowledge on the management of the problems
presented
2.0
Based on 1.0, give/prescribe over-the-counter medicine or herba l medicine
for cough and colds, specif)ing accurately the method of preparation
(specifically for herbal medicine), the dose and frequency of intake.
2.J
If mucus is thick and seems trapped in the chest, give/prescribe
a mucoly"tic preparation like those containing glyceryl guiacolate,
carbocystei.n or ambroxol. A decoction of sampaloc leaves or oregano
leaves can also be given.
2.2
If cough is dry or occurs very often, give/prescribe an antitussive
preparation like those containing dextromethorphan or butamirate
citrate. A decoctioo of lagundi leaves cim also be given.
2.3
If cough is associated \\ith a wheezing sound, give/prescribe a
prepar.1tior1 for asthma like those containing salbutamol, terbutaline
'
formoterol, etc.
2.4
If there is runny nose or nasal decongestion, give/prescribe
decongestant.
3.0
Advice the patient to:
stop smoking or avoid exposure to smoke;
3.2
avoid crowded places;
_
3.3
drink plenty of water and j uice but not caffeine or cola-containing
drinks
have steam inhalation for 10-.1 5 minutes as often as the patient likes;
3.4
there is no need to add anything to the water.
drain mucus from the lungs by postural drainage when needed and
this is done as follows:
3,5.1 Jet the patie.at lie face down partly on the bed with his head
and chest hanging over the edge and ms elbows o n the floor;
3.5.2 pound him/her ligbtJy on the back;
3.5.3 ask the patient to take a deep breath and then cough as ha.r d
as he/she could;
If there is epigastric pai n or history of intake of medicine for ulcer or recent
h istory of in take of medicines causing gastric irritation, do the following:
4.1
Give/prescribe medicine for ulcer.
4.2
Advice the patient to avoid spicy food, sour food, and caffeinecontaining drinks.
·
4 .3
Advice th e patient lo avoid lying down immediately after a meal
4 -4
Advice patient to take small frequent meals.
Advice the patient to observe the effe<-1 of the above intervention and to have
a follow-up after two or three days or earlier if any. RED symptom develops.
3.1
5.0
6.o
Do home visit if patient fai ls to return for follow-up after three d ays.
Do the following during follow-up:
Ask the patient if there was improvement in his condition. after the
management or interventions were started.
7.1
392
7.2
7.3
7.4
Iftl1ere was improvement and no other sign or symptom developed,
advice the patient to continue the above management for at least five
more days.
If there were no improvement, ask the patient if any new symptom
had developed since the last visit; if any red symptom has developed,
do the following :
.
7.3.1
examine the patient for any red signs which could have
developed since the patient's last visit.
7.3.2
proceed with either Plan B or Plan C depending on the
presence or absence· of red signs or symptoms.
If there were no .improvement and no new sign or symptom had
developed since the last visit, proceed with Plan B.
PLAN B:
1,0
Refer the patient to a doctor within 24 - 48 hours.
2 ,0
Advice the patient to do the following supportive management:
2.1
stop smoking or avoid exposure to smoke;
2.2
avoid crowded places;
2.3
drink plenty of water and juic.e but not caffeine or cola-containing
drinks;
2-4
have steam inhalation for 10-15 minutes as often as the patie.n t likes;
there is no need to add anything to the v,1ater;
2.5
drain mucus from the lungs by postural drainage following the
procedure described section 3.5 in Plan A;
2.6
continue taking the antihypertensive medicine until patient is seen
by the doctor;
2.7
continue taking the medicine for ulcer until patient is seen by the
doctor;
3.0
Provide the doctor with the necessary clinical record or referral note
containing the brief history of the disease, pertinent physical examination
findings result of laboratory examination (if available) and initial
management started at the referring level. (see Figure 3.2 for a sample
referral fom1)
Plan C:
1.0
2.0
Refer the patient immediately to a hospital, preferably the nearest one.
Make the patient as comfortable as possible.
3.0
If the patient coughed out large amount of blood, do the flowing:
3.1
give tranexamic acid by mouth if patient is no longer vomiting or
vitamin K preparation by parenteral route if available and patient is
not in a position to take anything per orem;
3.2
place ice on the patient's chest.
4.0
Provide the doctor with the necessary clinical record or referral note
containing the brief history of the disease, pertinent physical examination
findings result of laboratory examination (if available) and initial
management started at the referring level. (see Figure 3. 2 for a sample
referral form)
393
ASSESSMENT PROTOCOL FOR PROBLEM ON S KIN LES IONS:
ADULT PATIENT
(Logic Tree No. 9)
D IRECTION: Determine/identify which of the following symptoms/signs (S/S) o r
history dnta ( HxD) are present and follow the Howcharl for the appropriate p lan of
m anagem ent.
RED
S/S o r HxD
• Reddish. swolle n,
p,) i n ful p al t h
w hich srart ed
on t t'ie f.icc and
ra pid lv spread to
the oth~r parts
al the body.
• Alt er ed level o f
c0Mclousnes1
flke con fu~cd,
very Jl~cpy or
unl'onsdous
• No1tr1fs !apret)d our
w ,th eiJdl breath
• Skin behind the
collar bo nt' and
between 1he ri bs
sucli.c d tn when
Inhaling
• Patien t fooh very
4
BLUE
YELLOW
S/S or HXO
S/S or HxD
S/S or HxD
• P-atient had sexual
• Numbnes:- o n the
areas of t h~ skin
• Patient ale o r d r ank
!.Omc t hln J-1 or
1;:ontact two
to five wc·e ~s
lesion·
go t in co nt act
b efore the ~ore
appeared
• loss of ;,poetitc
wi t h !.omcth i11c
sevc r·al m i nu1cs
befor e t he
le !.1o ns w e r e
• Markr.d w c ieht loss
• Wound or sore h as
been there to r
• Boil is "ri pe .. o r has
r LJptur cd
• Ory scaly leslon.s
$(~ve ra l m onth~
involving large
• Lare~ sores or uleer.s
area, o l the
body
• lesfo n a ppea r iH
rings with small
pit in t he midd le
• Pocket!. of pus
n oted o n t he
• Sores noted at thecornt?r of the
mou th
acne. f.11mple or-
ln>ect bite
• Swollen feet
• Affected area could
not feet anything
• Non ..parnful toll'e on
the genitalia
grey skin
Itchy
• II chl ness m o re
!>evc•rc i n theevening
• O t h er m embers of
the family ai,o
1.1ffc cted
• Body wcatme-)S
• Hi,tory of all~rg y to
food. medicine,
,05m c tic,
sharp poi nte d
obj l!cts
(?lC.
jewelry, r u bber,
• History o f asthm~
.
• Family has history
of alle rgy or
as thma
• .Sm all ~or e-s noted
• Bllsl eri
ln\/Olved the
whole body a r a
m a inly betwee-n
gr ~.iter part o f ,t
the Hritcr !»,
• Grayi,h pr blackish
foul S-mell,ng
w r is t, wah:t and/
or eenital s
ulcer
.
394
noted
• Lesion ~ are vetry
gen tly with
when to uch ed
sick
Fas t but weak pul'.e
• Cool, rno,~t. pale
GREEN
• Mas1cs o n 1he n eck1
a rmpit. a nd/or
e,oln (e nlarged
lymph-nodes)
• Crusting of the
leslon
• Ory scaly lesions
Involving only
smaUarcas
• Wet ,,. weeping skin
lesio ns
• flat o r raised
pate.hes noted
o n t h e foce.
skin folds, scalp,
knees and/or
elbow
LOGICTREE fi,.QWq_fAflf '-fO, I
Yes
at least one
RED
s/s or HxD
No
Yes
at least one
BLUE
s/s or HxD
1-~ - -1~ 0~
_,__ __,______, Yes
at least one
YELLOW
l
s/s or HxD
l
Proceed with
Plan 8
No
at least one
GREEN
s/s or HxD
No
395
MANAGEMENT PROTOCOL FOR PROBLEM ON
SKIN LESIONS: ADULT PATIENT
(FLOW CHART NO. 9)
PLAN A:
1.
Determine knowledge of the patient or his companion on the management of
the problem presented.
2.
Based on 1.0, do the foUowing if the skin lesion is a sore or ulcer especially if
it is large.
2.1
Clean the sore with hydrogen pero:-.ide. povidone iodine, or plain
soap and water then cover "ith a sterile gauze. Mild ~1a,·a decoction
can also be used to clean the wound.
2 .2
Do not use any strong anti'septic solution like tinctures or alcohol.
2.3
Ad,ise the patient to ba,·e the wound cleaned everyday or eve ry other
day.
Based on 1.0, advise the patient to do the following ifhe has acne or pimple.
3.1
Wash the face at least twice a day with mild soap and water.
3.2
Use astringent before going to bed or to use Perla soap (the white
one) when washing the face at night.
3.3
Do not scratch, touch or squeeze th e pimple especially ifit is near the
eyes or around the area of the nose or mouth.
34
Eat a balanced meal and avoid fatty or oily foods, or those rich in
iodine.
3.5
Drink plenty ofliquid like water or juice.
3.6
Have enough sleep.
3.7
Let the sunshine fall on the affected area .
\•
I
Based on 1.0, do the follO\\ing if th e p atient bas very itchy skin lesions and
allergy, eczema or contact dermatitis js suspected.
4.1
Give/prescribe over-the-counter antihistamine preparation
specif)i.ng accuratelr the dose and frequency o( intake.
4 .2
Advise the patient not to operate any ma·c hine, drive a '(ehicle or
cross tl1e street alone while under treatment since tl1e medicines can
make the patient very sleepy.
4.3
Advise the patient or his companion to apply on the a ffected area any
over-tl1e-counter lotion or cream or herbal medicine for itchiness.
specifying accurately the method of prepa ration (specifically for
herbal medicines) and the frequency of application.
4.4
If the affected area is warm. advise the patient or h is companion to
apply cotton or gauze soaked in cool sal t solution for one hour three
times a day.
4.5
Advise the patient's companion to keep the patient's fingernails sl10rt
or to put gloves/ mittens over the patient's hands to protect h im from
scratching himself.
4.6
Advise the patient o r his companion to avoid substances wh ich could
have caused the allergy, like chocolate, eggs, ch icke n, sea foods,
cosmetics esp. perfumed ones.
\
\
'
lI ..
l
l! .
I
5.
Based on 1.0, advise the patient to do the following ifhe h as a boil.
5.1
Do not squee1.e or cul the boil i.fit is not yet "ripe".
u,.____3.96-------------------------------•
5.2
5.3
Apply wnrm compress over the boil and paint the surrounding area
with tin cture of iodine or povidone iodine solution
Return to the clinic for follow-up if the boil is already uripe".
Based on 1 . 0 1 advise the patient or his companion to do the following ifhe
bas pat ches o r r ings and fungal infection is suspected.
6.1
Shave th e head if sc.1\p is affected.
6 .2
App ly cala mine lo tion if a reil is reddislt.
6.3
Apply antifungal ointment or gentian violet twice a day for at least
three weeks .
Based on 1.0. advise the patient or his companion to do the following ifhe
has small sor es o n th e wrist, waist , ge nital area or between the fingers and
is very itchy es p ecially at night. The patient is most likely suffering from
scabies.
7 .l
All household members (even il they have no complaint) must
under go th e same t reatmcnl.
7 .2
BatJ.1e and scrub th e whole b-ody especially the affected areas with
sulfur soap and water.
7.3
Apply b cuzyl benzoate, or any p reparation for scabies, all over the
b o dy exce pt for the face and leave it there for one whole day (24
hours) e xcept rf househo ld member is a b aby.
7-4
Bathe well the following day .
7.5
P ut on clean clothes an d change the beddings.
7 .6
Was and boil contaminated clothes , towels and beddings.
7.7
Repeat the procedure twice at the most ifnecessaxy.
7 .8
Re mind the patient an d his companion the importance of personal
cleanliness.
8.
Based on 1.0, advise the patient or h.is companion to do the following if the
skin lesion is dry, scaly and reddish.
8.1
Take warm baths dai ly, gently rubbing the lesions with a soft brush.
8 .2
Apply calamine, starch solution or bland ointment containing 10%
coal t ar.
8.3
Expose affected area to sunlight for 10 -15 minutes everyday at
around 10-11 am.
9.
Advise the patient to have a follow-up after five days.
10.
Do home vis it if the patient fails.to return for a follow-up.
u.
Do the following during the follow-up
.
11..1
Ask the patient or his companion if the patient's condition·has
improved si n.c e the management was started.
11.2
If there were some improvement, advise patient or his companion
to continue the management until the signs and symptoms have
disappeared completely.
11..;3
If there was no improvement, ask the patient or bis companion if any
symptom developed since the last visit.
11-4
Examine the patient for any s igns which could have developed since
th e las t.vis it.
n.5
Proceed.with Plan B, C or D depending on the signs and/or
symptoms ide ntified.
397
PLAN B:
1.0
Refer the patient to a doctor within the week.
2.0
If there are sores, advise the patient to clean it daily ,vith a ny antiseptic
solution like those containing povidone iodine, mild soap and water or mild
guava decoction.
3.0
Provide the doctor w ith appropriate clinical record o r referral no te containing
a brief history, pertinent physical examination, laboratory result (if available)
and management initiated at the referring level (see Figure 3.2 for a sample
referral form).
PLAN C:
1.0
Refer the patient to a doctor witl1in 24-48 h ours.
2.0
lf there are sores, advise the patient to clean it daily ,vith any antiseptic
solution like those containing povidonc iodine, mild soap and watex or mild
guava decoction.
3.0
Provide the doctor with appropriate clinical record or referral note containing
a brief history, pertinent physical examination findings, laboratory results (if
available) and management initiated at the referring level (see Figure 3.2 for
a sample referraJ form).
PLAN D:
1.0
Refer tlle patient immediately to a hospital, preferably the nearest one, since
tlle patient might be suffering from a severe allergic reaction, from Gas
Gangren e or E rys ipelas
2.0
Make tlle patient as comfortable as possible.
3.0
Ifthere is fever, try to lower the patient's temperature by doing the following:
3 .1
Cover the patient lightly.
3.2
Gi