Epidemiology and Vital Statistics Epidemiology Epidemiology is the study of occurrences and distribution of diseases as well as the distribution

n and determinants of health states or events in specified population, and the application of this study to the control of health problem. Two main areas of investigation are concerned, the study of distribution and the search for the determinants (cause) of the disease and its observed distribution. The first area describes the distribution of health status in terms of age, gender, race, geography, time and so on might be considered in an expansion of the discipline of demography to health and diseases. The second area involves explanations of patterns of disease distribution in terms of causal factors. Epidemiology is the backbone of the prevention of the disease. In order to control a disease effectively, the conditions surrounding its occurrence and the factors favoring the development of the disease must first be known. The Multiple Causation Theory Disease development does not rest on a single cause. Health conditions result from a multitude of factors. The three models that explain the multiple causation theory are the wheel, the web and the ecologic triad.

The Ecologic Triad The ecologic triad is the most helpful to the nurse because it highlights not only the hosts and agents roles in disease development also regards the role of the environment as important in disease causation. The model implies that each must be analyzed and understood for comprehensions and prediction of patterns of a disease. Three Components of the Ecologic Triad a. Agent is any element, substance or force, either animate or inanimate, the presence or absence of which may serve as stimulus to initiate or perpetuate a disease process. This happens when the agent comes in contact with a susceptible host and under proper conditions. b. Host - is any organism that harbors and provides nourishment for another organism. The characteristics of the host will affect his or its risk of exposure to sources of infection and his or its susceptibility or resistance. c. Environment is the sumtotal of all external conditions and influences that affect the life and development of an organism. The environment both affects the agent and the host. - Three Components of the Environment: Physical Environment: composed of the inanimate surroundings such as the geophysical conditions or the climate. Biological Environment: makes up the living things around us such as plant and animal life. Socio-economic Environment: may be in the form of the level of economic development

1. 2. 3.

The Phases of Epidemiologic Approach DescriptiveEpidemiology: concerned with disease distribution and frequency.

AnalyticalEpidemiology: attempts to analyze the causes or determinants of disease through hypothesis testing.

Intervention or ExperimentalEpidemiology: answers questions about the effectiveness of new methods for controlling diseases.

EvaluationEpidemiology: attempts to measure the effectiveness of different health services. Descriptive Epidemiology Descriptive epidemiology aims to describe the occurrence of health conditions in the community in terms of person, place and time characteristics. In order to describe the occurrence of disease condition, the nurse needs to recognize the disease with reasonable certainty. This is done by conducting screening and case finding activities.

Screening - It is the presumptive identification of unrecognized diseases or defects through the application of diagnostic test and laboratory examinations and clinical assessment. Case Finding - It is done to look for previously unidentified cases of diseases. Sensitivity - It is the proportion of persons with a disease who test positive on the screening test. It measures the probability of the test correctly identifying a positive case of a disease. Specificity - It is the proportion of persons without a disease who have negative results on a screening test. It measures the probability of correctly identifying non-cases. Attack Rate - Is used to calculate an identifiable population exposed to an infectious agent. - It represents the incidence of the illness among the exposed population. Patterns of Occurrence and Distribution 1. Sporadic Intermittent occurrence of a few isolated and unrelated cases in a given locality. The cases are few and scattered, so that there is no apparent relationship between them and they occur on and off, intermittently, through a period of time. 2. Endemic Continuous occurrence throughout a period of time, of the usual number of cases in a given locality. The disease is therefore always occurring in the locality and the level of occurrence is more or less constant through a period of time. 3. Epidemic Unusually large number of cases in a relatively short period of time. There is a disproportionate relationship between the number of cases and the period of occurrence, the more acute is the disproportion, the more urgent and serious is the problem. The number of cases is not in itself necessarily big or large, but such number of cases when compared with the usual number of cases may constitute an epidemic in a given locality, as long as that number is so much more than the usual number in that locality. 4. Pandemic Simultaneous occurrence of epidemic of the same disease in several countries. It is another pattern of occurrence from an international perspective. Epidemiology Variables These variables are studied since they determine the individuals and populations at greatest risks of acquiring particular disease, and knowledge of these associations may have predictive value. 1. Time It refers both to the period during which cases of the disease being studied were exposed to the source of infection and the period during which the illness occurred. 2. Persons It refers to the characteristics of the individual who were exposed and who contacted the infection or the disease in question. - Person can be described in terms of their inherent or their acquired characteristics (such as age, race, sex, immune status); their activities (form of work, play, religious practices, customs); and the circumstances under which they live (social, economic and environmental condition). 3. Place It refers to the features, factor or conditions which existed in or described the environment in which the disease occurred. - It is the geographic area described in terms of street, address, city, municipality, province, region or country.

Vital Statistics Statistics It refers to a systematic approach of obtaining, organizing and analyzing numerical facts so that conclusion may be drawn from them.

Vital Statistics It refers to the systematic study of vital events such as births, illnesses, marriages, divorce, separation and deaths.

Uses of Vital Statistics: Indices of the health and illness status of a community Services as a bases for planning, implementing, monitoring and evaluating community health nursing programs and services

Sources of Data: Population census Registration of Vital data Health Survey Studies and researches

Rate and Ratios: Rate shows the relationship between a vital event and those persons exposed to the occurrence of said event, within a given area and during a specified unit of time, it is evident that the person experiencing the event (numerator) must come from the total population exposed to the risk of same event (denominator). Ratio is used to describe the relationship between two (2) numerical quantities or measures of events without taking particular considerations to the time and place. These quantities need not necessarily represent the same entities, although the unit of measure must be the same for both numerator and denominator of the ratio. Crude of General Rates referred to the total living population. It must be presumed that the total population was exposed to the risk of the occurrence of the event. Specific Rate the relationship is for a specific population class group. It limits the occurrence of the event to the portion of the population definitely exposed to it. Crude Birth Rate a measure of one characteristic of the natural growth or increase of a population. Total No. of live births registered in a given calendar year CBR = ------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 of same year General Fertility Rate Total No. of live births registered in a given calendar year GFR = ------------------------------------------------------------------------------- x 1000 Midyear population of women, 15-44 years of age Crude Death Rate a measure of one mortality from all causes which may result in a decrease in population. Total No. of deaths registered in a given calendar year CDR = ------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 of same year

Infant Mortality Rate measures the risk of dying during the 1 year of life. It is a good index of the general health condition of a community since it reflects the changes in the environment and medical condition of a community.

st

Total No. of death under 1 year of age registered in a given calendar year IMR = ------------------------------------------------------------------------------------------------------- x 1000 Total No. of registered live births of same calendar year Maternal Mortality Rate - measures the risk of dying from causes related to pregnancy, childbirth and puerperium. It is an index of the obstetrical care needed and received by women in a community. Total No. of deaths from maternal causes registered for a given year MMR = ---------------------------------------------------------------------------------------------- x 1000 Total No. of live births registered of same year Fetal Death Rate measures pregnancy wastage. Death of the product of conception occurs prior to its complete expulsion, irrespective of duration of pregnancy. Total No. of Fetal Deaths registered in a given calendar year FDR = ------------------------------------------------------------------------------------ x 1000 Total No. of live births registered on same year Neonatal Death Rate measures the risk of dying the 1 month of life. It serves as an index of the effects of prenatal care and obstetrical management of the newborn. No. of Deaths under 28 days of age registered in a given calendar year NDR = ------------------------------------------------------------------------------------------------- x 1000 No. of live births registered of same year Specific Death Rate describes more accurately the risk of exposure of certain classes or groups to particular diseases. To understand the forces of mortality, the rates should be made specific provided the data are available for both the population and the event in their specifications. Specific rates render more comparable and thus reveal the problem of public health. Deaths in a specific class/ group registered in a given calendar year SDR = ------------------------------------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 in same year specified class/group of said year Examples: Cause of Specific Death Rate No. of death from specific causes registered in a given year CSDR = --------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 of same year
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Age Specific Death Rate No. of death in a particular age group registered in a given calendar year

ASDR = ---------------------------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 in same age group of same year Sex Specific Death Rate No. of deaths of a certain sex registered in a given calendar year SSDR = ---------------------------------------------------------------------------------------- x 1000 Estimated population as of July 1 in same sex for same year Incidence Rate measures the frequency of occurrence of the phenomenon during a given period of time. No. of new cases of a particular disease registered during a specified period of time IR = ------------------------------------------------------------------------------------------------------------------ x 1000 Estimated population as of July of same year Prevalence Rate measures the proportion of the population which exhibits a particular disease at a particular time. This can only be determined following a survey of the population concerned, deals with total (new and old) number of cases. No. of new and old of a certain disease registered at a given time PR = ---------------------------------------------------------------------------------------- x 1000 Total No. of persons examined at the same given time Attack Rate a more accurate measure of the risk of exposure No. of persons acquiring a disease registered in a given year AR = ----------------------------------------------------------------------------------- x 1000 No. of exposed to same disease in the same year Case Fatality Ratio index of a killing power of a disease and is influenced by incomplete reporting and poor morbidity data. No. of registered deaths from s specified disease for a given year CFR = ----------------------------------------------------------------------------------------- x 1000 No. of registered cases from same specific disease in same year Proportionate Mortality (Death Ratios) shows the numerical relationship between deaths from all causes (or group of causes), age (or group of age) etc., and the total no. of deaths from all causes in all ages taken together.
st

No. of registered deaths from specific cause or age for a given calendar year PM = -------------------------------------------------------------------------------------------------------- x 1000 No. of registration deaths from all causes, all ages in same year

Presentation of Data Observation of events in the community are presented in the form of tables, charts and graphs Line or curved graphs

Show peaks, valleys and seasonal trends. Also used to show the trends of births and death rates over a period of time.

Bar graph Each bar represents or expresses a quantity in terms of rates or percentages of a particular observation like causes of illness and deaths.

Area Diagram (Pie Chart) Shows the relative importance of parts to the whole.

Functions of the Nurse: Collect data Tabulates data Analyses and interprets data Evaluates data Recommends redirection and / or strengthening of specific areas of heath programs as needed.

Community Health Nursing Process I. Community Diagnosis It is a comprehensive assessment of the community with regards to its social, physical and biological environment. Its other names are Community Assessment and Situational Analysis

Types of Community Diagnosis: In the assessment of the communitys health status, the nurse considers the degree of detail or depth she should go into. There are times when situations call for a comprehensive assessment and often times, the nurse is confronted with s specific problem area like a disaster situation or an outbreak of disease. I. Comprehensive Community Diagnosis A comprehensive community diagnosis aims to obtain general information about the community.

Elements of Comprehensive Community Diagnosis A. Demographic variables It shows the size, composition and geographical distribution of the population as indicated by the following: 1. Total population and geographical distribution including urban-rural index and population density 2. Age and sex composition 3. Selected vital indicators such as growth rate, crude birth rate, crude death rate, and life-expectancy at birth 4. Patterns of migration 5. Population projections B. Social-Economic and Cultural Variables Indicators 1. Social Indicators a. Social Indicators b. Communication network c. Transportation system d. Educational level e. Housing conditions suggestive of health hazards 2. Economic Indicators a. Poverty level income b. Unemployment and underemployment rates c. Proportion of salaried and wage earners to total economically active population d. Types of industry present in the community e. Occupation common in the community 3. Environmental Indicators a. Physical/geographical/topographical characteristics of the community Land areas that contribute to vector problems Terrain characteristics that contribute to accidents or pose as geographical zones Land usage in industry Climate/season b. Water supply Percent population with access to safe, adequate water supply Source of water supply c. Waste Disposal Percent population served by daily garbage collection system Percent population with safe excreta disposal system d. Air, water and land pollution Industries within the community having health hazards associated with it Air and water pollution index 4. Cultural factors a. Variables that may break up the people into groups within the community such as: Ethnicity Social class Language Religion Race Political orientation b. Cultural beliefs and practices that affect health c. Concepts about health and illness C. Health and Illness Patterns 1. Leading causes of mortality 2. Leading cause of morbidity 3. Leading cause of infant mortality

4. 5.

Leading cause of maternal mortality Leading cause of hospital admission

D. Health Resources The health resources that are available in the community is an important element of the community diagnosis mainly because they are the essential ingredients in the delivery of basic health services. 1. Manpower resources Categories of health manpower available Geographical distribution of health manpower Manpower-population ratio Distribution of health manpower according to health facilities Distribution of health manpower according to the type of organization Quality of health manpower Existing manpower development and policies 2. Material resources Health budget and expenditures Sources of health funding Categories of health institutions available in the community Hospital bed-population ratio Categories of health services available E. Political/Leadership Pattern It reflects the action potential of the state and its people to address the health needs and problems of the community. 1. Power structure in community 2. Attitudes of people toward authority 3. Conditions/events/issues that cause social conflict/upheavals 4. Practices/approaches that are effective in setting issues and concerns within the community. II. Problem-Oriented Community Diagnosis This is a type of assessment that responds to a particular need (Spradley, 1990)

Steps in conducting Community Diagnosis 1. Determining objectives In determining the objectives of the community diagnosis, the nurse decides on the depth and scope of the data she needs to gather. 2. Defining the Study Population Based on the objectives of the community diagnosis, the nurse identifies the population group to be included in the study. It may include the entire population in the community or focused on a specific population group such as women in the reproductive age-group or the infants and young children. 3. Determining the Data to be collected Whether the community diagnosis is going to be comprehensive or focused on a specific problem, the objectives will guide the nurse in identifying the specific data she will collect. 4. Collecting the Data The nurse decides on the specific methods depending on the type of data to be generated. Methods of Data Collection a. Records review data may be obtained by reviewing those that have been compiled by health or non-health agencies from the government or other sources. b. Surveys and observations can be used to obtain both qualitative and quantitative data.

c. Interviews can yield first hand information. d. Participant observation is used to obtain qualitative data by allowing the nurse to actively participate in the life of the community. 5. Developing the Instrument Instruments or tools facilitate the nurses data gathering activities. Common instruments use in data collection are: a. survey questionnaire b. interview guide c. observation checklist 6. Actual Data Gathering Before the actual data gathering, it is suggested that the nurse meet the people who will be involved in the data collection. The instruments are discussed and analyzed. The data collectors must be given an orientation and training on how they are going to use the instruments in data gathering. During the actual data gathering, the nurse supervises the data collectors by checking the filled-up instruments in terms of completeness, accuracy and reliability of the information collected. 7. Data Collation After data collection, the nurse now ready to put together all the information. Two types of data that may be generated during data collation: (1) numerical data which can be counted and (2) descriptive data - which can be described. The nurse develops categories for classification of responses. - These are (1) Mutually Exclusive choices which do not overlap and (2) Exhaustive Categories anticipate all possible answers that a respondent may give. In collating fixed responses questions, choices must be provided which will serve as categories for the respondents answer. In some community diagnosis designs, data collectors use flashcards to help the respondent choose his answer. Open ended questions do not provide choices or categories. The next step after categorizing the responses will be to summarize the data. - Two ways to summarize data: (1) One can do it manually by tallying the data or by using the computer and (2) Tallying involves entering the responses into the prepared tally sheets showing all possible responses. - When computers are going to be used in summarizing results, the responses are given numbers or codes. 8. Data Presentation Data presentation will depend largely on the type of data obtained Descriptive Data is presented in a narrative reports (example: geographic data, history of a place or beliefs regarding illness and death). Numerical Data may be presented into table or graphs. - Tables or graphs are useful in showing key information making it easier to show comparisons including patterns and trends. - The choice of graphs will depend on the type of data being presented. - Types of Graphs Line Graph shows trend data or changes with time or age with respect to some other variables Bar Graph/Pictograph for comparisons of absolute or relative counts and rates between categories Histogram/frequency polygon graphic presentation of frequency distribution or measurement Proportional or component bar graph/pie chart shows breakdown of a group or total where the number of categories is not too many Scattered diagram correlation data for two variables 9. Data Analysis

Data analysis in community diagnosis aims to establish trends and patterns in terms of health needs and problems of the community. It also allows for comparison of obtained data with standard values. Determining the interrelationship of factors will help the nurse view the significance of the problems and their implications on the health status of the community.

10. Identify Community Health Nursing Problems Category of Health Problem: a. Health Status Problem They may be described in terms of increased or decreased morbidity, mortality, fertility or reduced capability for wellness. b. Health Resource Problem They may be described in terms of lack of or absence of manpower, money, materials or institutions necessary to solve health problems. c. Health-Related Problem They may be described in terms of existence of social, economic, environment and political factors that aggravate the illness-inducing situations in the community. 11. Priority Setting After the problems have been identified, the next task for the nurse and the community is to prioritize which health problems can be attended to considering the resources available at the moment. Criteria in Prioritizing: a. Nature of the Problem Presented The problems are classified as health status, health-related or health-resources problem b. Magnitude of the Problem This refers to the severity of the problem which can be measured in terms of the proportion of the population affected by the health problem. c. Modifiability of the Problem This refers to the probability of reducing, controlling or eradicating the problem. d. Preventive Potential - This refers to the probability of controlling or reducing the effects posed by the problem. e. Social Concern This refers to the perception of the population or community as they are affected by the problem and their readiness to act on the problem. Scoring System Criteria Nature of the Problem Health Status Health Resources Health Related Magnitude of the Problem 75% - 100% affected 50% - 74% affected 25% - 49% affected <25% affected Modifiability High Moderate Low Not Modifiable Preventive Potential High Moderate Low Social Concern Urgent community concern; 3 2 1 3 4 3 2 1 4 3 2 1 0 1 3 2 1 1 2 Weight 1

express readiness Recognized as a problem but not needing urgent attention Not a community concern

1 0

II. Planning for Community Health Nursing Programs and Services Planning It is a process that entails formulation of steps to the undertaken in the future in order to achieve a desired end. Planning takes place in order to efficiently allocate available resources. This implies that the planner assesses the nature and extent of the problems for which the program is being planned for as well as constraints and limitations that may affect planning decisions. In general, planning is done in our desire to improve the present state of affairs. Concepts of Planning (Mercado, 1993) 1. Planning is futuristic 2. Planning is change-oriented 3. Planning is a continuous and dynamic process 4. Planning is flexible 5. Planning is systematic process The Planning Cycle 1. Situational Analysis Where are we now? Gather health data, tabulate, analyze, and interpret data in a manner that will provide a clear picture of the health status of the community, identify health problems, set priority In this phase o planning cycle, the nurse identifies and provides explanation to the problems. Three Activities during the Situational Analysis: 1. The nurse gathers data about the health status of the community. 2. The nurse identifies and explains the problem. 3. The nurse projects what situation needs to be changed. 2. Goal and Objective Setting Where do we want to go? Refersto the process of formulating the goals and objective of the health program and nursing services in order to change the status quo. It will serve as a guide to the nurses effort. A goal leads to a desired end and it may be a total change, improvement or maintenance of a situation. It is directed towards solving the health status problems which the nurse identified in the community diagnosis. 3. Strategy and Activity Setting How do we get there? It defines the strategies and the activities that the nurse sets to achieve in order to realize the goals and objectives. It implies the identification of resources manpower, money, materials, technology, time and institutionsneeded to implement a program. The nurse defines the strategy or approach in a health program. Program is defined as a timed series of activities to be carried out in order to correct the health problem. - Programs may be classified in terms of the focus of activities. - Activities may provide direct health care services to the population such as immunization, family planning services, nutrition supplementation etc - In some situations, the activities are directed towards transferring knowledge and skills to specific group of people in the community health workers training and mothers classes. 4. Evaluation How do we know we are there?

Find out if the programs and services achieved the purposes for which they are formulated.

Steps in Program Evaluation: 1. Deciding what to evaluate in terms of relevance, progress, effectivity, impact and effiency 2. Designing the evaluation plan specifying the evaluation indicators, data needed methods and tools for data collection and data sources 3. Collection of relevant data 4. Analyzing data 5. Making decisions 6. Preparing report and providing decision-makers feedback on the program evaluation.

Organizing for Health Promotion I. Community Organizing It is a process whereby the community members develop the capability to assess their health needs and problems, plan and implement actions to solve these problems, put up and sustain organizational structures which will support and monitor implementation of health initiatives by the people. It has a goal of motivating, enhancing and seeking wider community participation in decision-making in activities that have the potential to impact positively on community health. The emphasis is more on strengthening the members capability in problem-solving and decision making skills necessary for self-reliant development initiatives. II. Phases of Community Organizing

A. Preparatory Phase The activities in the preparatory phase include area selection, community profiling, entry in the community and integration with the people. 1. Area selection To guide the nurse in choosing and prioritizing areas for community health development, the following questions must be answered: Is the community in need of assistance? Do the community members feel the need to work together to overcome a specific health problem? Are there concerned groups and organizations that the nurse can possibly work with? What will be the counterpart of the community in terms of community support, commitment and human resources? 2. Community Profiling A community member who is known and accepted by the people will be chosen to act as the contact person and identify other persons who can be depended upon to initiate activities in the community. A community profile provides an overview of demographic characteristics, community and health related services and facilities. The community profile will serve as an initial database of the community and provide the basis for planning and programming of organizing activities. 3. Entry in the Community and Integration with the People Before actual entry into the community, basic information about the area in relation to the cultural practices and lifestyle of the people must be known. Establishing rapport and integrating with them will be much easier if one is able to understand, accept or imbibe their community life. Guidelines in Conducting Integration Work: Recognize the role and position of local authorities. Adapt a lifestyle in keeping with that of the community. Choose a modest dwelling which the people, especially the economically disadvantaged will not hesitate to enter. Avoid raising expectations of the people. Be clear your objectives and limitations. Participate directly in production process.

Make house calls and seek out people where they usually gather. Participate in some social activities.

B. Organizational Phase The organizational phase consists of activities leading to the formation of a peoples organization. 1. Social Preparation The integration work paves the way for the nurse to be introduced into the community and signals the beginning of the social preparation phase. While continuously learning more about the conditions of the community, the nurse deepens and strengthens her ties with the people. 2. Spotting and Developing Potential Leaders As a result of living and being with the people, the nurse comes to know who among them have deep concern and understanding of the conditions of the community. It is necessary that they should also be able to gain trust and respect of the community members. Providing opportunities that will demonstrate their potential as leaders can test their commitment to the communitys well-being. It is not necessary that the potential leader is highly educated or one belonging to affluent family in the community, what is important is for that person to be able to identify with, understand and articulate effectively the problems that beset the community. 3. Core Group Formation The core group consists of the identified potential leaders who will task with laying down the foundation of strong peoples organization. The core group represents the different sectors of the community women, youth, farmers or workers depending on the type of community. The nurse facilitates in skills development of core group members related to the tasks they will assume in the organization. The core group serves as training ground for developing the potential leaders in: - Democratic and collective leadership - Planning and assuming tasks for the formation of a community-wide organization - Handling and resolving group conflicts - Critical thinking and decision-making process 4. Setting Up the Community Organization The formation of community-wide organization facilitates wider participation and collective action on community problems. The nurse makes sure that there is maximum participation of and control by the members in all its activities. The organizational structure must be simple to facilitate consultation and decision-making among its members. Part of the organizational structure will be working committees specifically created to look into the different concerns of the organization community. One such committee is the health committee. C. Education and Training Phase The purpose of the education and training phase is to strengthen the organization and develop its capability to attend to the communitys basic health-care need. This can be done through: 1. Conducting Community Diagnosis It is done to come up with a profile of local health situation that will serve as basis of health programs and services to be delivered to the community. The nurse assists the people in developing a plan and in the actual conduct of community diagnosis. The nurse also helps the community to identify, analyze and understand the implications of the data that they have collected. 2. Training of Community Health Workers The community decides on the roles the community health workers are expected to perform and the competencies and personal qualities they should possess. The people will decide who will be trained as community health workers based on the expected roles of the CHWs. The nurse facilitates the conduct of a training needs assessment (TNA) to determine the level of health skills and knowledge the trainees possess.

The results of this assessment will serve as the basis for the health skills training curriculum which will focus on the required competencies.

3. Health Services and Mobilization The organization takes the lead in undertaking activities that will solve the problems the community is confronted with. Engaging them in collective work gives the people opportunities to test and strengthen collective spirit and at the same time, build and enhance their confidence. 4. Leadership-formation activities The process of developing community leaders is a continuous and sustained process. Leaders learn a lot by engaging in actual activities such as conduct of meetings, assessment, planning, implementation, monitoring and evaluation activities. They can utilize these opportunities in mastering organizing skills, human relations development or supervisory skills. As the nurse works with the organization and the community, she will be able to assess the specific training and other practical needs of the leaders and plan for a continuing education program for them. D. Intersectoral Collaboration Phase As an organization grows, its needs will also grow. The need for resources-material, human, financial will have to be sourced externally. Assistance and support in any form can be funneled into the organization through collaboration with other organizations and communities. The nurse is in the best position to facilitate and coordinate with institutions, agencies and other key people to articulate the communitys need for support and assistance. E. Phase-Out As the organization and the community assume greater responsibility in managing their health-care needs, the nurse gradually prepares for turn-over of work and develops a plan for monitoring and subsequent follow-up of the organizations activities until the community is ready for fulldisengagement and phase-out. Partnership and Collaboration The aim of partnership and collaboration is to get people to work together in order to address problems or concerns that affect them. It gives people the opportunity to learn skills in group relationship, interpersonal relations, critical analysis and most important of all, decision-making process in the context of democratic leadership. Ways to Commit and Work Together: A. Networking It consists of exchanging information about each others goal and objectives, services or facilities. B. Coordination It is the relationship where organizations modify their activities in order to provide better services to the target beneficiary. C. Cooperation It is the relationship where organizations share information and resources and make adjustments in ones own agenda to accommodate the other organizations agenda. D. Collaboration It is the level of organizational relationship where organizations help each other enhance their capacities in performing their tasks as well as in the provision of services. E. Coalition or Multi-sectoral Collaboration It is the level of relationship where organizations and citizens form a partnership.

Advocacy Advocacy work is one way the nurse can promote active community participation. The nurse is responsible for providing mechanisms for people to participate in activities that aim to improve the conditions of the community.

The nurse as an advocate helps empower the people to make decisions and carry out actions that have the potential to better their lives.

Advocacy Involves: A. Informing the people about the rightness of the cause B. Thorough discussing with the people the nature of the alternatives, their content and possible consequences. C. Supporting peoples right to make a choice and to act on their choice. D. Influencing public opinions Supervision It is a developmental and enabling process whereby the nurse supervisor ensures the work is done effectively and efficiently by the person being supervised and at the same time, keeps the person satisfied and motivated with his work. In community health nursing, supervision is seen more as a coaching rather than a function of control. In community, most of the supervisory functions of the nurse are directed towards lower level health workers, thus, they will require closer supervision than do professional health workers. The nurse as a coach to health workers uses persuasion, exhortation and judicious mixture of reward and punishment to motivate the players toward higher levels of performance. Objectives of Supervision 1. Identify the supervisory needs of the worker 2. Determine ways of meeting the needs of the worker 3. Develop the capability of the worker to solve own problems and meet own needs by providing continuing personal guidance and professional development 4. Evaluating the performance of the worker as it becomes the basis for providing help or guidance.

The Maternal Health Program III. Introduction The Philippines is tasked to reduced the maternal mortality ratio (MMR) by three quarters by 2015 to achieve its millennium development goal ( 112/100,000 live births in 2010 and 80/100,000 live births by 2015) The percentage of pregnant women with at least four prenatal visits decreased from 77% in 1998 to 70.4 in 2003. The 200 Philippine Health Statistics revealed that 25% of all maternal deaths are due to hypertension, 20.3% to postpartum hemorrhage, 9% pregnancy with abortive outcomes which are neither preventable nor nonpreventable. The births attended by health professionals increased from 56% in 1998 to 59.8% in 2003. The underlying causes of maternal deaths are (1) delays in taking critical actions, (2) delay in seeking care, (3) delay in making referral, and (4) delay in providing of appropriate medical management. IV. Overall Goal of the Program To improve the survival, health and well-being of mothers and unborn The Strategic Thrusts for 2005-2010 Launch and implement the Basic Emergency Obstetric Care (BEMOC) strategy in coordination with the DOH. It entails establishment of facilities that provide emergency obstetric care for every 125,000 population and which are located strategically. Improve the quality of prenatal and postnatal care. Reduce womens exposure to health risks through institutionalization of responsible parenthood and provision of health care package to all women of reproductive age. LGUs, NGOs and other stakeholders must advocate for health through resources generation and allocation for health services to be provided for the mother and the unborn.

V.

VI.

Essential Health Service Package Available in the Health Care Facilities A. Antenatal Registration Every pregnant women must visit the nearest health facility for antenatal registration and to avail prenatal care services This is the only way to guide her in pregnancy care to make her prepare for child birth

Standard Prenatal Visits: Prenatal Visits 1 Visit 2 Visit rd 3 Visit Every 2 Weeks
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Period of Pregnancy As early in pregnancy as possible before four months or during the first trimester During the 2 Trimester rd During the 3 Trimester th After 8 moths of pregnancy till delivery
nd

B. Tetatus Toxoid Immunization To protect the mother and neonate from deadly disease tetanus toxoid immunizationimportant for pregnant women and child bearing age women. A series of 2 doses of Tetanus Toxoid vaccination must be received one month before delivery for protection both for mother and child. Add 3 booster dose shots to complete the five doses following the recommended schedule to provide full protection for mother and child. The mother is then called as Fully immunized Mother (FIM). Tetanus Toxoid Immunization Schedule for Women Vaccine TT1 TT2 TT3 TT4 TT5 Minimum Age/ Interval As early as possible During pregnancy 4 Weeks later 6 months later 1 year later 1 year later 80% 95% 99% 99% % Protection 3 years 5 years 10 years Lifetime Duration of Protection

C. Micronutrient Supplementation These are necessary to prevent anemia, vitamin A deficiency and other nutritional disorders. Vitamins Vitamin A Dose 10,000 IU Schedule of Giving Twice a week starting th on the 4 month of pregnancy Remarks Do not give Vitamin A supplementation before th the 4 month of pregnancy. It might cause congenital problems in the baby.

Iron

60 mg/400 tablet

ug

Daily

D. Treatment of Diseases and Other Condition There other conditions that might occur among pregnant women, and these conditions may endanger her health and complication could occur.

First Aid Treatment during Such Condition/s: Condition/Disease Difficulty of breathing/obstruction of airway What to do Clear airway Place in best position then refer Refer women to hospital with capabilities EmOC is Do not give

Unconscious

Keep on her back arms at the side Tilt head backwards (unless trauma

Do not give Oral Rehydration Solution to a woman who is

 Postpartum bleeding

suspected) Lift chin to open airway Clear secretion from throat Give IVF to prevent or correct shock Monitor blood pressure, pulse and shortness of breath every 15 minutes If difficulty of breathing and puffiness develop, stop infusion. Monitor fluid given Massage uterus and expel clots If bleeding persists: - Placed cupped palmed on uterine fundus and feel for state of contraction - Massage fundus in a circular motion - Apply bimanual uterine compression if ergometrine treatment done and postpartum bleeding still persists - Give ergometrine 0.2 mg. IM and another dose after 15 minutes Give mebendazole 500 mg. tablet single dose anytime from 4-9 months of pregnancy if none was given in the past 6 months

unconscious or has convulsion Do not give IVF if you are not trained to do so.

Do not give ergometrine if women has eclampsia, preeclampsia or hypertension

Intestinal infection

parasite

Do not give mebendazole in the first 1-3 months of pregnancy. This might cause congenital problems in baby.

Malaria

Give sulfadoxin-pyrimethamine to women from malaria endemic areas st nd who are in 1 or 2 pregnancy, 500 mg.-25 mg. tab, 3 tabs at the beginning nd rd of 2 to 3 trimesters not less than one month interval.

E. Clean and Safe Delivery The presence of a skilled birth attendance will ensure hygiene during labor and delivery. It may also provide safe and non traumatic care, recognize complications and also manage and refer the woman to higher level of care when necessary. Steps to follow during labor, childbirth and immediate postpartum: 1. Do a quick check upon admission for emergency signs Unconscious/convulsion Vaginal bleeding Severe abdominal pain Looks very ill Severe headache with visual disturbance Severe breathing difficulty Fever Severe vomiting 2. Make the woman comfortable Establish rapport with the client by greeting and interviewing to make her comfortable 3. Assess the woman in labor Assess for the following: Last Menstrual Period (LMP) Number of pregnancy Start of labor pain

 Age/height Danger signs of pregnancy 4. Determine the stage of labor Labor can be determine when womans response to contraction is observed pushing down and vulva is bulging, with leaking of amniotic fluid, and vaginal bleeding. 5. Decide if the woman can safely deliver By assessing the condition of the client and not finding any indication that could harm the delivery of a baby. 6. Give supportive care throughout labor Encourage to take a bath at the onset of labor Encourage to drink but not to eat as this may interfere surgery in case needed Encourage to empty bladder every two hours Encourage to do breathing technique to help energy in pushing baby out the vagina 7. Monitor and Manage Labor Different Stages of Labor to Watch Out Stage of Labor st 1 Stage: not yet in active labor, cervix is dilated 0-3 cm and contractions are weak, less than 2 to 10 minutes. What to do Check every hour for emergency signs, frequency and duration of contractions, fetal heart rate, etc. Check every 4 hours for fever, pulse, BP and cervical dilation Record time of rupture of membranes and color of amniotic fluid Assess progress of labor - Refer women immediately to hospital facility with comprehensive emergency obstetrical care capabilities if after 8 hours, contractions are stronger and more frequent but no progress in cervical dilation, with or without membranes ruptured - It is false labor if after 8 hours there in no increase in contractions, membranes are not ruptured and no progress in cervical dilation Check every 30 minutes for emergency signs Check every 4 hours for fever, pulse, BP and cervical dilation Record time of rupture of membranes and color of amniotic fluid Record findings in partograph/patient record Not to do Do not do vaginal examination more frequently than every 4 hours

1 Stage: in active labor, cervix is dilated 4 cm or more

st

2 Stage: cervix dilated 10 cm or bulging thin perineum and head visible.

rd

nd

3 Stage: between birth of the baby and delivery of the placenta.

Check every 5 minutes for perineum thinning and bulging, visible descend of the head during contraction, emergency signs, fetal heart rate and mood and behavior. Continue recording in the partograph. Deliver the placenta. Check the completeness of placenta and membranes.

Do not allow woman to push unless delivery is imminent. It will just exhaust the woman. Do not give medications to speed up labor. It may endanger and cause trauma to mother and the baby. Do not apply fundal pressure to help deliver the baby.

Do not squeeze or massage the abdomen to deliver the placenta.

8. 9. 10. 11.

Monitor closely within 1 hour after delivery and give supportive care Continue care after 1 hour of postpartum. Keep watch closely for at least 2 hours Educate and counsel on Family Planning method. Provide one if available and if decision was made. Inform, teach and counsel Birth registration, Breastfeeding, newborn screening & schedule for post partum visits Recommended Schedule of Post Partum Care Visits: st st 1 visit at 1 week post partum (3 5 days)

2 visit at 6 weeks post partum

nd

F. Support Breastfeeding A support care groups like nurses have a critical role to motivate them to practice breastfeeding.

G. Family Planning counseling Proper counseling of couples on the importance of family planning will help them inform on the right choice of family planning methods, properspacing of birth and addressing the right number of children. Birth spacing of three to five years interval will help completely recover the health of a mother from previous pregnancy and childbirth. The risks of complications increases after second birth

Expanded Program on Immunization VII. The Concept and Importance of Vaccination Immunization is the process by which vaccines are introduced into the body before infection sets in. Vaccines are administered to induce immunity thereby causing the recipients immune system to react to the vaccine that produces antibodies to fight infection. Vaccination promotes health and protects children from disease causing agents. Infants and newborns need to be vaccinated at an early age since they belong to vulnerable age group. Presidential decree No. 996 (September 16, 1976). Providing for compulsory basic immunization for infants and children below eight years of age.

VIII. General Principles in Vaccination: 12. It is safe to administer all EPI vaccines on the same day at different body sites of the body. 13. Measles vaccine should be given as soon as the child is 9 months old, regardless of whether other vaccines will be given on that day. 14. Vaccination should not be restarted from the beginning even if the interval between doses exceeded the recommended interval. 15. Moderate fever, malnutrition, mild respiratory infection, cough, diarrhea and vomiting are not contraindications. 16. Absolute contraindications are: DPT2 or DPT3 to a child who has had a convulsion or shock within 3 days the previous dose. Vaccines with whole cell pertussis component should not be given to one with neurological disease (uncontrolled epilepsy of progressive encephalopathy) BCG should not be given to immunosuppressive agents or infant having irradiation 17. Local reaction, fever and systemic symptoms are safe. It is part of the normal immune response. 18. Giving doses of vaccine at less than the recommended 4 weeks interval may lessen the antibody response. 19. No extra doses for DPT/HB/OPV/TT must be given to children/mother who missed the dose. 20. Strictly follow the principle of never reconstitute the freeze dried vaccines in anything other than the diluents supplied with them. 21. False contraindication is: malnutrition, low grade fever, mild respiratory infections and other minor illnesses and diarrhea. 22. Repeat BCG if there is no scar develops 23. Use one syringe, one needle per child IX. The EPI Target Diseases Vaccination among infants and newborns (0-12 months) against the seven vaccine preventable diseases. These includes: (1) tuberculosis, (2) diphtheria, (3) pertussis, (4) tetanus, (5) poliomyelitis, (6) measles, and (7) hepatitis.

1. Measles A highly communicable disease with the history of the following: - Generalized blotchy rash, lasting for 3 or more days - Fever above 38C or hot to touch - Cough, runny nose, red eyes Agent: virus

Reservoir: humans Sources of Infection:close respiratory contact and aerosolized droplets Occurrence: worldwide, mortality and morbidity higher in developing countries Transmissible Period:4 days before until 2 days after rash Duration of Natural Immunity:lifelong after attack Risk Factor for Infection:crowding, low socio-economic status 2. Tuberculosis A child with history of contact with a suspect or confirmed case of pulmonary tuberculosis Any child who does not return to normal health after measles or whooping cough Loss of weight, cough and wheeze which does not respond to antibiotic therapy for acute respiratory disease Abdominal swelling with a hard painless mass and free fluid Painful firm or soft swelling in a group of superficial lympnodes Any bone or joint lesion or slow onset Signs suggesting meningitis or disease in the central nervous system Agent:Mycobacterium tuberculosis Reservoir:Man, diseased cattle Sources of Infection:droplet infection, that is through inhalation of bacilli Occurrence:worldwide, mortality and morbidity higher in developing countries Transmissible Period:a person who excretes tubercle bacilli is communicable; the degree of communicability depends upon the number of bacilli in the air, virulence of bacilli, environmental conditions like overcrowding. Durationof Natural Immunity:not known reactivation of old infection commonly causes disease Risk Factor for Infection: low access to care, immunodeficiency, malnutrition, alcoholism, diabetes 3. Diphtheria It is an acute pharyngitis, acute nasopharyngitis or acute laryngitis with pseudomembrane Agent:Corynebacterium diphtheria Reservoir:man Sources of Infection:by respiratory droplets from discharge of a case carrier Occurrence: worldwide, endemic in developing countries with unimmunized population Transmissible Period:may last for 2-3 weeks, maybe shortened in patients with antibiotic treatment Duration of Natural Immunity: usually lifelong Risk Factor for Infection:crowding, low socio-economic status 4. Pertussis History of severe cough and history of any of the following: cough persisting 2 or more weeks; fits of coughing, and cough followed by vomiting. Agent:Bordetella pertussis Reservoir:man Sources of Infection:primarily by direct contact with discharges from respiratory mucous membranes of infected persons, airborne route probably by droplets, indirect contact with articles freshly soiled with the discharges of infected persons, fecal-oral route, oral route through pharyngeal secretion, contact with infected persons Occurrence: worldwide, mortality and morbidity higher in developing countries Transmissible Period:highly communicable in early catarrhal stage, before paroxysmal cough, antibiotics may shorten the period of communicability from 7 days after onset of typical paroxysms to only 5 to 7 days after onset of therapy Duration of Natural Immunity:usually lifelong Risk Factor for Infection:young age, crowding 5. Poliomyelitis As suspected cases of polio is defined as any patient below 15 years of age with acute flaccid paralysis (including those diagnosed to have GuillaineBarre Syndrome) for which no other cause can be immediately identified. Agent:Poliovirus type 1, 2, and 3 Reservoir: man, mostly Sources of Infection:fecal-oral route, oral route through pharyngeal secretion, contact with infected person Occurrence: cyclical, worldwide, morbidity and mortality higher in developing countries Transmissible Period:7 to 16 days before onset of symptoms, first few days after onset of symptoms Duration of Natural Immunity: type specific immunity lifelong Risk Factor for Infection:poor environmental hygiene 6. Neonatal Tetanus

A newborn with history of all three of the following: - Normal suck for the first two days of life - Onset of illness between 3 to 26 days - Inability to suck followed by stiffness of the body and/or convulsion Agent:Clostridium tetani Reservoir:soil, intestinal canals of animals (horses), man Sources of Infection:unhygienic cutting of umbilical cord, improper handling of cord stump especially when treated with contaminated substances Occurrence: worldwide, morbidity higher in developing countries more common in agriculture and underdeveloped areas where contact with animal excreta is more likely Transmissible Period:4 days before until 2 days after rash Duration of Natural Immunity:no immunity induced by infection Risk Factor for Infection:contamination of umbilical cord, agricultural work 7. Hepatitis It is the liver infection caused by the B type of hepatitis virus It attacks the liver often resulting in inflammation Agent:Hepatitis B virus Reservoir:man Sources of Infection:Hepatitis B spreads through the following: from mother to child during birth, through sharing of unsterilized needles, knives or razors, through sexual intercourse Occurrence: In the country, 12% of the populations are chronic carriers, most Filipinos are infected before the age of 6, some infected infants are not able to develop immunity and become chronic carriers, and hepatitis B is especially dangerous for children Transmissible Period:Infants born to immune mothers may be protected up to 5 months, recovery from clinical attack in not always followed by lasting immunity, immunity is often acquired through inaparrent infection or complete immunization series with diphtheria toxoid Duration of Natural Immunity:if develops, lifelong Risk Factor for Infection:HBeAg + mother, multiple sexual partners

The EPI Routine Schedule of Immunization Wednesday immunization day in all parts of the country Monthly in a barangay health station Quarterly in far flung areas Some areas adopted local practices to provide everyday vaccination in their areas to cover all targets. XI. Routine Immunization Schedule for Infants Vaccine BCG Minimum Age at st 1 Dose Birth or anytime after birth Number of Doses 1 Minimum Interval Between Doses Reason BCG given earliest possible age protects the possibility of TB meningitis and other TB infectious in which infants are prone. An early start with DPT reduces the chance of severe pertussis. The extent of protection against polio is increased the earlier the OPV is given. An early start of Hepa B reduces the chance of being infected and becoming a carrier. Prevent liver cirrhosis and liver cancer. Prevents death, malnutrition, pneumonia, diarrhea complications.

X.

DPT OPV

6 weeks 6 weeks

3 3

4 weeks 4 weeks
st

Hepatitis B

At birth

6 weeks interval from 1 dose, and; 8 weeks nd interval from 2 dose to third -

Measles

9 months

XII. Tetanus Toxoid Immunization Schedule for Women Tetanus toxoid vaccination for women is important to prevent tetanus in both mother and the baby.

Vaccine TT1 TT2

Minimum Age/interval As early as possible during pregnancy At least 4 weeks later

Percent Protected 80%

Duration of Protection

Infants born to the mother will be protected from neonatal tetanus Gives 3 years protection for the mother Infants born to the mother will be protected from neonatal tetanus Gives 5 years protection for the mother Infants born to the mother will be protected from neonatal tetanus Gives 10 years protection for mother Gives life time protection for mother All infants born to that mother will be protected

TT3

At least 6 months later

95%

TT4

At least one year later

99%

TT5

At least one year later

99%

XIII.

The EPI Vaccines and its Characteristics Most sensitive to Heat: Vaccines: (1) Oral Polio (live attenuated) (2) Measles (freeze dried) Storage Temperature: -15C to -25C (freezer) Least Sensitive to Heat: Vaccines: (1) DPT / Hep B D Toxoid which is a weakened toxin P Killed bacteria T Toxoid which is a weakened toxin (2) Hepatitis B (3) BCG (freeze dried) (4) Tetanus Toxoid Storage Temperature: C to 8C (in the body of the refrigerator FEFO First Expiry and first Out is practiced to assure that all vaccines are utilized before its expiry date. Temperature monitoring is done twice a day in the early morning and in the afternoon before going home Cold chain equipments are: cold room, freezer, refrigerator, transport box, vaccine carrier. Other cold chain logistics are: thermometers, cold chain monitor, ice packs, temperature monitoring chart, safety collector box.

XIV.

Administration of Vaccines Dose Infants 0.05 ml 0.5 ml 2 drops or depending on manufacturers instruction 0.5 ml 0.5 ml 0.5 ml Route of Administration Intradermal Intramuscular Oral Site of Administration Right deltoid region of the arm Upper outer portion of the thigh Mouth

Vaccine BCG DPT OPV

Measles Hep B Tetanus

Subcutaneous Intramuscular Intramuscular

Outer part of the upper arm Upper outer portion of the thigh Deltoid region of the upper

Toxoid Procedures in Giving of Vaccines:

arm

Reconstituting the freeze dried BCG Vaccine: 1. Always keep the diluents cold by sustaining with BCG vaccine ampules in refrigerator or vaccine carrier. 2. Using a 5 ml. syringe fitted with a long needle, aspirate 2 ml. of saline solution from the opened ampule of diluents. 3. Inject the 2 ml. saline into the ampule of freeze dried BCG. 4. Thoroughly mix the diluents and vaccine by drawing the mixture back into the syringe and expel it slowly into the ampule several times. 5. Return the reconstituted vaccine on the slit of the foam provided in the vaccine carrier. Giving BCG Vaccine: 1. Clean the skin with a cotton balls moistened with water and let skin dry. 2. Hold the childs arm with your left hand so that: your hand is under the arm, and your thumb and fingers come around the arm and stretch the skin. 3. Hold the syringe in your right arm with the bevel and the scale pointing up towards you. 4. Lay the syringe and needle almost flat along the childs arm. 5. Insert the tip of the needle into the skin just the bevel and a little bit more. Keep the needle flat along the skin and the bevel facing upwards, so that the vaccine only goes into the upper layers of the skin. 6. Put your left thumb over the needle end of the syringe to hold it in position. Hold the plunger end of the syringe between the index and middle fingers of your right hand and press the plunger in with your right thumb. 7. If the vaccine is injected correctly into the skin, a flat wheal with the surface pitted like an orange peel will appear at the injection site. 8. Withdraw the needle gently. Giving Oral Polio Vaccine 1. Read the manufacturers instructions to determine number of drops to be given. Use the dropper provided for. 2. Let the mother hold the child lying firmly on his back. 3. If necessary open the childs mouth by squeezing the cheeks gently between your fingers to make his lips point upwards. 4. Put drops of vaccine straight from the dropper onto the childs tongue but do not let the droper touch the childs tongue. 5. Make sure that the child swallows the vaccine. If he spits it out, give another dose. Giving Hepatitis B/DPT 1. Ask mother to hold the child across her knees so that his thigh is facing upwards. Ask her to hold childs legs. 2. Clean the skin with a cotton ball moistened with water and let skin dry. 3. Place your thumb and index finger on each side of the injection site and grasp the muscles slightly. The best injection site is the outer part of the childs mid-thigh. 4. Quickly push the needle into the space between your fingers, going deep in the muscle. 5. Slightly pull the plunger back before injecting to be sure that vaccine is not injected into a vein (if using disposable syringes and needles). 6. Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton. Measles Reconstituting the Freeze Dried Measles Vaccine 1. Using a 10 ml. syringe fitted with a long needle, aspirate 5 ml. of special diluents from the ampule. 2. Empty the diluent from the syringe into the vial with the vaccine. 3. Thoroughly mix the diluents and vaccine by drawing the mixture back into the syringe and expelling it slowly into the vial several times. Do not shake the vial. 4. Protect reconstituted measles vaccine from sunlight. Wrap vial in foil. 5. Place the reconstituted vaccine in the slit of the foam provided in the vaccine carrier. Giving Measles Vaccine 1. Ask the mother to hold the child firmly. 2. Clean the skin with a cotton ball moistened with water and let the skin dry. 3. With the fingers of one hand, pinch up the skin on the outer side of the upper arm. 4. Without touching the needle, push the needle into the pinched-up skin so that it is not pointed. 5. Slightly pull the plunger back to make sure that the vaccine is not injected into a vein (if using a disposable syringes and needles). 6. Press the plunger gently and inject.

Tetanus Toxoid 1. Shake the vial. 2. Clean the skin with a cotton ball, moistened with water and let skin dry. 3. Place your thumb and index finger on each side of the injection site and grasp the muscles, slightly. The best injection site for a woman is outer side of the left upper arm. 4. Slightly pull the plunger back before injecting to be sure that vaccine is not injected into a vein. 5. Quickly push the needle into the space between your finger, going deep in the muscle. 6. Inject the vaccine. Withdraw the needle and press the injection spot quickly with a piece of cotton.