CHN Lecture

SY2015-2016
st
1 Semester
Home Visit - a family-nurse contact which allows the health worker to assess the home&
family situations in order to provide necessary nursing care & health related activities. It is a
professional face to face contact made by the nurse to the client/ family to provide necessary
health care activities & to further attain an objective of the health agency.

Purposes of home visit:

1. Give nursing care to the sick, a postpartum mother & her newborn with the
view to teach a responsible family member

2. Assess the living condition of the patient & his family & their health practices
in order to provide health teachings

3. Give health teaching for prevention of diseases

4. Detect, help prevent spread of communicable diseases

5. Establish close relationship between health agencies & public for promotion of
health

6. Make use of referral system & use of community

Arrangement of Home Visit

1. Nursing to postnatal cases

2. Health supervision to visit prenatal cases & infants

3. Visit to clients suffering from communicable diseases

Frequency of Home Visit- factors to consider:

1. Acceptance of family for services offered , their interest & willingness to

cooperate

2. Physical, psychological & educational needs of family

3. Policy of the health agency, emphasis on health program & priority

4. Number of health personnel involved in care

5. Evaluation of past services & how they made use of nursing services

6. Ability client/ family to recognize their needs, available resources & how they
utilize these resources
Principles in Planning for a Home Visit:

1. Home visit should have a purpose/ objective

2. Make use of information about client/family- family records,

information from health center personnel, other agencies
that gave services to the family

3. Revolve around essential needs of client/ family, priority to

those needs recognized

4. Plan for continuing care should involve individual & his family

5. Flexible & practical

BAG TECHNIQUE – is a tool making use of a Public Health Bag through which the
nurse during the home visit can perform a nursing procedure with ease & deftness,
saving time & effort with the end view of rendering effective nursing care.

Principles of Bag Technique:

1. Minimize if not totally prevent spread of infection

2. Save time & effort of the nurse in performance of procedures

3. Should not overshadow concern for patient but rather show

effectiveness of care

4. Can be performed in variety of ways depending on policies, actual home

situations, as long as principles of avoiding transfer of infection is
carried out
Public Health Bag - essential & indispensable equipment of Public Health nurse which she/he has
to carry along during home visit. Contents & arrangement of PHN Bag should be followed.

Principles to Consider & Procedures in the Use of PHN Bag:

1. The bag should contain all necessary articles, supplies & equipment which maybe
used to answer emergency needs

2. The bag & its contents should be cleaned as often, supplies replaced & ready for use
anytime

3. The bag & its contents should be protected from contact with any articles in the home
of patients. Consider the bag & its contents, clean & sterile while any article belonging
to patient as dirty & contaminated

4. Arrangement of contents of bag should be convenient to the user to facilitate

efficiency / avoid confusion

5. Handwashing is done frequently to minimize/avoid contamination

6. The bag when used for communicable diseases should be cleansed/ disinfected before
keeping/ reusing
PROCEDURE IN BAG TECHNIQUE:

1. Upon arriving a client’s home, place the bag on table or any flat surface lined
with paper lining, clean side out [ folded part touching table],Put bag ‘s handles/
strap beneath the bag

2. Ask for a basin of water/ glass of water if faucet not available, place this outside
working area

3. Open the bag, take the linen/ plastic lining & spread over work field area. The
paper lining, clean side out.

4. Take out hand towel, soap in soap dish & apron & place them at one corner of
work area[ within the confines of linen/plastic lining]

5. Do handwashing. Wipe dry with towel.

6. Put on apron, right side out & wrong side with crease, touching the body, sliding
the head into the head strap. Neatly tie straps at the back

7. Put out things most needed when rendering nursing care [thermometer, kidney
basin, CB, waste paper bag [& place at one corner of work area.
8. Place paper receptacle outside work area

9. Close the bag

10. Proceed to nursing care & treatment

11. After completing nursing care / treatment, clean & alcoholize things used

12. Do handwashing again

13. Open bag & put back all articles in their proper places

14. Remove apron, folding away from body, with soiled side folded inwards, & the
clean side out. Place it in the bag

15. Clean & fold linen/ plastic lining, place it in the bag & close the bag

16. Get the bag, fold the paper lining & place in between the flaps & cover the bag
Definitions:

Health - a state of complete physical, mental and social well- being and not
merely the absence of disease or infirmity. [World Health Organization
1958]

Social Health - connotes community vitality & is a result of positive

interaction among groups within the community with an emphasis on
health promotion & illness prevention.

Community - a collection of people who interact with one another & whose
common interests or characteristics form basis for a sense of unity or
belonging.

Population – group of people having common personal or environmental

characteristics.

Aggregates – subgroups or subpopulations that have common

characteristics or concerns vulnerable to similar heath problems.
Determinants of Health & Disease:
1. Income / social status- higher income /social status are linked to
better health
2. Education – low education linked to poor health
3. Physical environment – safe water, clean air
4. Employment / working condition
5. Social support networks – families, friends , communities
6. Culture - customs, traditions, beliefs
7. Genetics- inheritance
8. Personal behavior/ coping skills-
9. Health services
10. Gender – men/women suffer different diseases at different ages
C. E. Winslow classic definition of Public Health:
Public Health is the science & art of:
1. Preventing disease
2. Prolonging life and
3. Promoting health & efficiency through organized community effort for:
a. sanitation o f environment
b. control of communicable infections
c. education of individual in personal hygiene
d. organization of medical /nursing services for the early diagnosis &
preventive treatment of disease and
e. development of social machinery to ensure everyone a standard of living
adequate for maintenance of health, so organizing theses benefits as to
enable every citizen to realize his birthright of health & longevity.
Core Public Health Functions [Institute of Medicine USA [1988]
1. Assessment – regular collection , analysis & information -sharing about health
conditions, risks, & resources in the community
2. Policy development- use of information gathered during assessment to develop local
/state health policies & to direct resources toward those policies
3. Assurance – focuses on availability of necessary health services throughout the
community. Includes maintaining the ability of public/ private health agencies to
manage day to day operations & having the capacity to respond to critical situations &
emergencies.
Core Business of Public Health:
a. Disease control
b. Injury prevention
c. Health protection
d. Healthy public policy including those in relation to environmental hazards –workplaces,
housing, food, water etc.
e. Promotion of health & equitable health gain
Public Health Nursing/Community Health Nursing
1. A field of professional practice in nursing /public health in which technical nursing,
interpersonal, analytical & organizational skills are applied to problems of health as they affect
the community. These skills are applied with those other persons engaged in health care
through comprehensive nursing care of families & other groups &through measures for
evaluation or control of threats to health, health education & mobilization of public health
action. – Ruth B. Freeman [1963]
2. A special field of nursing that combines skills of nursing, public health & some phases of social
assistance, & functions as part of total health program for promotion of health, improvement
of conditions in social & physical environment, rehabilitation & prevention of
illness/disability.-World Health Organization Expert[ WHO] Committee on Nursing
3. It is the synthesis of nursing practice & public health practice applied to promoting &
preserving the health of populations. - American Nurses Association [ANA] 1980.
4. Department of Health [DOH] Community Health Nursing [CHN] - is a unique blend of nursing &
public health practice woven into human service, has a tremendous impact on human well-
being. Care & supervision of individuals& families in their homes, places of work, schools &
clinics.
In CHN, services are delivered outside of purely curative institution
[hospitals] but in community settings- home, schools, places of work,
health centre’s, clinics. Scope of services - promotive, preventive,
curative, rehabilitative nursing services. The ultimate objective of care
is achieving the highest possible level of community health by
developing/enhancing capabilities of individuals, families, population
groups & the community.

Public Health Nursing was coined by Lilian Wald when she was the
director of Henry Street Settlement in New York to denote a service
that was available to all people.
LEVELS of CLIENTELE:

1. INDIVIDUAL - as the client /patient. From the healthy/well to the dying- all age
group, from birth to senescence. Ex. The nurse may do prenatal check up on a
healthy young women, assess health status of infants coming to health center
during a well-baby clinic, follow up on medications /treatments of an elderly
newly discharged from hospital, assist a diabetic patient on meal planning, or
help a family care for terminal cancer patient.

2. FAMILY - refers to 2 or more individuals joined / related by ties of blood,

marriage or adoption & who constitute a single household, interact with each
other/ create/ maintain common culture. The basic unit of society.
3. POPULATION GROUP- Certain groups with unique health needs at risk of developing/or
have already developed certain health problems & to whom the nurse delivers health –
promotive, preventive, curative , or rehabilitative nursing services. Ex: childbearing
women, infants, preschool children, elderly, out of school youths, street children,
communicable diseases, chronic diseases, disabled, physically & mentally retarded. The
Community Health Nurse utilizes group approach- identifying common health/ nursing
needs of members & addressing them for the whole grouped. The nurse may
organize/conduct meal planning for DM: mothers’ class- primigravidas, support group
for HIV/AIDS patients.

4. COMMUNITY - a place with spatial boundaries/physical/ environmental characteristics

& natural/ Man-made resources- barangay, village, barrio, town, city, province, region,
country. A group of people who share common needs, interests, ethnic or cultural ties,
committed to their group’s well- being- squatters/ informal settlers: Chinese community.
Christian community in Mindanao.s
LEVELS OF PREVENTION in PUBLIC HEALTH [Leavell, Clark 1965]

Level of Prevention Objectives & Focus of Activities

1. Primary Prevention Health Promotion Specific Protection

2. Secondary Prevention Early Diagnosis Prompt Treatment
3. Tertiary Prevention Rehabilitation
LEVELS OF PREVENTION in PUBLIC HEALTH [Leavell, Clark 1965]

Level of Prevention Objectives & Focus of Activities

1. Primary Prevention Health Promotion Specific Protection
2. Secondary Prevention Early Diagnosis Prompt Treatment
3. Tertiary Prevention Rehabilitation

1. Primary Prevention - activities undertaken before disease strikes, applied to generally

healthy people to keep them well. Health promotion are activities aimed at maintaining
/ enhancing people’s physical, mental or social well – being- Healthy lifestyle,
enactment of laws, formulation of policies/ regulations , providing information that
protect people. Education on hygiene, nutrition, exercise, sleep & rest, use of tobacco,
alcohol & drugs, guidance on sexuality/ relationships. Specific Protection- activities
which protect people from specific & known potential or actual threats to health-
diseases or accidental injuries. It involves identification/ reduction of risks/ hazards to
healthier- immunization, Vita capsules, fluoridation of water, promoting use of
mosquito nets, eradicating breeding places of mosquitoes to prevent malaria/dengue.
2. SECONDARY PREVENTION - Activities for early diagnosis & prompt treatment of
diseases or health problem which has not been prevented, with the objectives
of halting its progress, minimizing severity, shortening its duration,
preventing/reducing its complications & bringing about cure. Ex. Breast/uterine/
prostate cancers are curable when diagnosed early/ treat promptly. Screening &
periodic check-ups- annual Pap smear, mammogram for women, periodic chest
x-ray, BP monitoring.

3. TERTIARY PREVENTION - Activities done when disease/ injury /calamity has

already exacted its damage & ill-effects, with consequent disability or loss of
function in varying degrees. The objective of rehabilitation is to restore the
patient to an optimum level of functioning [OLOF] physically, psychologically,
socially & economically within the constraints imposed by disability. Ex. teaching
a DM client to identify/ prevent complications.
Example:

A 40y.o.male may begin a program for walking 3 miles each day. If the
goal of his program were “to decrease the risk of cardiovascular
disease’ then the activity be considered DISEASE PREVENTION OR
HEALTH PROTECTION. By contrast, if the motivation for his walking
regimen were to “increase his overall health & feeling of well-being”
then the activity would be considered HEALTH PROMOTION behavior.
Health promotion & health protection as complementary process –
both affect quality of life.
CONCEPTS/PRINCIPLES IN CHN

1. The family is the unit of care.

2. Community is the locus of service & the patient.
3. Goals in improving community health is thru multidisciplinary approach
4. Four levels of clientele- individual, family, population groups, &
community
5. Public health nurse works WITH and not for the patient who is an active
partner
6. Practice is affected by changes in society & development in health care
7. CHN is part & functions with a large/complex system & any change
affects it.
BASIC ETHICAL PRINCIPLES:

1. Respect for persons/autonomy- protect client’s rights

2. BENEFICENCE/ utility- Do good for everyone
3. NON-MALEFICENCE-“PRIMUM NON NOCERE”- at first do
no harm
4. Justice - treats everyone equally
5. Inviolability of life – maintain dignity of human life
ROLES of COMMUNITY HEALTH NURSE:
Case Manager, advocate, teacher, partner/collaborator, health
planner/programmer, manager, supervisor, community organizer, health
educator/trainer, case finder, epidemiologist, recorder/reporter/statistician,
community leader
PRELIMS
HEALTH CARE DELIVERY SYSTEM
Anderson & Mc Farlane [2011] Factors in shaping 21st century health that further
influence health care delivery system:
1. Health care reforms
2. Demographics
3. Globalization
4. Poverty & growing disparities
5. Social disintegration
WHO – World Health Organization - a global health organization .April 7 each year
as World Health Day. Headquarters at Geneva Switzerland, WHO has 147 country
offices. The Philippines is member of Western Pacific Region.

WHO – Core Functions:

1. Providing leadership on matters critical to health & engaging in partnerships
where joint action is needed[ WHO 193 member countries]
2. Shaping research agenda
3. Setting norms / standards & promoting/ monitoring implementation- health
related issues
4. Ethical & evidenced- based policy options
5. Providing technical support, catalyzing change & building sustainable
institutional capacity.
United Nations Millennium Declaration [UN 2013] 8 Millennium
Development Goals:

1. Eradicate extreme poverty & hunger

2. Achieve universal primary education
3. Promote gender equality & empower women
4. Reduce mortality rate
5. Improve maternal health
6. Combat HIV/AIDS , malaria, & other diseases
7. Ensure environmental sustainability
8. Develop global partnership for development
Philippine Health Care Delivery System

Department of Health [DOH] Vision “The Leader of Health for All in

the Philippines”. Health for All Filipinos and Health in the Hands of the
People by the year 2020.

DOH Mission ‘Guarantee equitable, sustainable & quality health for

all Filipinos especially the poor and to lead the quest for excellence in
health”.
DOH major roles:
1. Leader in health
2. Enabler & capacity builder
3. Administrator of specific services

Leadership Roles – DOH

1. Planning/ formulating policies of health programs/services
2. Monitoring & evaluating implementation of health programs, projects,
research, training & services
3. Advocating for health promotion & healthy lifestyle
4. Serving as technical authority in disease
5. Providing administrative & technical leadership in health care financing
& implementing the National Health Insurance Law
As enabler & capacity builder, DOH performs:

1. Providing logistical support to LGUs, private sector & other

agencies in implementing health programs & services
2. Serving as lead agency in health & medical research
3. Protecting standards of excellence in training & education of
health care provider at all levels of health care system
As administrator of specific services, DOH is tasked to:
1. Serve as administrator of selected health facilities at subnational levels
that act as referral centers for local health systems, tertiary & special
hospitals, reference laboratories, training centers, centers for health
promotion, centers for disease control & prevention , and regulatory
offices
2. Provide specific program components for conditions that affect large
segments of population such as tuberculosis, malaria, schistosomiasis,
HIV/AIDS & micronutrient deficiencies
3. Develop strategies for responding to emerging health needs
4. Provide leadership in health emergency preparedness & response
services, including referral & networking systems for trauma, injuries &
catastrophic events
DOH Core Values

1. Integrity
2. Excellence
3. Compassion & respect for human dignity
4. Commitment
5. Professionalism
6. Teamwork
7. Stewardship of health of people
LEVELS OF HEALTH CARE DELIVERY- DOH

1. Primary – BHS/ RHU

2. Secondary- RHU/infirmaries/ municipal & district hospitals /
private or government/OPD
3. Tertiary- Provincial Hospitals/ medical centers/ regional /
specialized hospitals
Hospitals classification scheme:

a. General hospital – provides services for all kinds of illnesses,

injuries or deformities, level 1, 2 or 3.

b. Specialty hospital – offers services for specific disease/ condition/

type of patient- women /children
Other classifications:

1. Category A - Primary Care Facility- first contact health care facility, offers basic
services, emergency services/ provision for normal deliveries
a. without in-patient beds like health centers, out patient clinics, dental
clinics
b. with in patient beds- short stay,1 or 2 days, infirmaries, birthing[ lying – I ]
facilities

2. Category B - Custodial Care Facility- provide long term care, basic services like
food / shelter to patients with chronic conditions/ rehabilitation- custodial
psychiatric facilities, substance drug abuse treatment/ rehabilitation centers,
sanitaria/ leprosaria & nursing homes
3. Category C- Diagnostic / Therapeutic Facility- facility for examination of human body,
specimens from human body for diagnosis, treatment of disease, drinking water
analysis.

a. Laboratory facility-clinical laboratory, HIV testing lab, Blood service lab, drug testing
lab, newborn screening lab, laboratory for drinking water analysis
b. Radiologic facility providing services such as X- ray, CT scan, MRI, ultrasonography
c. Nuclear medicine facility- regulated by Phil. Nuclear Research Institute [PNRI]
utilizing application of radioactive materials in diagnosis, treatment or medical
research except the use of sealed radiation sources in radiotherapy as in internal
radiation therapy

4. Category D - Specialized Outpatient Facility- dialysis clinic, ambulatory surgical clinic,

cancer chemotherapy, physical medicine & rehabilitation center
Philippine National Objectives on Health:

1. Improve health of population

2. Reduce morbidity/ mortality
3. Eliminate diseases as public health problems
4. Promote healthy lifestyle/environmental health
5. Protect groups with special needs/ nutrition needs
6. Strengthen national/local health systems to ensure better health services
7. Pursue public health / hospital reforms
8. Reduce cost & ensure quality of essential drugs
9. Institute health reforms
10. Strengthen health governance/ management
11. Institute safety for vulnerable / marginalized groups
12. Expand health insurance
13. Mobilize resources for health
14. Improve allocation, production & utilization of health resources
NATIONAL HEALTH PLAN [NHP] - long term directional plan/ blueprint for health
covering the period 1995- 2020. A multi-sectoral effort from the government,
private & non – government sector, people’s organizations, & other health –
oriented groups. Guided by these concepts: 1] health is a basic human right 2]
health is both a means & an end of development.

Broad Objectives of NHP:

1. Promote equity in health
2. Address health problems of population
3. Upgrade status of health care delivery system to a responsive, dynamic ,
efficient & effective
4. Promote active people’s participation
RESTRUCTURED HEALTH CARE DELIVERY SYSTEM
To strengthen rural health services to a more efficient / effective health services in
the country

Referral System - A client is first cared for by the family which may/ or may not
seek assistance of the barangay. From either of theses 2 entities, the case is
referred to BHS. Necessary referrals may then be made to the main health center or
private agencies within the poblacion. Further management maybe provided as the
case may warrant through system of referrals to district / provincial/ regional
hospitals & central referral system.
Population – Based Rural Health Manpower Needs – RURAL HEALTH UNIT

Municipal Health Officer/Rural Health Physicians 1 for every 20,000 population

Public Health Nurses 1 for every 20,000 population
Rural Health Midwives 1 for every 5,000 population
Sanitary Inspectors 1 or every 20,000 populations
Dentists 1 for every 50,000 population
Medical Technicians 1 for every 20,000 population
Roles /Functions of RHU personnel:
1. Municipal Health Officer [MHO] or Rural Health Physician-
a. Administrator of RHU- prepares municipal health plan / budget: monitors
implementation of basic health services: management of RHU staff
b. Community Physician – conducts epidemiological studies: formulates health
education campaign on disease prevention: prepares/ implements control measure
/ rehabilitation plan
c. Medico- legal officer of municipality
2. Public Health Nurse [PHN]
a. Supervises / guides RHM in municipality
b. Prepares FHSIS quarterly & annual reports of municipality for Provincial Health
Office
c. Utilizes nursing process in health care needs, health education of individual ,
families & catchment community
d. Collaborates with health team, government/ private agencies, NGOs to address
health problems
3. Rural Health Midwives [RHM]:
a. Manages BHS/ supervises / trains BHW
b. Provides midwifery services to women of reproductive age, family planning
c. Conducts patient assessment / diagnosis for referral/ further management
d. Performs health information, education,& communication activities
e. Organizes community
f. Facilitates barangay health planning/health services

4. Rural Sanitary Inspector- ensures healthy physical environment in municipality, advocacy,

monitoring, regulation – water supply/ unhygienic household conditions

5. Grassroots/ Auxiliary/ Barangay Health Workers [BHW]- assist RHM in organizing/

mobilizing community: monitoring nutrition programs
DEVOLUTION – transfer of power / authority from national government to LGU as the
territorial & political subdivisions of state to enable them to perform specific
functions/responsibilities

Health Sector Reform: Universal Health Care [UHC] – KALUSUGAN PANGKALAHATAN also
called AUINO HEALTH AGENDA –latest in series of continuing efforts of government to bring
health reforms. Built upon 2 previous platform reforms:

1. Health sector reform agenda [1999- 2004]

2. FOURmula One for Health [2005- 2010] UHC is for implementation until 2016- DOH: its
rationale- equity in health service delivery.
RESTRUCTURED HEALTH CARE DELIVERY SYSTEM [RHCDS]
SENTRONG SIGLA MOVEMENT

• Joint effort of DOH & LGUs

• Aim: Promote quality services in health centers/hospitals &
make these accessible to all Filipinos.
• Main Component: Certification/ recognition program that
develops & promote standards for health facilities.
• 1998- DOH formulated Quality Assurance Program [QAP] – goal:
to make DOH & LGUs active partners in quality health services
• 1999- QAP renamed SENTRONG SIGLA [Centers of Vitality]
MOVEMENT [ SSM] Four [4 pillars]:

1. Quality assurance
2. Grants & technical assistance
3. Awards
4. Health promotion
• Guiding Principles for Sentrong Sigla :
1. Recognition for achieving good quality
2. Quality improvement is unending process
3. SS certification focus on core public health- child health,
maternal care, prevention of communicable diseases,
healthy lifestyle
4. Quality improvement is a partnership of stakeholders
5. Roles, responsibilities /contributions promote reciprocity
6. Even distribution of quality health services
7. SS shall involve partners – NGOs, GO, as advocates
HEALTH SECTOR REFORM AGENDA[ HSRA] 1999-2004 : health
reform areas:
1. Local health system development - networking of facilities
2. Hospital reforms - cost efficient hospitals
3. Public health program reforms - strengthen public health
delivery system
4. Health regulatory reforms - DOH ensure health products,
facilities, devices are safe, affordable
5. Social health insurance reforms - Phil Health Insurance
Corporation
FOURmula ONE FOR HEALTH [ 2005- 2020]
• Designed to implement health interventions as single package,
includes public / private, sectors, national agencies/LGUs, civil
society

Goals
1. Better health outcomes
2. More responsive health systems
3. Equitable health care financing
FOURmula ONE Components:
1. Health financing - better, sustained investment in health. Phil
Health thru National Health Insurance Program & DOH
2. Health regulation - access to affordable products, devices,
services & facilities.
3. Health service delivery - accessible/available basic health care
for all
4. Good governance - improve health systems performance at
national/local levels
MAJOR PUBLIC HEALTH PROGRAMS:

1. Reproductive & maternal health – pre-pregnancy services & care during

pregnancy, delivery & postpartum period
2. Expanded GARANTISADONG PAMBATA [ child health] – advocacy for
breastfeeding in 1st 6months of life, newborn screening, immunization,
nutrition services & integrated management of childhood illnesses
3. Control of communicable diseases- TB, mosquito borne diseases, rabies,
schistosomiasis & STI –sexually transmitted infections
4. Control of non-communicable diseases/ lifestyle diseases
5. Environmental health
PRIMARY HEALTH CARE [PHC] - Brief History

On September 6-12 , 1978, health leaders form around 200 countries attended
International Conference for Primary Health Care held at Alma Ata USSR initiated by
WHO & United Nations Children’s Fund. The universal goal of PHC is HEALTH FOR
ALL by the year 2000.

Letter of Instruction 949 was signed on October 19, 1979 to formally launch PHC.

RATIONALE for the Development of PHC:

1. Magnitude of health problems
2. Inadequate / unequal distribution of health resources
3. Increasing cost of medical care
4. Isolation of health care activities from other development
Definitions:
• An approach of organizing thru involvement & participation by the use of
community resources , indigenous technologies & linkages in attaining self-
reliance & development
• An approach whereby essential health services are made available, acceptable,
accessible, affordable & sustainable thru active community participation,
utilizing technology supported by intrasectoral/ intersectoral collaboration
leading to self- reliance & social transformation

Mission: To strengthen the health care system by increasing opportunities &

supporting the conditions wherein people will manage their own health care.

Key strategy to achieve the Goal: Partnership with and empowerment of the
People.
The Alma Ata Declaration listed 8 essential services:

E - Education for health

L - Locally endemic disease control
E - Expanded program for immunization
M- Maternal & child health including responsible parenthood
E - Essential drugs
N - Nutrition
T - Treatment of communicable /non-communicable diseases
S - Safe water & sanitation
Key Principles of PHC:

1. Accessibility, affordability, acceptability ,availability- such as Botika ng Bayan,

Ligtas Tigdas ang Pinas
2. Support mechanisms- people, government, private sector- NGOs
3. Multisectoral approach

a. Intrasectoral linkages- communication, cooperation & collaboration within

the health sector: among members of health team, & among health
agencies [ team approach]: two- referral system
b. Intersectoral linkages - encompasses communication, cooperation &
collaboration between health sector & other sectors of society like
education, public works, agriculture, & LGUs. Example: Rabies Prevention
& control Program
4. Community Participation – individuals, families, communities are active
participants to achieve health thru self- reliance & self- determination

5. Equitable distribution of health resources- Doctors to the Barrios Program,

Registered Nurses Health Enhancement and Local Service [RN HEALS] –
deployed to underserved, economically depressed areas

6. Appropriate technology – safety, effectiveness, affordability, simplicity,

acceptability, feasibility & reliability : ecological effects: potential to contribute
to individual & community development

R.A. 8423 Traditional & Alternative Medicine Act of 1997 - signed into law through Dr. Juan
Flavier – the then Sec. of Health. It created the Phil. Institute of Traditional & Alternative
Health Care [PITAHC], tasked to promote / advocate the use of traditional/ alternative health
care- herbal medicine, reflexology, chiropractics, nutritional therapy etc.
ENVIRONMENTAL HEALTH – definitions:

• The characteristics of environmental conditions that affect the quality of health.

It is the aspect of public health that is concerned with those forms of life ,
substances , forces, and conditions in the surroundings or person that may exert
an influence on human health & well- being.[ DOH- Code of Sanitation P.D. 856]

• Environmental health comprises of those aspects of human health, including

quality of life , that are determined by physical, chemical, biological, social, &
psychosocial factors in the environment. It also refers to the theory & practice of
assessing, correcting, controlling & preventing those factors in the environment
that can potentially affect adversely the health of present & future generations-[
WHO in Sofia, Bulgaria]
Executive Order No. 489- Interagency Committee on Environmental Health [IACEH],
develop [NEHAP] National Environmental Health Action Plan and identified 7
components of environmental health:

1. Solid waste
2. Water
3. Air
4. Toxic & hazardous waste
5. Occupational health
6. Food safety
7. Sanitation & climate change
8 Environmental Health Indicators that need to be monitored- DOH:
1. Households with access to improved or safe water

a. Level 1[ point source] – protected well [ shallow or deep] , improved dug well,
developed spring, or rainwater cistern with an outlet but without distribution
system: rural areas : served 15-25 households: point of consumption is at the
source itself, placing water reservoir at risk for contamination

b. Level 11[ communal point system or stand post] composed of a source , reservoir,
piped distribution network & a communal faucet located no more than 25 meters
from the farthest house, suitable for rural/ urban areas. Contamination from level
11 sources may take place during it transport / storage in households

c. Level 111[waterworks system] with a source, transmission pipes, reservoir, & a

piped distribution network for household taps. Suited for densely populated areas.
Example- water districts with individual household connections.
2. Households with sanitary toilets- with flush toilets connected to septic tanks/
sewerage system, sanitary pit latrine, ventilated improved pit latrine
3. Households with satisfactory disposal of solid waste
4. Households with complete basic sanitation facilities- access to water, available
sanitary toilet, satisfactory garbage disposal
5. Food establishments- refer to those where food /drinks are manufactured,
processed, stored, sold, or served, including those in vessels
6. Food establishments with sanitary permits-written certification of
city/municipal health officer or sanitary engineer that establishment complies
with minimum sanitation requirements
7. Food handlers- persons who handle, store, prepare, or serve food/drink/ ice or
who come in contact with eating /cooking utensils or food vending machine.
8. Food handlers with health certificates- written certification to a person who
passed physical / medical exam & immunization
SOLID WASTE MANAGEMENT

R.A. 9003- “Ecological Solid Waste Management Act of 2000 “

Solid Waste Classification:

1. Municipal waste- discarded nonhazardous household,

commercial & institutional waste, street sweepings & construction
debris
2. Health care waste/ biomedical waste- refuse generated in diagnosis, treatment or
immunization of humans, animals, & those related with production or research of the
same. Classified as:
a. Infectious waste- suspected to contain bacterial, viral, parasitic, or fungal pathogens:
include lab cultures, contaminated waste form clients with infectious diseases, dressings,
swabs, instruments, material in contact with infected human / animal
b. Pathological waste- tissues, organs, body parts, human fetuses, animal carcasses, blood &
body fluids
c. Pharmaceutical waste-drugs, vaccines,& sera no longer required/ need to be disposed:
bottles, boxes with residues, gloves, masks, tubing’s, vials
d. Chemical waste- chemical matter from clinical/ lab activities, environmental work,
housekeeping, disinfecting
e. Sharps- needles, broken glass, scalpel / blades
f. Radioactive waste – sealed radiation sources used in cancer treatment, liquid & gaseous
materials contaminated with radioactivity, excreta of patients who underwent
radionuclide diagnostic / therapeutic applications, paraphernalia & tap water washings
3. Industrial waste- arising from production, agricultural& mining
industries, rubbish mixed with contaminated soil, ashes, hazardous
wastes

4. Hazardous waste- substances that pose immediate/ long term

danger to humans because of
a. Toxic
b. Corrosive – acids of pH<2 and bases of pH> 12
c. Flammable
d. Reactive – cause explosion
e. Genotoxic – cytostatic drugs
COLOR CODING of hospital wastes bins:

1. Black / colorless- nonhazardous & non-biodegradable wastes

2. Green- nonhazardous biodegradable wastes
3. Yellow with biohazard symbol- pathological/anatomical wastes
4. Yellow with black band- pharmaceutical, cytotoxic or chemical
wastes[labeled separately]
5. Yellow bag that can be autoclaved- infectious wastes
6. Orange with radioactive symbol- radioactive wastes
R.A. 9003 – prohibited act:

1. Open burning of solid wastes

2. Open dumping
3. Burying in flood- prone areas
4. Squatting in landfills
5. Operation of landfills on any aquifer, groundwater reservoir,
watershed
6. Construction of any establishment within 200 meters from a
dump or landfill
WATER SANITATION - the general requirements of safe drinking water
are the following:

1. Microbial quality tested thru parameters of total coliform, fecal

coliform & heterotrophic plate count
2. Chemical /physical quality tested thru pH, chemical specific levels,
color, odor, turbidity, hardness, total dissolved solids
3. Radiological quality tested thru gross alpha activity, gross beta, &
radon
PD 856 Code of Sanitation of the Philippines - Water Supply
provisions:
1. Washing / bathing within radius of 25 meters from any well,
source of drinking water is prohibited
2. No artesian, deep or shallow well shall be constructed within 25
meters from source of pollution[ septic tank/ sewerage
system].Drilling wells within 50 meters distance from cemetery is
prohibited
3. No radioactive material shall be stored within 25 meters from
well or source of drinking water
4. No dwellings shall be constructed within catchment area of
protected spring water source, off limits to people / animals
Emergency Water Treatment – [Water Engineering & Development Center]
A. Pre-treatment process:
1. Aeration- remove volatile substances reduce carbon dioxide; oxidize minerals for
sedimentation /filtration. Method is to rapidly shake a container partially full of water
for 5 minutes
2. Settlement- allowing water to stand undisturbed in the dark for a day, causing death of
50% harmful bacteria.
3. Filtration – utilize filters [clean cloth, sand, and ceramics] to block particles while
allowing water to pass through.
B. Disinfection Processes:
1. Boiling- effective, water brought to boil for at least 1 minute.
2. Chemical disinfection – chlorine kills bacteria/ viruses, some protozoa, helminthes are
resistant to chlorination.
3. Solar disinfection [SODIS] - ultraviolet rays form sun destroys organisms. Fill plastic
containers 1-2 liters of water & expose to direct sunlight for 5 hours. If skies are cloudy,
the bottles are exposed for 2 consecutive days.
AIR PURITY – The DENR A.O. 2000-81 definitions:
1. Air pollutant - any matter in atmosphere other than natural
concentrations of oxygen, nitrogen, water vapor, carbon dioxide &
inert gases that maybe detrimental to health or environment.
2. Chlorofluorocarbons-ozone – depleting substances particulate
matter, material that exists in a finely divided form liquid / solid
other than water, greenhouse gases, which induce global warming
such as: carbon dioxide, methane & oxides of nitrogen,
chlorofluorocarbons & fuel components such as aromatics,
benzene & sulfur.
Clean Air Act identified 2 sources of air pollution:
1. Mobile source- vehicle, machine –propelled by/ through oxidation, including
combustion of carbon – based or fuel, constructed / operated for conveyance
of persons or transportation of property / goods that emit air pollutants.
2. Stationary source- building or fixed structure, facility or installations that emit
air pollutants.

DENR/ DOTC initiated programs to address air pollution:

a. Bantay Tsimineya Program – monitors point source air pollution from industries
b. Bantay Tambutso Program & Standard Setting- Euro 11 emission standards
c. Improved Fuel Quality Program – phased out leaded gasoline / regulate sulfur,
benzene , aromatic content of fuel
d. National Research & Development Program for Prevention & Control of Air
Pollution
Rule XXIX Section1 DENR AO 2000- 81 ‘ Ban on Smoking” has directed LGUs to
implement or enforce a ban on smoking inside public building or an enclosed
public place, including public vehicles & other means of transport or in any
enclosed area outside of one’s private residence , private place of work or any duly
designated smoking area which shall be enclosed.

TOXIC & HAZARDOUS WASTE CONTROL- The National Poison Management &
Control Center [NPMCC] PGH reported 1,286 poisoning cases, the top causes are:

1. Jewelry cleaners [high in cyanide]

2. Pesticides
3. Button batteries
4. Watusi firecrackers
5. Jatropha seeds
6. Multivitamins
7. Malathion
8. Xylene
9. Camphor with methyl ASA
10. Turpentine
FOOD SAFETY RA 9711 Food and Drug Administration Act which strengthened the
FDA in safeguarding the safety & quality of processed foods, drugs, diagnostic
reagents , medical devices, cosmetics, & household substances.

SANITATION PD 856 Code on Sanitation of the Philippines of 1976.

Four [4] Components of sanitation facilities:
1. Toilet- receptacle [ bowl]
2. Collection system – sewerage system transport wastewater for treatment /
disposal
3. Treatment – process of reducing liquid & solid waste to nonpolluting matter
4. Disposal/ reuse- finally release treated waste to environment
Privy - toilet system not connected to sewerage system [vacuum –
flush toilets of buses / airplanes. DOH describes 3 components of
sanitary privy:

1. Earthen pit [ 1 m2 wide]

2. A floor covering the pit
3. Water-sealed bowl
Types of sanitation facilities:
1. Box & can privy [ bucket latrine]- fecal material are collected in
can / bucket, periodically removed for emptying & cleaning
2. Pit latrine [pit privy] - fecal are eliminated into a hole in the
ground that leads to dug pit, with squatting plate or riser with a
seat. The pit reduces volume of contents as liquid infiltrates soil
3. Antipolo toilet- made up of elevated pit privy that has covered
latrine, bottom of pit is 1.5 meters above water table
4. Septic privy- fecal matter is collected in built septic tank that is not
connected to sewerage system. Septic tank contains water but
there is no drop pipe from latrine that is dipped into the water.
5. Aqua privy- feces are eliminated into water – sealed drop pipe
that leads from latrine to small water filled septic tank located
directly below squatting plate. The drop pipe extends below
septic water tank level to form a simple water seal. An effluent
pipe is installed in septic tank to prevent overflow of water
through squatting plate. Water loss is then replaced by adding
water with each toilet use. Ventilation pipe with fly screen on top
is part of design of housing facility.
6. Overhung latrine- fecal material is directly eliminated into body of
water [flowing river] underneath facility. WHO recognized this
during disaster situations?
7. Ventilated – improved pi [VIP] – latrine- pit latrine with screened
air vent installed directly over the pit. The ambient air that enters
the pit hole pushes foul air into air vent. Screen on top of vent
prevents insects from smell. Filled pits are then covered with soil
for composting, & the facility is redirected / relocated to another
pit.
8. Concrete vault privy- feces is collected in pit privy line with
concrete to make it water tight.
9. Chemical privy- feces is collected into a tank containing caustic
chemical which controls/ facilitates waste decomposition
10. Compost privy- feces is collected into a pit with urine & anal
cleansing materials with addition of organic garbage – leaves/
grass to allow biological decomposition/ production of
agricultural/fishpond compost or night soil
11. Pour – flush latrine-with bowl & water seal trap similar to tank-
flush toilet except that it requires small volume of water for
flushing.
12. Tank – flush toilet- feces are excreted into bowl with water –
sealed trap. The water tank that receives limited water empties
into bowl for flushing of feces thru water- sealed trap & into
sewerage system
13. Urine diversion dehydration toilet [UDDT] - waterless system that
allows separate collection & on site storage/ treatment of
urine/feces. Urine side leading to collecting container for
agricultural use, & fecal side leading to ventilated vault, kept dry &
feces are left to dehydrate for agriculture use.
VERMIN & VECTOR CONTROL
Vermin - insects / small animals – flies, mosquitoes, cockroaches, fleas, lice,
bedbugs, mice, rats which are vectors of diseases.
Insects - flies, mosquitoes, cockroaches, bedbugs, fleas, lice, ticks, ants, & other
arthropods.
Pest - any destructive or unwanted insect or other small animals [rats, mice etc.]
that cause annoyance, discomfort, nuisance, or transmission of diseases to humans,
& damage to structures.
Rodents - small mammals - rats /mice, characterized by constantly growing incisor
teeth used for gnawing or nibbling
Vector- any organism that transmits infection by inoculation into skin/ mucous
membrane by biting: or by deposit of infective materials on skin, food, or other
objects: or by biological reproduction within the organism.
DOH vermin control methods:
1. Environmental sanitation control- cleanliness
2. Naturalistic control- pest control utilizing nature without
disturbing balance in nature
3. Biological/ genetic control- utilizes living predator , parasites &
other natural enemies of pests, aimed at killing larvae without
pollution
4. Mechanical / physical control- rodent traps, fly trap, mosquito
traps, air curtain, ultraviolet rays
5. Chemical control- pesticides, environmental measures, natural,
mechanical, biological measures
BUILT ENVIRONMENTS - man-made structures, [National Building Code of the
Philippines PD 1096] to protect public health

1. Minimum air space

• School rooms- 3.00 m3 with 1.00 m2 of floor area per person
• Workshops, factories, offices- 12.00m3 of air space person
• Habitable rooms – 14.00m3 of air space per person

2. Minimum sizes of rooms & heir least horizontal dimensions shall be as follows:
• Rooms for human habitations- 6.00m2 with at least horizontal dimension of
2.00m
• Kitchen- 3.00m2 with at least horizontal dimension of 1.50m
• Bath & toilets – 1.20m2 with at least horizontal dimension of 900mm
INFORMATION & COMMUNICATION TECHNOLOGY [ICT] & COMMUNITY HEALTH
eHealth – the use of ICT for health [WHO 2012 ]: a cost- effective way of using ICT
in health care services, health surveillance , health literature, health education &
research.

Considerations in eHealth:
1. Communicating with patient thru teleconference, electronic mail [ e-mail],
short message service [SMS]
2. Recording. Retrieving, & mining data in electronic medical record [EMR]
3. Providing patient teachings with the aid of radio, TV, computers, smartphones
& tablets
Benefits of well- managed patient information system:

1. Data are readily mapped enabling more interventions/feedback

2. Data readily retrieved / recovered
3. Redundancy of data minimized
4. Research data more available
5. Resources used efficiently
Factors affecting eHealth:

1. Limited budget
2. Emergence of free/ open source software
3. Decentralized government
4. Target users are unfamiliar with technology
5. Surplus of “ digital native” registered nurse
A.O. No.2010- 0036 – Universal Health Care also known as
KALUSUGAN PANGKALAHATAN [KP] DOH. This health reform agenda
has 3 priority health directions

1. Financial risk protection thru expansion in Health Insurance

Program [Phil health] enrolment & benefits
2. Improved access to quality hospitals / health care facilities
3. Attainment of health – related Millennium Development Goals
[MDGs]
TELEMEDICINE- delivery of health care services , where distance is a
critical factor , by all health care professionals using information &
communications technologies for the exchange of valid information
for diagnosis , treatment & prevention of disease & injuries,
research & evaluation and for continuing education of health care
providers, all in the interests of advancing the health of individuals &
their communities- WHO.

4 Elements of Telemedicine:
1. Provide clinical support
2. Overcome geographical barriers, connecting users who are not in
same physical location
3. Use of various types of ICT
4. Goal – to improve health outcomes
HEALTH PROMOTION, RISK REDUCTION & CAPACITY BUILDING STRATEGIES
HEALTH PROMOTION
• Any combination of health education & related organizational, economic &
environmental supports for behavior of individuals, groups, or communities
conducive to health.
• Behavior motivated by desire to increase well being & to reach health potential
Health Protection – behaviors one engages with intent to prevent disease, detect
disease in early stages or maximize health within the constraints of disease.
Examples- immunization, screening for cervical cancer
Risk - probability that a specific event will occur in a given time frame. Exposure
that is associated with a disease.
Risk reduction – proactive process, individuals participate in behaviors that enable
them to react to actual or potential threats to their health [Pender 1996].
Nutritional guidelines for Filipinos:
1. Eat variety of foods
2. Breastfeeding exclusively from birth- 6 months
3. Maintain children’s normal growth- proper diet
4. Consume fish, lean meat, poultry , dried beans
5. Eat foods cooked in edible oil
6. Consume milk, milk products & calcium – rich foods
7. Eat more vegetables/ fruits/ root crops
8. Use iodized salt, avoid salty foods
9. Eat clean / safe foods
10. Exercise regularly, avoid smoking & alcohol
OTTAWA CHARTER FOR HEALTH PROMOTION

Organized by WHO , the first International Conference on Health

Promotion was held at Ottawa, Canada on November 17- 21, 1986,
calls for commitment to health promotion to achieve the goal of
HEALTH FOR ALL BY THE YEAR 2000 & BEYOND [ WHO , 1986 }.

Health promotion - process of enabling people to increase control

over, & to improve, their health, which requires that an individual /
group must be able to identify & realize aspirations, to satisfy needs &
to change or cope with the environment- Ottawa Charter
Prerequisites for health:
1. Peace
2. Shelter
3. Education
4. Food
5. Income
6. Stable ecosystem
7. Sustainable resources
8. Social justice/ equity
HEALTH EDUCATION- process of changing people’s knowledge, skills
& attitudes for health promotion & risk reduction

Basic principles:
1. Message
2. Format
3. Environment
4. Experience
5. Participation
6. Evaluations
MATERNAL, NEWBORN AND CHILDHEALTH & NUTRITION
Leading Causes of maternal deaths [Philippines] 2006
1. Complications related to pregnancy occurring in the course of labor, delivery,&
puerperium
2. Hypertension complicating pregnancy, childbirth & puerperium
3. Postpartum hemorrhage
4. Pregnancy with abortive outcomes
Risk factors of maternal/neonatal death:
a. Having mistimed, unplanned, unwanted/unsupported pregnancy
b. Not securing adequate care during pregnancy
c. Delivering without skilled birth attendance[MD, nurse, midwives]/ no access to
emergency /neonatal care
d. Not having postpartum/postnatal care for mother /baby
Leading causes of infant mortality [Philippines] 2006
1. Bacterial sepsis of newborn
2. Respiratory distress
3. Pneumonia
4. Disorders related to short gestation/low birth weight
5. Congenital malformations of heart
6. Congenital pneumonia
7. Neonatal aspiration syndrome
8. Other congenital malformations
9. Intrauterine hypoxia/ birth asphyxia
10. Diarrhea/ gastroenteritis
MNCHN Maternal Newborn & Child Health & Nutrition strategy aims:

1. Every pregnancy is wanted, planned & supported

2. Every pregnancy is managed
3. Every delivery is facility- based/managed by health professionals
4. Every mother/newborn secure postpartum/newborn care
Pre-pregnancy package:
1. Nutrition- counseling, use of iodized salt, micronutrient supplementation :
a. Iron & folate 60mg elemental iron/ 400ug folic acid 1 tablet daily for 3-
6months
b. Vit. A 5,000 IU every week/ daily vitamin as option
2. Healthy lifestyle
3. Advise on Family Planning /services
4. Prevention/ management of lifestyle diseases
5. Prevention of infection/ deworming- reduce iron deficiency anemia
6. Counselling STI/HIV/AIDS, nutrition, personal hygiene/ consequences of
abortion
7. Adolescent health services
8. Oral health services
Prenatal Package
1. Prenatal visits- at least 4 visits throughout pregnancy: one visit in 1st & 2nd trimester: 2 visits on 3rd
trimester: weight, height, BP, Fundic height, FHB , CBC, blood typing, urinalysis, screening for STI,
blood sugar, cervical cancer screening using acetic acid wash, papanicolau smear
2. Micronutrient supplementation
• Iron & folate [ 60mg/ 400ug] once a day for 6 months or 180 tablets [DOH-IMS 2011]
• Vitamin A 10,000 IU twice a week from 4th pregnancy
• Elemental iodine 200mg given once during pregnancy
3. Tetanus toxoid [TT] immunization
• TT 0.5 ml IM
• Prevents tetanus in mother & newborn[ newborn develops passive immunity as maternal
antibodies pass thru placenta into fetal circulation
4. Exclusive breastfeeding, newborn screening, infant immunization
5. Healthy lifestyle- smoking cessation , healthy diet, regular exercise, STI/HIV prevention, oral health
6. Early detection / management of complications of pregnancy
7. Prevention/management of hypertension, anemia, diabetes, tb, malaria, schistosomiasis,
STI/HIV/AIDS
8. Birth plan/promotion of health facility based delivery
CHILDBIRTH PACKAGE
1. Skilled birth attendance/ facility based deliveries/ use of partograph
2. Proper management of pregnancy/ delivery complications/newborn complications- EINC practices
[Unang Yakap] based on scientific evidence
• Maternal support by having companion during labor/delivery
• Freedom of movement during labor
• Monitor progress of labor using partograph [graphic recording of progress of labor/ detect
deviations/ early referral]
• Nondrug pain relief before labor anesthesia
• Position of choice during labor/ delivery
• Spontaneous pushing in semi-upright position
• Hand hygiene
• Non routine episiotomy
• Active management of 3rd stage of labor[AMTSL]
3. Access to basic emergency obstetric and newborn care [ BEmONC] or comprehensive emergency
obstetric and newborn care [CEmONC]
POSTPARTUM PACKAGE
1. Postpartum visits: within 72 hours and on 7th day postpartum-
check for bleeding/ infections
2. Micronutrient supplementation
• Iron and folate [ 60 mg / 400ug] once a day for 3 months or 90
tablets
• Vitamin A 200,000 IU within 4 weeks after delivery
3. Counseling on nutrition, child care, family planning etc
NEWBORN [first week of life] CARE PACKAGE- EINC
1. Interventions within first 90 minutes
a. Immediate / thorough drying- protect from cold stress, hypothermia, stimulate
breathing, immediate first action for all newborns regardless of AOG /birth weight
b. Skin to skin contact between mother & newborn- provide warmth, bonding,
protection against infections & hypoglycemia, promote early breastfeeding
c. Cord clamping 1-3 minutes after birth - allows placental transfusion at birth which
increase blood volume/iron reserves to prevent iron deficiency anemia. In preterm
infants, delayed cord clamping reduces blood transfusion & lower incidence of
brain hemorrhage
d. Early breastfeeding- within an hour after birth- reduces infant death due to
diaarhea. Benefits to mother include stimulation of oxytocin resulting to uterine
contraction
e. Nonseparation of mother & baby- rooming –in
2. Essential newborn care after 90 minutes to 6 hours
a. Vitamin K prophylaxis
b. Hepatitis B & BCG vaccination
c. Examination of baby for birth injuries, malformations, defects
d. Additional care for small baby[ birthweight < 2, 500 g or twin]

3. Care prior to discharge: after the first 90 minutes

a. Support unrestricted, per demand breastfeeding
b. Ensure warmth- [ skin to skin with mother- kangaroo mother Cssare [KMC] –
warmth, breastfeeding, protection from infection, stimulation, safety, love
c. Washing / bathing[ hygiene]
d. Look for danger signs / start resuscitation, keep warm, give first 2 doses of IM
antibiotics, give oxygen
e. Look for signs of jaundice/ local infection
f. Newborn screening[ blood spot] / newborn hearing screening
g. Provide instructions on discharge
CHILD CARE PACKAGE
1. Immunization
2. Nutrition- exclusive breastfeeding up to 6 months: sustained
breastfeeding up to 24 months with complementary feeding:
micronutrient supplementation
3. Integrated management of childhood illnesses [IMCI]
4. Injury prevention
5. Oral health
6. Insecticide - treated nets in malaria- endemic areas
MNCHN SERVICE DELIVERY NETWORK- 3 levels of care:

A. Community level service providers or Community Health Team [CHT] – vies

primary health care services, include RHU, BHS, private clinics with
professional health staff/ volunteers, BHWs, traditional birth attendants. 2
functions:

1. Navigation – informs / assists families of health risks & needs assessment,

use birth plans, facilitate access to critical health services, emergency
transport, financing source [PhilHealth].
2. Basic service delivery- advocate /counsel on birth spacing, tracking/
master listing pregnant women, women of reproductive age, children
below 1 year old, detect/ refer maternal/ neonatal deaths
B. BEmONC- capable facility 6 signal obstetric functions:
1. Parenteral administration of oxytocin in 3rd stage of labor
2. Parenteral anticonvulsant
3. Parenteral antibiotics
4. Performance of assisted deliveries[ imminent breech delivery]
5. Removal of retained products of conception
6. Manual removal of placenta
Newborn resuscitation
Treatment of neonatal sepsis/ infection
Oxygen support
Provide blood transfusion – if with qualified personnel
 • Based on RHU, BHS, Lying in clinics, birthing home. [RHU with skilled health
professionals – doctors, nurses, midwives, medical technologist]. A midwife,
who is supervised by Rural Health Physician or has referral arrangement
with hospital or doctor trained in management of maternal/newborn
emergencies, can provide lifesaving interventions within the intent of DOH
A.O.2010- 0014 – Administration of Life- saving Drugs & medicines by
Midwives to Rapidly Reduce Maternal & Neonatal Morbidity & Mortality.
• 1 BEmONC facility per 125, 000 population [WHO]

C. CEmONC – capable facility- can perform 6 signal functions, provide cesarean

section, blood banking/ transfusion & other highly specialized obstetric
interventions, provide neonatal emergency interventions , management of low
birth weight/ preterm
• 1 CEmONC facility per 500,000 population [WHO]
REPRODUCTIVE HEALTH PROGRAM

Reproductive health [RH] – state of complete physical, mental &

social well- being, & not merely the absence of disease or infirmity, in
matters relating to reproductive system & to its functions / processes.

RA 9710 – Magna Carta of Women [2009]

RA 10354 Responsible Parenthood & Reproductive Health Act of 2012

Ten elements of reproductive health care – [gender equity]
1. Family planning
2. Maternal & child health & nutrition[ MCHN]
3. Prevention/ control of reproductive tract infections/ STIs, /HIV/AIDS
4. Adolescent reproductive health
5. Prevention/management of abortions/ complications
6. Prevention / management of breast/ reproductive cancers / gynecological
condition
7. Education/ counseling on sexuality/ sexual health
8. Men’s reproductive health & involvement
9. Prevention & management of violence against women / children
10. Prevention & treatment of infertility / sexual dysfunction
Philippine Family Planning program [PFPP]

A. O. 50-A s 2001 – National Family Planning Policy, asserts that family planning as
health intervention shall be made available to all men & women of reproductive
age [15-44 years old]. FP prevents high – risks pregnancies brought about by the
following conditions:

1. Too young / too old- Less than 18 years old or over 34 years old
2. Having too many [ 4 or more] pregnancies
3. Having closely spaced [ too close] pregnancies [ less than 36 months]
4. Being too ill or unhealthy/ too sick or having an existing disease/ disorder – iron
deficiency anemia
4 Pillars [guiding principles] of PFPP

1. Responsible parenthood
2. Respect for life
3. Birth spacing
4. Informed choice
NEWBORN SCREENING
• RA 9288 Newborn Screening Act of 2004
Disorders --- Long term effects
1. Congenital hypothyroidism- severe mental retardation
2. Congenital hyperplasia - death
3. Galactosemia- death/ cataract
4. Phynylketonuria – severe mental retardation
5. G6PD- Glucose -6-phosphate dehydrogenase deficiency- severe anemia/ kernicterus
6. Maple syrup urine disease- death
• Newborn screening procedure - Specimen is obtained by heel prick. Few drops of blood
blotted on special absorbent filter card & sent to NSC [National Screening Center]. Blood
sample may be obtained by physician, nurse, medical technologist or trained midwife.
Available in hospitals, lying in clinics, RHUs, health centers, private clinics. If babies are
delivered at home, they are brought to nearest institution offering NBS.
• Normal [negative] result available by 7- 14 working days. Positive result relayed to parents
immediately, referred to specialist for confirmatory testing / further management
NEWBORN HEARING SCREENING

• RA 9709 Universal Newborn Hearing Screening & Intervention

Act of 2009
• Early detection of congenital hearing loss on newborns &
referral for interventions
EXPANDED PROGRAM ON IMMUNIZATION [EPI]
• Initially, 6 vaccine preventable diseases included in EPI- TB,
poliomyelitis, diphtheria, tetanus, pertussis, & measles
• RA 10152- Mandatory Infants & Children Health Immunization Act
of 2011
-added to 6 six immunizable disease are- hepatitis B, mumps,
rubella, disease caused by haemuphilus influenza type B [ Hi] & other
diseases
• RA 7846 compulsory immunization against Hepatitis B for infants/
children below 8 years old, and Hepa B immunization within 24
hours after birth of babies of women with Hepa B
Considerations to schedule / manner of immunization:
1. Use only one syringe and needle per client
2. There is no need to restart a vaccination series regardless of the
time that has elapsed between doses
3. All EPI antigens are safe & effective when administered
simultaneously, during same immunization session but at different
sites. It is NOT recommended to mix different vaccines in one
syringe before injection, or to use a fluid vaccine for
reconstitution of a freeze –dried vaccine. If more than one
injection has to be given on the same limb, the injection sites
should be 2.5 – 5cm apart to prevent overlapping of local
reactions.]
4. Recommended sequence of administration of vaccine is OPV first,
followed by Rotavirus vaccine, then other appropriate vaccines
5. OPV is administered by putting drops of vaccine straight from
dropper onto child’s tongue, don’t let dropper touch tongue
6. Only monovalent hepatitis B vaccine must be used for birth dose.
Pentavalent vaccine must NOT be used for the birth dose because
DPT and Hib vaccine should NOT be given at birth.
7. Children who have not received AMV1 as scheduled & children
whose parents/ caregivers do not know whether they have
received AMV1, shall be given AMV as soon as possible, then
AMV2 one month after AMV1 dose
8. All children entering day care centers/ preschool & Grade 1 shall be
screened for measles immunization. Hose without immunization shall
be referred to health facility
9. The first dose of Rotavirus vaccine is administered only to infants aged 6
weeks to 15 weeks. Second dose is given only to infants aged 10 weeks
up to a maximum of 32 weeks
10. Administer the entire dose of Rotavirus vaccine slowly down one side of
the mouth [ between cheek & gum] with the tip of applicator directed
toward back of infant’s mouth. To prevent spitting or failed swallowing,
stimulate the rooting & sucking reflex of the young infant. For infants
aged 5 months or older, lightly stroke the throat in downward motion to
stimulate swallowing.
• EPI vaccines-are either inactivated [killed] microorganisms,
fragment s from microorganisms like hepatitis B vaccines or toxoid.
Attenuated vaccines – are live microorganisms that have been
altered so they are no longer pathogenic, but are still antigenic.
Toxoids- are inactivated or altered bacterial exotoxins

• Target – setting & vaccine requirements- FORMULA

Estimated number of infants = total population X 2.7%

Estimated number of 12 to 59 month old children = total population X 10.8%
Estimated number of pregnant women = total population X 3.5%
Maintaining the potency of EPI vaccines
A. Maintain cold chain – system for ensuring potency of vaccines from time of
manufacture to the time it is given to an eligible client. The Cold Chain Officer [
Public Health Nurse] – in charge of maintaining cold chain equipment &
supplies such as freezer/ refrigerator, transport box, vaccine bags/ carriers, cold
chain monitors, thermometers & cold packs. The nurse implements emergency
plan in an event of electrical breakdown/ power failure.
B. EPI vaccines & special diluents have cold chain requirements:
1. OPV: -15 to -25 degrees centigrade. Stored in freezer. In the vaccine bag,
OPV is placed in contact with cold packs
2. All other vaccines, including measles vaccine, MMR and rotavirus vaccine,
have to be stored in refrigerator at temperature of +2 to +8 degrees
centigrade. These vaccines should be stocked neatly on the shelves of
refrigerator. Do not stock vaccines at refrigerator door shelves
3. Hepatitis B vaccine, Pentavalent vaccine, Rotavirus vaccine and TT are
damaged by freezing, so they should not be stored in freezer. Wrap the
containers of these vaccines with paper before putting them in the vaccine
bag with cold packs.
4. Keep diluents cold by storing them in refrigerator in the lower or door
shelves
5. Observe First expiry – First out policy
6. Comply with recommended duration of storage & transport. At the health
center/ RHU duration of storage should not exceed one month, using
transport boxes, vaccines be kept only to maximum of 5 days
7. Take note if vaccine container vaccine vial monitor [VVM] – round disc of
heat – sensitive material placed on vaccine vial to register cumulative heat
exposure. The lower the temperature, the slower the color changes: the
higher the temperature, the faster the color change.
8. Abide by open – vial policy of DOH. A multidose vial maybe opened for one or two
clients if the health worker feels that a client cannot come back for the scheduled
immunization session. Multidose liquid vaccines, such as OPV, Pentavalent vaccine,
hepatitis B vaccine and TT from which one or more doses have been taken
FOLLOWING STANDARD STERILE PROCEDURES, maybe used in next immunization
sessions for UP TO A MAXIMUM OF 4 WEEKS, provided that all the following
conditions are met:
a. Expiry date has not passed
b. Vaccine has not been contaminated
c. Vials have been stored under appropriate cold chain condition
d. Vaccine vial septum has not been submerged in water
e. VVM on vial ,if attached, has not reached discard point
9. Reconstitute freeze- dried vaccines – BCG,AMV & MMR Only with the diluents
supplied with them
10. Discard reconstituted freeze- dried vaccines 6 hours after reconstitution or at the
end of immunization session, whichever comes sooner
11. Protect BCG from sunlight and Rotavirus vaccine from light
Side Effects and Adverse Reactions of Immunizations

BCG injection results in formation of a WHEAL that disappears within

30 minutes. After weeks, small, red, tender swelling appears at
injection site, which may develop into small abscess which ulcerates.
The ulcer heals by itself & leaves a scar. The whole course takes about
2 weeks. This is expected & does not require management.
Contraindications to immunization, few only. DO NOT GIVE:
1. Pentavalent vaccine / DPT to children over 5 years of age
2. Pentavalent vaccine / DPT to a child with recurrent convulsions or another active
neurological disease of CNS
3. Pentavalent vaccine 2 or 3/ DPT 2 or 3 to a child who has had convulsion s or shock
within 3 days of the most recent dose
4. Rotavirus vaccine when the child has history of hypersensitivity to previous dose of
vaccine, intussusceptions or intestinal malformation or acute gastroenteritis
5. BCG to a child who has signs /symptoms of AIDS or other immune deficiency
conditions or who are immunosuppressed
6. Some are false conditions , the health worker may continue immunization:
a. Malnutrition
b. Low grade fever
c. Mild respiratory infection
d. Diarrhea
EPI Recording and Reporting
1. Fully immunized children [FIC] – those given BCG , 3 doses OPV, 3 doses
DPT and Hepatitis B vaccine or 3 doses of Pentavalent vaccine & 1 dose
of anti- measles vaccine before reaching 1 year of age
2. Completely immunized children- completed their immunization before
age 12 – 23 months
3. Child protected at birth [CPAB] – a child whose mother has received
a. 2 doses of TT during this pregnancy, provided that the second doses
was given at least a month prior to delivery, OR
b. At least 3 doses of TT anytime prior to pregnancy with this child
INFANT and YOUNG CHILD FEEDING
• EO 51 -Milk Code – prohibits advertising, promotion , marketing materials that imply
bottle-feeding is equivalent /superior to breastfeeding
• EO 382- provided for National Food Fortification Day every November 7
• RA 7600- Rooming – in and Breastfeeding Act , newborns infants put to breast of
mother immediately after birth
• RA 8172 – ASIN [Act for Salt Iodization Nationwide] Law
• RA 8976 Philippine Food Fortification Act, fortification of rice with iron, wheat flour
with Vitamin A and iron, refined sugar with Vitamin A, cooking oil with Vitamin A,
thru Sangkap Pinoy Seal Program
• RA 10028 Expanded Breastfeeding Promotion Act, setting of lactation stations in all
health & non-health facilities, break intervals for nursing employees to breastfeed/
express milk
• AO 36 s 2010 Expanded Garantisadong Pambata [ GP] – integrated package on
health, nutrition, environment for children
Recommended infant & young child feeding practices:

1. Early initiation of breastfeeding

2. Exclusive breastfeeding for first 6 months
3. Extended breastfeeding up to 2 years & beyond
4. Appropriate complementary feeding using locally available
foods
5. Micronutrient supplementation
6. Universal salt iodization
7. Food fortification
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS [IMCI] – 3
components:

1. Improvement in case management skills of health care staff

2. Improvement in health system for effective management of
childhood illness
3. Improvement in family/ community practices
Elements of IMCI

a. Assess child for danger signs

b. Classify child’s illnesses using color coded triage system-
urgent referral – pink: specific medical treatment / advice-
yellow: simple advise on home management- green
c. Identify specific treatments for the child
d. Provide practical treatment instructions
e. Assess feeding, breastfeeding practices & counsel
f. When child is brought back to clinic, give follow- up care,
reassess child for new problems
CHN LECTURE - FINALS
DISASTER MANAGEMENT
Disaster - any event that causes a level of destruction, death, or injury that affects
the abilities of the community to respond to incident using available resources

Types of disasters:
1. Natural hazard – physical force- typhoon, flood, landslide, earthquake &
volcanic activity
2. Biological hazard-s process/ phenomenon of organic origin or conveyed by
biological vectors, including exposure to pathogenic microorganisms, toxins, &
bioactive substances- disease outbreaks, red tide poisoning
3. Technological hazard- arises from technological/ industrial conditions,
accidents, dangerous procedures, infrastructure failures- stampede, armed
conflicts, terrorist activities, riots
Types of disasters, Philippines:
a. Natural Disasters: Communicable disease outbreaks, droughts,
earthquake, floods, heat waves, landslides, mudflow/ debris flow[
lahar], red tide phenomena, tsunamis, volcanic activities, weather
disturbance [ tornadoes, typhoon]
b. Man – made disasters- civil unrest, riots, explosions, bombings,
fires, mass transit accidents, mining accidents, pollution,
stampedes, structural failure[ bridges] , terrorist related events,
toxic/ hazardous spills, wars, open armed conflicts
• RA 10121 – Philippine Disaster Risk Reduction and Management
Act: developing & implementing[ NDRRMP] National Risk
Reduction and Management Plan : priority areas:
a. Disaster prevention/ mitigation by reducing vulnerabilities
b. Disaster preparedness
c. Disaster response
d. Rehabilitation / recovery

• Designated the Office of Civil Defense [ DND] as the operating arm

/ Secretariat of NDRRMC
CONTROL OF NONCOMMUNICABLE DISEASES
Top 10 causes of mortality in the Philippines [2009] - NSO
1. Diseases of the heart
2. Cerebrovascular diseases
3. Malignant neoplasm
4. Pneumonia
5. Tuberculosis
6. COPD
7. Diabetes
8. Nephritis, nephritic syndrome
9. Assault
10. Certain conditions arising from perinatal period
Risk factors for non-communicable diseases:
1. Physical inactivity
2. Cigarette smoking
3. Unhealthy eating or obesogenic
4. Excessive alcohol drinking
5. Viruses
6. Radiation
Prevention of non-communicable diseases:
1. Promote physical activity/ exercise
2. Promote healthy diet/ nutrition
a. Choose sensible portion of foods lower in fat, watch portion sizes
b. Learn healthier ways to make favorite foods
c. Learn to recognize/ control environmental cues that make you want to eat
d. Have a healthy snack an hour before social gathering
e. Engage in moderate- intensity physical activity for 30 minutes each day
f. Do not eat meals in front of TV
g. Keep records of your food intake & physical activity, weigh yourself weekly
h. Pay attention to WHY you are eating
3. Promote smoke free environment
4. Stress management
Physical Activity Guidelines:
Level of Activity ----------------- Metabolic Equivalents [METs] Each Intensity
1. Low [ less than 150minutes /week]- LIGHT [<3.0 METs]- walking slowly around home,
store , office: sitting using computer: working at desk, using light hand tools, standing,
performing light work such as bed making, washing dishes, ironing, preparing food/
doing store clerk tasks, doing arts & crafts, playing cards
2. Medium [150- 300 minutes of moderate intensity/ week or 75- 150 minutes of vigorous
intensity physical activity]. MODERATE [ 3.0 -6.0 METs]- walking briskly, cleaning,
weeping floors, vacuuming carpet, washing car, doing carpentry: playing badminton,
basketball shooting, bicycling on flat surfaces, ballroom dancing, fishing, playing golf,
surfing, swimming leisurely, playing table tennis doubles, playing noncompetitive
volleyball
3. High [ activity of more than 300 minutes of moderate intensity a week ]- VIGOROUS
[>6.0 METs]- running, hiking, jogging, shoveling sand, carrying heavy loads, digging
ditches, participating in basketball game, playing soccer, playing tennis singles, playing
competitive volleyball at gym or beach
Roles of Public Health Nurse in NCD Prevention & control:

1. Health advocate
2. Health educator
3. Health care provider
4. Community organizer
5. Health trainer
6. Researchers
MENTAL HEALTH - a state of social well- being in which the individual
realizes his/ her own potential [self- image], can cope with normal
stresses of life [resiliency], can work productively / fruitfully
[productive/creative], & is able to make contribution to his/her
community [sense of purpose] – WHO 1999.

Mental illness / disorder - any illness experienced by a person that

interferes with his/ her thinking , feeling or social activities / daily
functioning.
Mental health problems – 4 facets as a public health problem:

1. Defined of direct burden- cost of treatment, quality of

life/disability
2. Undefined / indirect burden- impact on family, or community
3. Hidden burden- stigma, violation of human rights to person
affected
4. Future or health burden-aging population or increasing social
problem – complications, illnesses, death
Conditions that can lead to mental illness:

1. Stressful life events- death of loved one, financial, marital

conflict, violence
2. Difficult family background- neglect, violence, unhappy
childhood
3. Brain diseases- mental retardation, brain infection, AIDS, head
injuries, epilepsy, and stroke
4. Heredity/ environment
5. Medical problems- kidney diseases, liver failure, medicines
taken
DISABILITY
• RA 7277- National Health Program for Persons with Disabilities [
Magna Carta for Disabled Persons: requires
a. National program for PWDs
b. Establishment of medical rehab centers in provincial hospitals
c. Integrated/ comprehensive program for PWDs

VISUAL IMPAIRMENT
• AO 179 s 2004-National Prevention of Blindness Program –
advocacy / health education on nature , risk factors extent of visual
impairment , complications, early diagnosis, treatment &
prevention of visual impairment.
COMMUNICABLE DISEASES
Top 10 causes of morbidity in the Philippines [2010]
1. Acute respiratory infection
2. Acute lower respiratory tract infection& pneumonia
3. Bronchitis
4. Hypertension
5. Acute watery diarrhea
6. Influenza
7. Urinary tract infection
8. Tuberculosis [TB] respiratory
9. Accidents
10. Injuries
• Communicable diseases- caused by infectious agents or its toxic
products, transmitted directly or indirectly to person, animal or
intermediary host or inanimate environment
• Communicable disease could either be contagious or infectious disease
• “Contagion“ derivative of “contact” is transmitted by direct physical
contact
• Infectious disease is transmitted indirectly thru contaminated food, body
fluids, objects, airborne inhalation or thru vector organisms that would
require a break or inoculation in skin or mucous membranes of
individuals
• Infectious diseases is sometimes called contagious, however other
infectious diseases are usually NOT regarded as contagious
EPIDEMIOLOGIC TRIANGLE MODEL- 3 components:
1. Agent - bacteria [ TB] , viruses [ influenza], rickettsia[ rocky mountain spotted fever
], fungi [ athlete’s foot] ,protozoa[ malaria ], helminths [ ascariasis] & arthropods [
scabies]
2. Host- any organism that harbors / provides nutrition for the agent- humans,
animals. The ability of host to fight the agent causing infection influenced by-age,
gender, socio economic status, ethnicity, nutrition & immune status, genetics,
hygiene, behavior
3. Environment – condition in which agent may exist, survive or originate comprising:
a. Physical –temperature, weather, soil, water, food sources
b. Biological- animals, insects, flora, other humans as reservoir or foster survival
of organisms
c. Socioeconomic- behavior, personality attitudes, cultural characteristics,
occupation, urbanization
CHAIN OF INFECTION - elements:
1. Causative agent- bacteria, viruses, rickettsia, fungi, protozoa, helminthes
2. Reservoir- environment / object in or on which organism survives &
multiplies- inanimate objects, humans, animals
3. Portal of exit- path by which an agent leaves its reservoir- respiratory,
genitourinary, skin, mucous membranes, gastrointestinal tract
4. Mode of transmission- means by which agent passes from the portal of
exit in reservoir to susceptible host. Transmitted thru contact, airborne,
droplet, vehicle, vector – borne
5. Portal of entry- path by which an agent invades susceptible host, same as
portal of exit.
6. Susceptible host- various factors of individual that present barriers to
invasion & multiplication of agents
Functions of Public Health Nurse in the Control of Communicable
Diseases:
1. Report immediately to Municipal Health Office any known
case of notifiable disease
2. Refer immediately to nearest hospital
3. Conduct health education toward prevention of outbreak
4. Assist in diagnosis of suspect based on signs/ symptoms
5. Conduct epidemiologic investigation as a means of
contacting families, case finding, individual / community
health education
END SLIDE