A Comprehensive Textbook of Community Health Nursing Bijayalaskhmi Dash
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Introduction to Community Health NursingCHAPTER 1

Health is the level of functional or metabolic efficiency of a living organism. In humans it is the general condition of a person's mind and body, usually meaning to be free from illness, injury or pain. Generally we mean, health is absence of disease. Individuals describe health in their own way. From the immemorial time man has been interested in trying to control disease. In ancient time health and illness were interpreted in an anthropological perspective. Primitive people also believed that health is a god gift.
Health is a common theme in most culture. In fact all communities have their concept of health at part of their culture. Among definitions still used probably the oldest is that health is absence of disease. The determinants of health are not yet clear. The current meaning or definition of health is elusive and there is no single yardstick for measuring health. In some cultures health and harmony are considered equivalent, harmony is being defined as being at peace with the self the community, God and Cosmos. During the past few decades there has been a preawakening that health is a fundamental right and a worldwide social goal which is essential to satisfy the basic human needs to an improved quality of life and that it is to be attained by all people.
So in 1977 30th World Health Assembly decided that the main social target of government and WHO in the coming decades should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life called health for all. So health is an integral part of socioeconomic development by United Nations 1979 and it has also become a major instrument of overall socioeconomic development and the creation of a new social order.
Health is perceived as different within different communities. An understanding of health which is a basis of all health care is not perceived in same way by all members in a community including various professional groups (e.g. biomedical scientists, social science specialist. Health administrator, ecologists, etc.) being giving rise to confusion about the concept of health. In a world of continuous changes new concepts are bound to emerge based on new pattern of thought. Primitive people believed that health is a GOD gift and it cannot be earned. Health has evolved over the centuries as a concept form an individual concern to world wide social goal and encompass the whole quality of life.
Biomedical Concept
According to the biomedical model, health constitutes the freedom from disease, pain, or defect, thus making the normal human condition ‘healthy’. The model's focus on the physical processes, such as the pathology, the biochemistry and the physiology of a disease, does not take into account the role of social factors or individual subjectivity. Traditionally health has been viewed as an absence of diseases and if one is free from diseases that the person was consider as healthy. This biomedical concept is based on the Germ Theories of disease. According to this theory, the medical profession viewed the human body as a machine. Disease break down the machine and doctor repair it. The criticism that is leveled against biomedical concept is that this concept has minimized the role of environmental, social, psychological and cultural determinant of health. The biomedical model is only for treating diseases but also inadequate to solve some of major health problems of mankind (e.g. malnutrition, accidental, mental illness).
By elaborating the medical technology development in medical and social sciences the conclusion is that biomedical concept of health was inadequate.
Ecological Concept
Inadequacy in biomedical model concept gave rise to other concept The ward ecology derived from Greek 2word Oikos—means house. The ecologist put forward a hypothesis that health is a dynamic equilibrium between man and his environment. The disease is due to maladjustment of human organism to the environment Ecology is defined as the science of mutual relationship between living organisms and their environment. A fall understanding of health requires that humanity seen as a part of an ecosystem. Dubas defined ‘Health implies the relative absence of pain and discomfort and maladaptation and adjustment to the environment to ensure optimal function. The ecological concept raises two issue. Imperfect man and imperfect environment, history argues and also accept this. The human ecosystem includes—Natural environment and man made environment. The dimensions of environment are, physical, chemical, biological, psychological and also our cultural and its product. Disease is embedded in the ecosystem of man. In a greener pasture, where people inhale fresh air, no black smoke emitted from factory chimneys, the general health condition of local inhabitants is bound to be noteworthy. With global warming, we have experienced erratic rain, drought accompanied by famine. Not only that, with holes in ozone layer, injurious ultraviolet rays are coming into the atmosphere, which may eventually cause skin cancer. These negative aspects arising from ruining the ecosystem by mankind are all will affect to our Health. With good counsel, we can save Mother Earth, by not further damaging the ecosystem, thus not jeopardizing the health of its inhabitants. Health according to ecological concept is visualized as a state of dynamic equilibrium between man and his environment. By instantly altering of ecosystem or environment by such activities Urbanization, Industrialization, Deforestation, Land reclamation, Construction of irrigation canals and dams, man has created himself new health problems. Today the greatest threat to human health in India is ever increasing due to unplanned urbanization, growth of slum and deterioration of environment. The changes of ecological cycle of disease has resulted in zoozatic diseases like Yellow fever, monkey pox, etc. Ecological factors are the root of the geographic distribution of diseases. Therefore good public health is good ecology.
Psychosocial Concept
Contemporary development in social sciences revealed that health is not only a biomedical phenomenon and ecological phenomenon but one which is influenced by social, psychological, cultural, economic and political factors of the people concerned. These factors must be taken into consideration in defining and measuring health.
Psychosocial concept is difficult to define. The social, economical and cultural background of the different countries are highly varied in their social standard and value system. The psychosocial concept is defined as ‘Those factors affecting personal health care and community well-being that stream from the psychosocial make up the individuals and it structure avoid and functions within the social group. The factor include cultural value, habits, attitudes, religion, lifestyle, health services, customs beliefs, moral education, community life and social and political organization.
In addition to this broad aspect of psychosocial environment, man is constant interaction with the part of social environment as people. He is a member of family, caste, community and nation. Between the individual and other member of group there can be harmony and disharmony. There can be started conflict. The individual behavior can affect on the other members of group. The custom attitude belief tradition all regulate the interaction among group of individual and families. It develops through the process of socialization. Lifestyles are learnt through social interaction with parent, pear group, friends, school and mass media. So the favorable social environment can improve the health and fulfillment and provide quality of life. Many current health problem specially in the developed countries are due to associated with changes of lifestyle. Coronary heart disease, hypertension, drug addiction, handicapped, Emotional symptoms such as feelings of anxiety, depression, anger, frustration, etc. and road accidents are now the principal cause of death in young people, which is related to psychosocial anxiety, frustration, preoccupation which are related to the changes of psychological factors. Social factors include the custom attitude belief tradition all regulate the interaction among group of individual and families. It develops through the process of socialization. Lifestyles are learnt through social interaction with parent, pear group, friends, school and mass media. So the favorable social environment can improve the health and fulfillment and provide quality of life. Malnutrition, hookworm infestation, diarrhea and cancer can occur due to the influence of social factors.
Holistic Concept
The holistic model is the synthesis of all models or concepts. It recognizes the strength of physical, psychological, social, economic, political and environmental influences of health. Holistic Concept of health has been variously defined as a unified multidimensional process involving the well-being of whole person in the contest of his environmental. In ancient time it 3is stated that health impulse a sound mind in a social body in a sound family in sound environment. The holistic approach implies that all sectors of society have an effect on health in particular. Agriculture, animal husbandry, food industry, education, housing, public work communication and a good social system, all these are emphasis on promotion and protection of health.
By following the holistic concept WHO gave a definition in (1948) Health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity. Operational definition of Health by WHO— a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental dimensions of health and wellness.
The WHO definition of health has been criticized as being to broad. Some argue that health cannot be defined as a state of all but must be seen as a process of continuous adjustment to the changing demand of living and of the changing meaning, we give to life, it is a dynamic concept. It helps people live well, work well and enjoy themselves so there is some new philosophy of health. In broad sense health can be seen as a condition or quality of the human organism expressing the adequate functioning of the organism in a given condition, genetic or environment. Overall good health and wellness are interdependent on five dimensions, namely physical, intellectual, emotional, social and spiritual.
Physical Dimensions
Physical dimensions means ability to carry out daily tasks and achieve fitness. Physical health is easy to detect and describe. A person is physically healthy if he or she looks alert and responsive. A healthy body maintained by good nutrition, regular exercise, avoiding harmful habits, making informed decisions about health and seeking medical assistance when necessary. A person who enjoys good physical health is one who:
  • Is energetic
  • Has good posture
  • Weighs normal for age and height
  • Has all body organs functioning normally
  • Has a clear and clean skin
  • Has bright eyes
  • Has good textured and shining hair
  • Has a clean breath
  • Has a good appetite
  • Gets sound sleep.
A person is mentally healthy if he or she is relaxed and free from any worries. Mental dimensions has two branch, intellectual dimension and emotional dimension.
Intellectual Dimension
Intellectual dimension is a state in which mind is engaged in lively interaction with the world. It involves continued learning, problem solving and creativity. It also involves ability to learn and use information effectively for personal, family, and career development striving for continued growth and learning to deal with new challenges effectively, encompasses cognitive abilities, educational background and past experiences, positive sense of purpose. These influence a client's response to teaching about health and reactions to health care during illness.
Emotional Dimension
Emotional Dimension is the ability to understand own feelings, accept own limitations, achieve emotional stability and become comfortable with his/her emotions. It refers to feelings, affect and person's ability to express these, includes belief in one's worth. Long-term stress affects the body systems and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change body responses to illness.
Mental health can be achieved by control on emotions, sensitive to the needs of others, confidence in one's own abilities, freedom from unnecessary tensions, anxieties and worries, accept one's limitations, recognize, accept, and express feelings and ability to manage stress and express emotions appropriately.
Social Dimension
Social dimension concerns the sense of having support available from family and friends; practices, values and beliefs that determine health. The ability to relate well to others, both within and outside the family unit. It encourages contributing to a healthy community by supporting a healthy living environment and initiating better communication with other. It is the ability to interact successfully with people and within the environment of which each person is a part and develop and maintain intimacy with significant others develop respect and tolerance for those with different opinions and beliefs.4
Spiritual dimension denotes the sense that life is meaningful and has a purpose; the ethics, values and morals that guide us and give meaning and direction to life. The spiritual dimension is understood to imply a phenomenon that is not material in nature, but belongs to the realm of ideas, beliefs, values and ethics that have arisen in the minds and conscience of human beings, particularly ennobling ideas have given rise to health ideals which have led to a practical strategy for Health for All which aims at attaining a goal that has both a material and nonmaterial component. If the material component of the strategy can be provided to people, the nonmaterial or spiritual one is something that has to arise within people and communities in keeping with their social and cultural patterns. The spiritual dimension plays a great role in motivating people's achievement in all aspects of life.
A positive concept of health refers to the aspect of physical emotional, intellectual and social well-being of a person in terms of being free from any ailments or diseases, it also implies a state of physical, mental and social well-being with the harmonious balance of this state of human individual integrated into his environment. In short the notion of ‘perfect functioning’ of the body and mind. A positive healthy individual should be:
As a state in which every cell and every organ is functioning at optimum capacity and in perfect harmony with the rest of the body.
As a state in which the individual feels a sense of perfect well-being and of mastery over his environment.
As a state in which the individual's capacities for participation in the social system are optimal.
Dubos said, ‘The concept of perfect positive health cannot become a reality because man will never be so perfectly adapted to his environment that his life will not involve struggles, failures and sufferings. Positive health will therefore always remain a mirage, because everything in our life is subject to change. Health is the ability of an individual or social group to modify himself or itself continually.’
The face of changing condition of life health fluctuates within a range of optimum well-being to various levels of dysfunction, including the state of total dysfunction namely the death. Health of an individual is not static, it is dynamic phenomenon and a process of continuous change. There are degrees or levels of health as there are degrees or severity of illness.
Individuals functions according to their needs for physical, emotional and social well-being. Well-being is the state of being healthy and happy and living a full life. How individuals might describe their feelings about physical, emotional and social well-being.
Types of well-being
I am usually pretty healthy. I never miss work because of sickness.
I have enough energy to do the things I should do every day.
I can eat a variety of foods without having stomach problems.
Everyone says I am a healthy, cheerful person.
I am even tempered, but certain things make me a little anxious.
Playing on the football team helps me make a lot of friends.
Well-being of an individual or group of individuals have objective and subjective components. the objective components relate to such concerns generally known by the term ‘Standard of living or level of living’. It referred to as quality of life.
  1. Standard of living: Refers to usual scale of our expenditure, the goods we consume and the services we enjoy. It includes the level of education, employment status, food, dress, house, amusements and comforts of modern living.
    According to WHO—Income and occupation standards of housing, sanction and nutrition, the level of provision of health, educational, recreational and other services collectively as an index of the standard of living.
  2. Level of living: It consists of nine components health, food consumption, education, occupation and working condition, housing, social security, clothing, recreation and leisure and human rights. Health is the most important component of the level of living because its impairment always means impairment of the level of livings.5
  3. Quality of life: Quality of life was defined by the condition of the effects of the complete range of factors such as those determining health, happiness (including comfort in the physical environment and a satisfying occupation), education, social and intellectual attainments freedom of action, justice and freedom of expression. The quality of life can be maintained by maintaining harmony to all factors.
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Fig. 1.1: Quality of life mode
The different aspects of quality of life are:
  • Having a purpose in life: The absence of purpose in life leads to alcoholism, drug, dependence, suicide and depression.
  • Maintaining positive attitudes: If you keep a journal for one week, of all your attitudes towards life, you will become aware of how much you pollute the environment with your negative attitudes, the positive attitude can be developed by the person's inner motivation. Keep up the journal writing until the positive attitudes are predominant and a part of your thinking process.
  • Using one's abilities fully: A person may have a lot of hidden qualities which may be ignore to himself/herself. By using one's abilities fully an individual can improve his/her quality of life.
  • Having the will to be whole and healthy: If you program yourself to be sick, you will be sick constantly telling yourself you are not strong, you catch cold easily, you are allergic to this and that will maintain your body in ill health. Activate your warrior, listen to positive programming and you will reach a high level of wellness.
  • Being adaptable: If we stay stuck like old cement we will crack and break from the winds of change. It is better to be flexible and adapt to the wind like the reels and the swaying bamboos we need to have lots of give.
  • Cooperating with other people: This leads to harmony and greater achievement of peace and prosperity.
  • Accepting responsibility for one's thought and action: It is so easy to blame others, but it is a sign of maturity to see that all your thoughts, feelings, words and actions are under your control. Take self responsibility and to be a power for good in the world.
Health is a dynamic state that fluctuates a person adapts to changes in the internal and external environments to maintain a state of well-being. Illness is a process in which the functioning of a person is diminished or impaired when compared with the person's previous condition. High level wellness and severe illness are at opposite ends of the continuum. There are a variety of risk factors which are important in identifying level of health. Risk factors include genetic, physiological, environmental, age and lifestyle factors.
Illness is any change, temporary or long lasting in a person's physical and emotional health and social well-being. An illness may be acute, chronic and terminal.
Illness shows positive and negative behavior. It can make persons feel helpless and defenseless. Sick people are unable to do anything for themselves even though they want to during illness. We should respond to patient's need for comfort and safety. A back rub or an extra blanket make patient comfortable, be sure side rails are raised for any patient who is weak or unconscious.
The person who is not healthy has expects and deserves competent care may choose to assume the sick role.
Webster defines disease as a condition in which body health is impaired a departure from a state of health and alternation of the human body interrupting the performance of vital function.
The Oxford English Dictionary defines disease as a condition in which the functions are disrupted or dearranged.
From an ecological point of view, disease is defined as maladjustment of the human organism to the environment.
From sociological point of view, disease is consider a social phenomena occurring in all societies and defined and fought in terms of particular cultural forces prevalent in the society.
The simplest definition in disease is opposite to health.
Epidemiological aspects of diseases:
Disease is a dynamic process and it is just the opposite of health. Health denotes perfect harmony and normal 6functioning of all the body systems, i.e. state of complete well-being. Whereas disease denotes the disharmony and deviations from normal functioning of various body systems, i.e. state of illness. Perfect health and severe disease or wellness and illness are the two end points of health and disease continuum. The disharmony and deviations range from biochemical disturbance to severe disability culminating to death. There are various causative factors which cause the occurrence of a disease. These factors are related to humanbeing and their environment.
The concept of disease causation differed from time to time with the progress of civilization. It changed from supernatural causes during primitive period to multifactorial causes during modern time. It is very important to understand the concept of disease causation and disease progress because it can help in identifying public health measures to prevent and control diseases. The aims of epidemiological studies are to acquire knowledge about the nature of disease/health problems, their etiological factors and then utilize that knowledge in planning community health services to prevent and control diseases/health problems.
Before the discovery of microorganisms (bacteria by Louis Pasteur, 1822–1895), the French scientist in 1860, several theories explaining the causes of diseases were put forward from time to time. The earliest attempt to attribute a cause to illness occurred during the religious era (2000 BC to 600 BC). During this period, disease was thought to be caused by divine power as punishment for sins as bad deeds or considered as fate. This theory is referred as supernatural theory. With the discovery of microorganisms by Louis Pasteur and Roberkoch (1843–1910), the bacteriologic era commenced in the late 1870, which was the turning point in disease causation. The germ theory was put forward by these scientists.
The Germ Theory
The germ theory became popular during the 19th and early part of 20th century. This theory attributes microorganisms as the only cause of diseases. According to this theory there is one single specific microorganism (causative agent) to every disease. This refers to one relationship between the causative agent and the disease. This is also called as single cause theory.
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Fig. 1.2: Single cause theory
For example diphtheria due to corynebacterium diphtheria, cholera due to vibrio cholerae, tuberculosis due to tuberculosis bacilli. This theory is limited to infectious disease only. The single cause theory was further supported by the identification of other specific agents as causative agents for certain health problems, i.e. lack of vitamin ‘C’ was found to cause survey.
Theory of Epidemiological Triad
The germ theory or single cause theory has many limitations. It was experienced that everyone exposed to disease agent did not contract the disease. For example—tuberculosis, all those who were exposed to the tuberculosis organism did not suffer from tuberculosis. Only those who were under nourished, lived in dark places and who did not have immunity against tuberculosis got the disease. This means it was not only the causative agent that was responsible for causing disease but there were other factors related to man (host) and environment which contributed to the occurrence of a disease.
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Fig. 1.3: Epidemiological triad
State of Health Equilibrium
This model is also called as ecological model. It is evolved through the study of infectious diseases. According to this model there are three elements or major factors which are responsible for a particular disease causation. These are agent, host and environment. The agent is considered to be the primary factor (e.g. amoeba, bacteria, fungi, virus) without which a particular disease cannot occur. The host refers to human beings who come in contact with the agent. The host related factors which play an important role are genetic make up, age, sex, race, immunity, health behavior, etc. The environment includes all that is external to the host and agent but that may influence interaction between them.
As long as they remain in equilibrium or in balance disease will not occur and is referred as state of health equilibrium.7
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Fig. 1.4: Ecological model of health equilibrium
The disease will occur when equilibrium is disturbed due to change or disruption in any of these factors. For example—poor environmental sanitation, open defecation, contamination of water, foods, etc. all these environmental conditions increase the possibility of getting people infected with disease producing organisms.
Other examples of disruption that could increase the possibility of disease occurrence include:
  • Conditions in the host such a severe malnutrition, disturbed immune system, poor specific resistance, etc. which increases susceptibility to disease.
  • The increased number and mutation of virus which may increase their virulence and ability to infect the human host.
In fact, there has to be optimal interaction of all the three factors to cause a disease in a man. It implies that disease will occur only when the agent is strong and enters the host through the right channel and in sufficient amount, the host is susceptible and when environmental conditions facilitate the interaction of host and agent.
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Fig. 1.5: Epidemiological concept of interaction of host, agent and environment
For example the causation of pulmonary tuberculosis, the live tuberculosis bacilli must enter through respiratory tract and insufficient amount, the host must be susceptible, i.e. has no specific resistance and weak general body resistance and the environment must facilitate interaction of host and organisms, i.e. environment is crowded, dark and dingy.
Elements of epidemiological triad and related risk factors:
Agent factors: A disease agent is the primary link in the development of disease. The disease agent is defined as an element, a substance living or nonliving, or a force tangible or intangible, the presence or absence of which may follow the effective contact with susceptible human host under proper environmental conditions serve as a stimulus to initiate or perpetuate a disease process. The disease agents are usually classified as under:
  • Biological agents: Biological agents are living agents and include arthropods and helminths, protozoa, fungi, bacteria, rickettsial and viruses.
  • Physical agents: Physical agents include abnormalities in atmospheric pressures temperature and humidity, unusual intensity of sound, abnormalities of radiation and electricity. These agents are usually associated with certain occupational exposure.
  • Chemical agents: Chemical agents may include useful substances like iodide and fluoride and harmful substances like noxious gases, volatile drugs and fumes, airborne solid particles. Some chemicals may also be produced in the body as a result of malfunctioning of body systems for example urea, bilirubin, ketones, calcium carbonate, uric acid, etc.
  • Mechanical agents: It include chronic friction and mechanical forces that result in crushing, tearing or penetrating wounds, sprains, dislocation and other accidental injuries and even death.
  • Nutrient agents: It include fats, carbohydrates, proteins, vitamins, minerals and water. Intake of these elements either in excess or in deficiency results in nutritional disorders for example anemia, night blindness, PEM, goiter. Though there are a variety types of agents are responsible for diseases still in epidemiological triad, agent means microbial agent which is responsible for communicable diseases. Epidemiological tread is applicable to communicable diseases.
Host Factors
Host is one of the epidemiological determinants of disease. The host related attributes predispose the interaction of host and agent to cause a disease are:
  • Demographic characteristics, i.e. age, sex, race, marital status, etc.
  • Biological factors include genetic factors, blood chemistry, blood groups, immune system.
  • Psychosocial and economic characteristics: These include personality traits, education, occupation, 8social class and status, mental status, emotional make up health knowledge and attitude, etc.
  • Lifestyle: These include daily living and cultural practices including customs and traditions, health habits and health seeking behaviors such as physical exercise, nutrition practices, sexual practices, use of alcohol, drugs and smoking, etc.
  • Past history of exposure: Exposure can range from infectious diseases to smoke in the environment, exposure to various occupational hazards.
Environmental risk factors: It is third important epidemiological determinant of disease. The various environmental factors influence the life and development of agents and host and their interaction to cause various diseases. The environment has three component. These are:
  1. Biological environment: It includes all the living beings like Animal kingdom, Plants and microorganisms. Among of them some are infectious agents, reservoir of infection, intermediate host and vectors that transmit diseases.
  2. Physical environment: It includes the nonliving chemical agents and physical factors. These are air, water, soil, environmental sanitation, housing radiation, gravity, atmospheric pressure, noise, electricity, television, radar, etc.
  3. Psychosocial environment: It include over all socioeconomic and political organization that affects health care and its delivery system, health legislation, sociocultural customs, traditions, belief and attitude, lifestyle, family and community life.
Multifactorial Causation
According to this theory disease is due to multiple factors. As a result of advances in public health chemotherapy and vector control, communicable disease began to decline and replaced by new type of disease called modern disease of civilization, e.g. lung cancer, coronary heart disease, chronic bronchitis, mental illness, etc. These disease could not explained by germ theory and they will neither be prevented by the traditional methods of isolation, immunization or improvement sanitation. The realization began to dawn that the single cause idea was an over simplification and that there are other factors in etiology of disease—social, economic, cultural, genetic and psychological which are equally important for coronary heart disease and cancer due to multiple factors. For example excess cigaret smoking, obesity, lack of physical exercises all are involved in disease condition. Therefore new model of disease causation have been developed which de-emphasize the concept of disease agent and stress multiplicity of interaction between host and environment. This theory of multifactorial causation was put forth by Pettenkofer of Munich (1819–1901). It is now known that most of these factors are much linked to lifestyle and human behaviour that they are considered as ‘Risk Factors’, in the web causation of disease.
Web of Causation: This epidemiological concept of disease aetiology is given by Mac Mohan and Pugh. According to this concept, disease (effect) never depends upon single isolated cause. Rather it develops as a result of chains of causation in which each link itself is the result of complex interaction of preceding events. These chains which may be fraction of the whole complex known as Web of causation. The web of causation considers all the predisposing factor of any type and their complex inter-relationship with each other. The web of causation does not imply that the disease cannot be controlled unless all multiple factors should changed. It may causes by changes of causation at least a number of them approximately controlled or removed. This model is particularly applicable to chronic diseases where the causative agent is unknown and which are due to interaction of multiple factors, e.g. cardiovascular diseases, cancer.
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Fig. 1.6: Web of causation of disease
Dever's Epidemiologic Model
This model is composed of four major categories of factors responsible for diseases such as human biology, lifestyle, environment and health care system. This four factors include all factors in its sub categories for ex- human biological factors are all host related factors of epidemiological triad and include genetic inheritance, complex physiologic systems, factors related to maturation and ageing. Similarly lifestyle factors include daily living activities, customs, traditions, health habits and behaviour etc which influence the quality of life. Environmental factors include physical, biological, Psychosocial components of environment. Health care system factors include availability, accessibility, adequacy and use of health care services at all levels. All these factors influence health status either positively or negatively.
The high level wellness model developed by Halber Dunn in 1997 focuses on maximizing the health potential of an individual, family or community. It requires the individual to maintain a continuum of balance and purposeful direction within the environment.
Halbert Dunn defined high level wellness as an integrated method of functioning which is oriented towards maximizing the potential of which an individual is capable within the environment where he is functioning. Dunn stressed that wellness is an ongoing process directed towards higher potential, not a static goal and that high level wellness is a feeling of being alive to the tips of the fingers with energy to burn tingling with vitality.
The model represented on the left side of the figure bring the client back from illness or disease to a neutral point. The right side represents the potential for high level health and wellness. The objective of this model is to demonstrate how people can move from the point of illness or neutralize into the realm of high level wellness and to reduce the occurrence or recurrence of illness and disease.
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Fig. 1.7: Health illness spectrum
Health always involves a continuum, a range of degrees from optimal health at one end to death or total disability at the other. The health of an individual moves back and forth along this continuum throughout life, according to health illness continuum model health is a dynamic state that fluctuates as a person adapts to changes in the internal and external environment to maintain a state of total well-being. Internal environment refers to physiological system, body temperature, blood pressure, humidity, dust, etc.
High level wellness and severe illness at opposite ends of continuum. According to Newman (1990), health on a continuum is the degree of client's wellness that exists at any point in time, ranging from an optimal wellness condition, with available energy at its maximum to death, which represents total energy depletion. A nurse can determine a client level of health at any point on the health illness continuum.
Health and disease lie along a continuum and there is no single cut off point. The lowest point on the health disease spectrum is death and highest point corresponds to the WHO definition of positive health (Fig. 1.7).
Health care directed a helping a client achieve high level wellness emphasizes health promotion and illness prevention rather than treatment. High level wellness is a dynamic process not a passive static state. No one ever reaches the point of perfect health, but there is constant attempt to achieve at optimal level of health a possible. Health is a dynamic process that varies as interaction between the individuals and their environment changes.
The natural history of diseases denotes the evolution of a disease process in an individual, from its early stage to final stage of recovery or death, in the absence of any intervention such as prevention or treatment. The natural history of an infectious disease occurs in 2 phases
  1. Prepathogenesis Phase
  2. Pathogenesis Phase
Prepathogenesis Phase
This phase refers to the period before the onset of disease. During this phase, interaction is taking place among the three components of epidemiological triad namely agent, host and environment, each representing the angle of a triangle respectively. As long as there equilibrium among these three interacting factors, so long the person will be healthy. Once the equilibrium is disturbed, disease process starts. Here the disease agent 10has not yet entered man, but the factors which favour its interaction with the human host are already existing in the environment.
Pathogenesis Phase
This phase begins with the entry of the disease ‘Agent’ in the susceptible human host and multiplies and induces tissue causing physiological changes, the disease progresses through a period of incubation and later through early and late pathogenesis The final outcome of the disease may be recovery, disability or death.
The pathogenesis phase is divided into
  • Stage of subclinical disease
  • Stage of clinical disease
  • Stage of disability
Stage of Subclinical Disease
Stage of subclinical disease denoted by presymptomatic stage. A period of subclinical or in apparent pathologic changes follows exposure, ending with the onset of symptoms. The characteristic incubation period has a range for every disease. For example, for Hepatitis A: 2 to 6 weeks and for HIV/AIDS it become 6 months to 8 years.
Stage of Clinical Disease
This phase starts with onset of sign and symptoms which may be mild to severe or fatal. The onset of symptoms marks the transition from subclinical to clinical disease. The clinical spectrum also depends on infectivity which refers to the proportion of exposed persons who become infected and pathogenicity which refers to the proportion of infected persons who develop clinical disease and virulence which refers to the proportion of persons with clinical disease who become severely ill or die.
Stage of Disability
Some diseases resolve completely but some may leave residual effect of short term or long term duration, leaving a person disabled to lesser or greater extent. Here tertiary level of prevention can be applicable.
According to this concept, the disease in the community is compared to an Iceberg. When a piece of ice is allowed to float on water, a small portion is visible and a major portion is submerged in the water. The visible tip of ice is compared to clinical cases, which the physician sees in the community. The major submerged portion of ice corresponds to hidden mass of unrecognised diseases such as latent cases, in apparent, carriers, asymptomatic and undiagnosed cases in the community, which are responsible for the constant prevalence of the disease in the community. In some diseases like HTN, diabetes, anaemia, malnutrition, mental illness etc. the unknown morbidity is more than the known morbidity in the community and constitutes an important, undiagnosed reservoirs of disease in the community
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Fig. 1.8: Iceberg phenomenon of disease
This model is trying to explain why people were not participating in disease detection programs. The HBM is based on the understanding that a person will take a health-related action if that person feels that a negative health condition can be avoided and has a positive expectation that by taking a recommended action. Than he/she will avoid a negative health condition, i.e. using condoms will be effective at preventing HIV, and believes that he/she can successfully take a recommended health action (i.e. he/she can use condoms comfortably and with confidence). People can vary greatly in regards to their perception of susceptibility. On one extreme are individuals who completely deny any possibility of acquiring the disease. In the middle are people who admit to the possibility of acquiring disease, but believe it will not likely happen to them. At the other end, people who are so fearful of acquiring the disease that they believe that they will in all probability acquire it. The more susceptible a person feels, the greater the likelihood they will take preventive measures. For example: In cancer control programme for promotion of breast self-examination, the individual has to perceive herself for suspectable to breast cancer and the consequence/seriousness of it, then only she can practice it. In this programme the Nurse has to teach them regarding breast self-examination, it's exact 11technique and benefits, ability to detect cancer an other diseases early. The health educator also can teach them on feeling good about oneself, feeling in control of one's health, and feeling more responsible toward oneself and one's family. In using this construct, health educators need to specify the exact action to be taken and specify the advantages or benefits that would result from that course of action. The health belief model is concerned with what people perceive, or believe, to be true about themselves in relation to their health.
This model is based on three components of individual perceptions of threat of a disease:
Perceived Susceptibility to a Disease
It is the subjective belief that a person may acquire a disease or enter a harmful state as a result of a particular disease. It is the belief that one either may or may not contract a disease. The belief ranges from being afraid of contracting a disease to completely denying that certain behaviors will result in illness. For example, one person who smokes cigarets may believe he or she is at danger for lung cancer and may stop smoking, while another person may believe smoking poses no serious threat and continues to smoke.
Perceived Seriousness of a Disease
This belief is the extent of harm that can result from the acquired disease or harmful state of a particular behavior. This component is related to how much the person knows about the disease and can result in a change in health behavior. If a person who smokes believes that lung cancer can lead to physical disability or death and would, therefore, affect his or her ability to work and care for the family, the person is more likely to stop smoking.
Perceived Seriousness of a Disease
Belief in the extent of harm that can result from the acquired disease or harmful state of a particular behavior. This component is related to how much the person knows about the disease and can result in a change in health behavior.
If a person who smokes believes that lung cancer can lead to physical disability or death and would, therefore, affect his or her ability to work and care for the family, the person is more likely to stop smoking.
Perceived Benefits
Perceived benefits is the belief in the advantages of the methods suggested for reducing the risk or seriousness of the disease of harmful state from a particular behavior is concerned with how effective the individual believes measures will be in preventing illness. This factor is influenced by:
  • The person's conviction that carrying out a recommended action will prevent or modify the disease.
  • The person's perception of the cost and unpleasant effects of performing the health behavior. For example, the person may believe that stopping smoking will prevent future breathing problems and that the initial withdrawal symptoms can be overcome; therefore, the person may stop smoking.
Perceived Barriers
Perceived barriers means the perceived impediments to taking action to improve a health condition. Barriers are mainly resources, previous believes and other resistances. Sometimes the new behavior will take too much time. The health educator should encourage the peopleand motivating them to overcome these barriers.
Cues to Action
Cues to Action are the causes or forces that would make a person feel the need to take action. Demographic variables (such as age and gender):
  • Sociopsychological variables (such as personality and peer group pressure)
  • Structural variables (such as knowledge and prior contact with the disease).
These factors interact to influence the perceived benefits of preventive action minus the perceived barriers to preventive action.
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Fig. 1.9: Health illness continuum
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Fig. 1.10: Health belief model
Indicator also termed as Index or Variable is only an indication of a given situation or a reflection of that situation Health Indicator is a variable, susceptible to direct measurement, that reflects the state of health of persons in a community. Health Indicator means health measurement. Health cannot be measured in exact measurable forms. Measurement have been framed in terms of illness (or lack of health), consequences or condition of ill-health (morbidity, mortality) and economic, occupation and domestic factors that promote ill health. WHO defines Indicators as ‘variables which measure change’ Health Indicators help to measure the extent to which the objectives and targets of a program are being attained. Health Index is a numerical indication of the health of a given population derived from a specified composite formula.
Characteristics of Health Indicators
  1. Valid: They should actually measure that they are supposed to measure
  2. Reliable: The results should be the same when measured by different people in similar circumstances
  3. Sensitive: They should be sensitive to changes in the situation concerned
  4. Specific: They should reflect changes only in the situation concerned
  5. Feasible: They should have the ability to obtain data when needed
  6. Relevant: They should contribute to the understanding of the phenomenon of interest.
Uses of Indicators of Health
  • Measurement of the health of the community.
  • Description of the health of the community.
  • Comparison of the health of different communities.
  • Identification of health needs and prioritizing them.
  • communicating critical information about population health.
  • support planning (identify priorities, develop and target resources, identify benchmarks) and track progress toward broad community objectives and allocation of health resources.
  • Concurrent evaluation and terminal evaluation of health services.
  • Inform policy and policy makers, and can be used to promote accountability among governmental and non-governmental agencies.
Indicators are powerful tools for monitoring and Indicators are used to Engagement of partners into civic and collaborative action by build awareness of problems and trends, generate interventions.
Mortality Indicators
Crude Death Rate
Crude Death Rate is considered a fair indicator for the comparison of the health status of the people. It is defined as the number of deaths per 1000 population per year in a given community, usually the midyear population. The usefulness is restricted because it is influenced by the age-sex composition of the population, socioeconomic and sociocultural environment of the communities. Current CDR is 7.48 deaths/1,000 population.
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Expectation of Life
Expectation of life is the average number of years that will be lived by those born alive into a population if the current age specific mortality rates persist. It is a statistical abstraction based on existing age-specific death rates which is estimated for both sexes separately. Longer life expectancy is the indicator of good health. It is a good indicator to measure the socioeconomic development. Now current Life expectancy at birth for general population is 65.2 years, for male it is 64.3 years, for female it is 66.1 years.
Infant Mortality Rate
This indicator provides a complete picture of the health status of not only infants but also whole population, 13socioeconomic conditions, availability of health services utilization and effectiveness of health care, particularly perinatal care, etc. The formula for IMR is the ratio of deaths under 1 year of age in a given year to the total number of live births in the same year, usually expressed as a rate per 1000 live births. The Current IMR – 67/1000 live birth.
Child Mortality Rate
The Child Mortality Rate is the number of deaths at ages 1–4 years in a given year, per 1000 children in that age group at the mid-point of the year which is correlates with inadequate MCH services, malnutrition, low immunization coverage and environmental factors (current rate – 18/1000). Other indicators are Perinatal mortality rate, Neonatal mortality rate, Stillbirth rate, etc. are also correlates with inadequate antenatal care and perinatal care.
Maternal Mortality Rate
Ratio of number of deaths arising during pregnancy or puerperal period per 100000 live births. It is also term as Maternal Mortality ratio which accounts for the greatest number of deaths among women of reproductive age in developing countries. Current MMR in India is 212/100000 live.
Disease Specific Death Rate
Disease Specific Death Rate is mortality rate which is computed for specific diseases, e.g. TB mortality is 23 per 100000 population per year (Source: TB INDIA 2011, RNTCP Annual Report 2011). Proportional Mortality Rate is the proportion of all deaths attributed to the specific disease, e.g. Coronary heart disease causes 25 to 30% of all deaths in developed world.
Morbidity Indicators
Morbidity Indicators reveal the burden of ill health in a community, but do not measure the subclinical or inapparent disease states.
The number of new events or new cases of a disease in a defined population, within a specified period of time. For example, Incidence of TB is 168 per 100000 population per year. From this definition it is clear that incidence rate refers:
  • Only to new cases
  • During a given period
  • In a specified population or population at risk.
Prevalence rate is defined as the total number of all individuals who have disease at a particular time divided by population at risk of having disease at this point of time. It reflects the chronicity of the disease, e.g. Prevalence of TB (sputum positive in population). It is 249 per 100000 population. It is the cross sectional measurement of any disease or condition.
Notification Rates
Notification rate, is calculated from the reporting to public authorities of certain disease, yellow fever, poliomyelitis, cholera, plague. They provide information regarding geographic clustering of infections, quality of reporting system.
Some other ways also we can measure morbidity status like
  • Attendance rates at OPDs and at health centers.
  • Admission, Readmission and discharge rates.
  • Duration of stay in hospital – reflects the virulence and resistance developed by the etiological factor.
  • Spells of sickness or absence from work or school.
    • Reflects economical loss to the community.
  • Hospital data constitute a basic and primary source of information about diseases prevalent in the community.
Disability Rates
Disability Rates are of two categories they are event type Indicators which is measured by number of days of restricted activity (bed disability days, work-loss days within a specified period) and Person type Indicators measure by limitation of mobility, e.g. confined to bed, confined to house, special aid in getting around and limitation of activity, e.g. limitation to perform the basic activities of daily living (ADL), e.g. eating, washing, dressing, etc.
Disability Rates Sullivan's Index refers to ‘expectation of life free of disability’. Sullivan's Index = life expectancy of the country—probable duration of bed disability and inability to perform major activities from. It is considered as one of the most advanced indicators currently available.
HALE is Health Adjusted Life Expectancy. It is based on the framework of WHO's ICIDH. It is based on life expectancy at birth but includes an adjustment for time spent in poor health. It is the equivalent number of years in full health that a newborn can expect to live based on current rates of ill-health and mortality.
Disability Rates DALYs: Disability Adjusted Life Years. It is defined as the number of years of healthy life lost due to all causes whether from premature mortality 14or disability. It is the simplest and the most commonly used measure to find the burden of illness in a defined population and the effectiveness of the interventions. Two things needed to measure DALYs are—Life table of that country, to measure the losses from premature deaths—Loss of healthy life years resulting from disability; the disability may be permanent (polio) or temporary (TB, leprosy), physical or mental. Disability Rates, uses of DALYs to assist in selecting health service priorities to identify the disadvantaged groups targeting health interventions measuring the results of health interventions providing comparable measures for planning and evaluating programmes to compare the health status of different countries. DALY express years of life lost to premature death and years lived with disability for the severity of the disability. One DALY is one lost year of healthy life.
Disability Rates Premature death: Defined as one that occurs before the age to which a dying person could have expected to survive if he or she was a member of a standardized mode population with a life expectancy at birth equal to that of world longest surviving population, e.g. Japan.
QALY is Quality Adjusted Life Year. It is the most commonly used to measure the cost effectiveness of health interventions. It estimates the number of years of life added by a successful treatment or adjustment for quality of life.
Nutritional Status Indicators
Nutritional Status is a positive health indicator. Newborns are measured for their: i. Birth–weight, ii. Length, iii. Head circumference. They reflect the maternal nutrition status Anthropometric measurements of pre-school children Weight—measures acute malnutrition Heigh—measures chronic malnutrition Mid-arm circumference - measures chronic malnutrition Growth Monitoring of children is done by measuring weight-for-age, height-for-age, weight-for- height, head and chest circumference and mid-arm circumference. In adults Underweight, Obesity and Anemia are generally considered reliable nutritional indicators.
Health Care Delivery Indicators
These indicators reflect the equity of distribution of health resources in different parts of the country and of the provision of health care Doctor-population Ratio—1/1700 (sug. norm 1/3500) Nurse-population ratio—0.8/1000 (sug. norm 1/500) Population-bed Ratio—8.9/10000 Population per PHC/sub center is 20000-30000 in Karnataka while in some states, it is more than 50000. Population per traditional birth attendant—0.47/1000.
Utilization Rates
Utilization Rates or actual rates is expressed as the proportion of people in need of a service who actually receive it in a given period, usually a year. It depends on availability and accessibility of health services and the attitude of an individual towards health care system. They direct attention towards discharge of social responsibility for the organization in delivery of services, e.g. Proportion of infants who are fully immunized—43% Proportion of pregnant women who receive ANC care or have institutional deliveries Percentage of population who adopt family planning Bed occupancy ratio, bed-turn over ratio, etc.
Indicators of Social and Mental Health
The Indicators of social and mental health include rates of suicide, homicide, other crime, road traffic accident, juvenile delinquency, alcohol and substance abuse, domestic violence, battered-baby syndrome, etc. These indicators provide a guide to social action for improving the health of people. Social and mental health of the children depend on their parents, e.g. Substance abuse in orphan children.
Environmental Indicators
The Environmental indicators reflect the quality of physical and biological environment in which diseases occur and people live. The most important are those measuring the proportion of population having access to safe drinking water and sanitation facilities. These indicators explains the prevalence of communicable diseases in a community. The other indicators are those measuring the pollution of air and water, radiation, noise pollution, exposure to toxic substances in food and water.
Socioeconomic Indicators
Socioeconomic indicators do not directly measure health but are important in interpreting health indicators. These are per capita income, level of unemployment, literacy rate, per capita caloric availability, total fertility rate, family size contraceptive use.
Health Policy Indicators
The single most important indicator of political commitment is allocation of adequate resources. The 15relevant indicators are Proportion of GNP spent on health services, Proportion of GNP spent on health related activities like water supply and sanitation and housing and nutrition proportion of total health resources devoted primary health care.
Indicators of Quality of Life
Indicators of Quality of Life expectancy is no longer important. The Quality of Life has gained its importance Physical Quality of Life Index. It consolidates infant mortality, life expectancy at age of 1 year and literacy. For each component the performance of individual country is placed on a scale of 1 to 100. The composite index is calculated by averaging the three indicators giving equal weight to each of them. The resulting is placed on the 0 to 100 scale. The PQLI does not consider the GNP.
It is defined as a composite index combining indicators representing 3 dimensions – longevity (life expectancy at birth), knowledge (2/3 adult literacy rate and 1/3 mean years of schooling), income (real GDP per capita in purchasing power parity in US dollars).
Other Indicators Series
Social Indicators as defined by the UN Statistical Office has been divided into 12 categories: Thats are population, family formation, families and households, learning and educational services, earning activities, distribution of income, consumption and accumulation, social security and welfare services, health services and nutrition, housing and its environment, public order and safety, time use, leisure and culture, social stratification and mobility. Basic Needs Indicators are used by ILO and include calorie consumption, access to water, life expectancy, deaths due to disease, illiteracy, doctors and nurses per population, rooms per person, GNP per capita.
Other indicators series health for all indicators for monitoring the progress towards the goal of health for all by 2000, the WHO has listed the following four categories of indicators. Health policy indicators political commitment to HFA resource allocation degree of equity of distribution of health services community involvement organizational framework and managerial process.
It also include 40 Social and indicators related to health Rate of population growth GNP or GDP Income distribution, Work conditions, Adult literacy rate, Housing Food availability, Indicators for the provision of health care, Availability, Accessibility, Utilisation, Quality of care.
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Fig. 1.11: Determinants of health
Biological Determinants Otherwise Known as Human Biology
It encompasses those aspects of health (both mental and physical) which are determined by the organic structure and physiological functioning of the human body. The genetic makeup of the individual determines the likelihood of inherited disorders and the predisposition to later acquired diseases. The transmission of genetic characters from parents to offspring is dependent upon the segregation and recombination of genes, chromosomal anomalies, errors of Metabolism, and mental retardation are the examples of genetic disorders. The individual's constitution is also a determinant of susceptibility to risk factors arising from certain lifestyles and environments. Changes in the human body due to maturation and aging are also important factors that can interact with the other three Health Field elements in determining the individual's state of health. The human biology elements has many facets, only a few of which are adequately understood. The medical and allied sciences have made great progress in understanding the complex process of the human body and mind, but much remains to be elucidated.
Environmental factor is classified into two types: Internal environment and External environment.16
Internal environment (cells, tissues, organs): The environment inside an organism is called Internal environment in animal Internal Environment In order for cells of the body to function optimally, the physical factors and the chemical factors within the internal environment must be maintained at a relatively constant level. Example: Temperature For human, the internal environment need to be maintain around 37 °C. At this temperature, the enzymes give the optimal enzyme activity. If the temperature too high, enzymes denatured—so lose ability to function. If the temperature too low, enzymes become inactive. The Harmonious functioning should be maintained.
External environment: External environment has mainly three components:
  1. Physical component
  2. Biological component
  3. Psychosocial component.
Physical Environment: The Physical Environment include all nonliving things surrounds us that are air, water and soil. Safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. The quality of air, water and soil, the safety of food, drugs, and other products which human consume or exposed to, the physical handling and disposal of waste and excessive noise all are determinants to health. They are Directly affects by exposure to potentially hazardous agents (chemicals or radiation) and etc. and Indirectly affects by global warming, redundant hunt of animals, etc.
Biological Environment
Biological environment include all animals, plants including microorganism, so many animals can directly create zoonotic disease and, spread different vector borne diseases also. Some of the disease can spread by eating the meat and drinking the milk of infected animals. Similarly different plants can spread different diseases. Microorganism are the agents and that are directly responsible for diseases.
The Social Environment
The social environment also act as determinants of health. In a community social environment include Custom, culture and tradition of society, social organization and stress. The WHO‘s world health report 2002 identified five important risk factors for non-communicable disease in the top ten leading risks to health. These are raised blood pressure, raised cholesterol, tobacco use, alcohol consumption, and overweight. Other factors associated with higher risk of NCDs include a person‘s economic and social conditions, also known as the advance life, the social gradient, social determinants and due to imbalance social environment. It also include labor market, unemployment, non-employment, job insecurity, psychosocial environment at work, transportation, social support and social cohesion, Poverty, social exclusion, and minorities, social patterning of individual health behaviors, the social determination of ethnic/racial inequalities in health, the social determinants of health in older age, neighborhoods, housing, sexual behavior, and sexual health social vulnerability and inequality.
Behavioral and Sociocultural
Behavioral and Sociocultural Lifestyle (the way people live) Culture, Behavior, Personal habits, Parents, peer groups, friends, siblings, schools, mass media greater support from families, friends and communities are linked to better health. Culture—customs and traditions, and the beliefs of the family and community all affect health. Adequate nutrition, enough sleep, sufficient physical activity are consider as Healthy LifeStyles. Lack of sanitation, poor nutrition, poor personal hygeine elementary human habits, harmful customs and cultural patterns are harmful lifestyles. Some of the disease are linked with Lifestyles are Coronary heart diseases, obesity lung cancer, drug addiction.
Socioeconomic Conditions
Poor socioeconomic conditions leads to inadequate education or illiteracy poor nutrition. Illiteracy also leads to poor health. Employment, housing, Political system, higher income and social status are linked to better health. The greater the gap between the richest and poorest people leads to the greater differences in health.
Health Services
Though Government of India made differ health schemes, still health services are not accessible to all population and also not acceptable due to lack of motivation. Immunization of children still also incomplete in urban slums, some rural area and also tribal area. Doctor population and Nurse population ratio is inadequate to provide health services properly. Provision of safe drinking water for all and proper care of pregnant and children till now in half way.
Aging of the Population
Aging of the population by 2020—1 Billion are aged > 60, 2/3 are living in developing countries. The reasons for increase in the size of elderly people are decrease of mortality from infection and chronic disease 17during this century and improvement in sanitation, housing, nutrition and medical innovations, including vaccination and the discovery of antibiotics which prevent disease and increases longevity of life. Aging process leads to a number of changes in human being. It acts as a determinants of health as it acts on the health of individual.
Men and women suffer from different types of diseases at different ages. Women are more vulnerable than men and more prone to different diseases like malnutrition and anemia, etc. Some of the aspects we should more careful for women like reproductive health, violence, nutrition and occupational health but women health is specially neglected in developing country like India. Women's health is closely related to the economic and political position of women in society, the division between productive and reproductive labor, and cultural values in relation to motherhood, sexuality and decent.
Health economics has developed into discipline itself due to size and differentia characteristic of health sector in economy. Health Economics is a branch of economics concerned with issues related to scarcity in the allocation of health and health care. In developing countries like India where less than two percentage of GDP is invested for delivering health care services, health economics is very much essential. The main focus of health economics is to provide the maximum benefits for the money invested in health care. Benefits refers to the reduction in the disease burden of community and improvement in people's health and welfare. Health economics is the application of the principle and tools of economics to health services. The goods and services with which health economics is concerned include medical, surgical, cold chain equipment, drugs, vaccines, diagnostic and therapeutic services, environmental sanitation, family planning, school health and reproductive and child health.
Definitions: Health economics is the study of distribution of health care. It is a branch of economics concerned with issue related to efficiency, effectiveness, value and behavior in the production and consumption of health and health care.
Concepts in Health Economics
Resources: Resources are the inputs, factors of production, i.e. land, labor, capital. It covers all the inputs used to produce goods and services, have health stock in order to improve the health status of individuals in terms of healthy days or quality of life.
Scarce Resources: Resources are considered scarce when society demands more resources and good services than are available.
Scarcity: It has two sides, the infinite nature of human wants and the finite or limited nature of resources available to produce goods and services as depicted by
Scarcity = Infinite wants vs. Limited resources available to produce services
Opportunity: It means the value of forgone benefit which could be obtained from a resource in its next-best alternative use.
Need for Health Economics
There is a need to study health economics due to increasing demand and rising cost of health care services. The reason are:
  • Medical advances, such as organ transplants and gene therapy, have provided new treatments and therefore greater hopes and new needs arise among public.
  • Due to increase in life expectancy, more resources are required for medical treatment and continuing care for the elderly.
  • Changes in the family structure and norms, i.e. more likely the elderly may not be cared for by their families.
  • Higher expectation among general people about their levels of the health and demanding more and better health care.
  • Public awareness about their rights for their health and its facilities.
  • Advance in health research and concern for cost effectiveness programs in the health market.
Hence the health economics need to understand the relationship between resources used and health outcomes achieved by alternative options and compare them in order to balance between demand and cost of health services.
Importance of Health Economics
  • To formulate heath services policy, might be in the form of demand studies, or by trying to discover what policy makers preferences are
  • To established the true cost of delivering health care or to estimate all real costs like the use of patients’ time, loss of output elsewhere in the system, etc.
  • To evaluate the relative costs and benefits of particular policy options18
  • To estimate the effects of certain economic variables like user charges, time and distance costs of accessibility, etc. on the utilization of health services
  • To evaluate planning and budgeting systems and make possible changes therein in health care delivery system.
Major Tasks of Economics in Health (care )
  • Descriptive quantification
    • It refers to the identification, definition, and measurement of phenomena. It also concerned with determining the nature of the phenomena as well as obtaining estimates of their magnitude.
  • Explanatory or predictive
    • It means identifying impact of change. It involves explaining and predicting certain phenomena, conducting an analysis in a cause effect format and performed with the aid of models that classify various causal factors in a systematic framework.
  • Evaluative
    • This means relative preference over situations. It involves judging or ranking alternative phenomena according to some standard. An acceptable standard must be obtained. Based on the standard, alternative ways of using scarce resources are then ranked. In choosing the standard, one major criterion is acceptability.
Features of Health Economics
  • Health and medical care is considered as economics goods
  • Health is a private or public good
  • Measurement of health is also considered in economics
  • Stock of health
  • Investment aspects of health
  • loss due to ill health
  • Planning of health and medical care
  • Choice of technology in health care system
  • Provision of equity in health outcomes and health care
  • Resource costs of different diseases, effects of health and medical care provision.
Areas of Health Economics
  • Economic aspects of relationship between health status and productivity
  • Financial aspects of health care services
  • Economic decision making in health and medical care institutions
  • Planning of health development and such other related aspects.
Factors Influencing Health Economics
Extensive Government Intervention
Generally the Government intervention are the Regulatory actions taken by a government in order to affect or interfere with decisions made by individuals, groups or organizations regarding social and economic matters. Extensive government intervention like changing health policies frequently can affect the health economics.
Intractable Uncertainty in Several Dimensions
Intractable means not easily controlled or managed and uncertainty is the situation which involves imperfect and/or unknown information. So Intractable Uncertainty is some predicted unknown situation which is difficult to manage. For example lack of IPR skill among health personnel can reduce the output which cannot predicted before.
Information Asymmetric
Asymmetric information is a situation in which one party in a transaction has more or superior information compared to another. This often happens in transactions where the seller knows more than the buyer, although the reverse can happen as well. Potentially, this could be a harmful situation because one party can take advantage of the other party's lack of knowledge. Some time market failure may results.
Barriers to Entry
Barriers to entry are the existence of high start-up costs or other obstacles that prevent new competitors from easily entering an industry or area of business. Because barriers to entry protect incumbent firms and restrict competition in a market, they can contribute to distortionary prices and are therefore are most important when discussing antitrust policy.
Externalities and the Presence of a Third Party Agent
An externalities is a consequence of an economic activity experienced by unrelated third parties; it can be either positive or negative. Pollution emitted by a factory that spoils the surrounding environment and affects the health of nearby residents is an example of a negative externalities. The effect of a well-educated labor force on the productivity of a company is an example of a positive externalities.19
The presence of third party agent may also influence the business without direct involvement in costs for example: in health care, the third party agent is the physician, who makes purchasing decisions (lab test, treatment prescription, etc.) while being insulated from the price of the product or services.
Although there are many possible causes of human disease, family history is often one of the strongest risk factors for common disease complexes such as cancer, cardiovascular disease (CVD), diabetes, autoimmune disorders, and psychiatric illnesses. A person inherits a complete set of genes from each parent, as well as a vast array of cultural and socioeconomic experiences from his/her family. Family history is thought to be a good predictor of an individual's disease risk because family members most closely represent the unique genomic and environmental interactions that an individual experiences. Inherited genetic variation within families clearly contributes both directly and indirectly to the pathogenesis of disease. A Community health Nurse must have to know the genetic factors affecting health condition and eugenics.
The word eugenics was coined by Francis Gatton in 1883. This word has been derived from two Greek word; Eu–good or well and genes means born. It is considered as the study of improving the genetic qualities.
  • Eugenic is mainly concerned with the decrease of hereditary diseases and improvement of the overall health status of the people or community. Eugenics results in reducing genetic morbidity.
  • Eugenics is the science which deals with all influences that improve inborn qualities of a race also with that develop them to utmost advantage. (F. Gaton, 1940)
  • Eugenics is the way by which a healthy society, community can be created. Nurse can reduce the human suffering through education among the community.
  • To improve the genetic composition of population
  • To save the resources
  • To create healthy community
  • To have intelligent people or to have the community to free from mentally retarded people.
  • To decrease the human suffering
  • To reduce economic burden on nation due to disease.
How Eugenic Measures Reducing Health Problem
Eugenics is helpful in reducing morbidity due to hereditary diseases among the community by:
  • Positive eugenics: Positive eugenics encourages reproduction among genetically advantages population. Various ways of positive eugenics are in vitro fertilization, cloning. Positive eugenics is difficult to achieve due to complexity of the trait, multifactorial causes and unawareness regarding which gene to be transmitted or which not to be transmitted.
  • Negative eugenics: It is mainly concerned with decreasing or lowering the fertility among genetic disadvantages. The various ways of negative eugenics are abortion, sterilization, adoption of family planning methods. It is considered as immoral because it:
    • Enforces sterilization among genetically defective
    • Allows to kill institutionalized population.
The various ways to achieve healthy community by eugenics are:
  • Euthenics: Euthenics is manipulating the environment in order to improve the genotype. As environmental factors are involved such as smoking, diet, obesity, lack of exercise in reducing diseases such as cancer, hypertension, DM which can cause abnormalities in genetic constitution. So it is required to provide stable environment to achieve normal genetic constitution. Community health nurses can take appropriate steps to provide safe environment to people to achieve euthenics. As man is adopting the environment it leads to increased chances of having healthy Population.
  • Genetic counseling: It includes screening of the cases and informing them the risk of having the affected children. It helps to provide information by nurses regarding the cost of correction of diseases, prognosis and burden of care on the family members will help them to take decision and prevention of further occurrences of genetic diseases.
  • Marriage restriction: Genetically disadvantaged people is considered one of the way to achieve genetic endowment among population. Marriages if restricted among the people who can produce affected children will help in achieving the genetic health among the populations.
In following cases marriages need to be restricted:
  • Marriages among the individuals suffering congenital abnormalities, mental retardation, gout, thalassemia, sickle cell anemia may increase the risk of the defective children.
  • Consanguineous marriages can cause increased risk in the off-spring of the recessive trait, even premature deaths due to consanguineous marriages are also noted.
  • Late marriage increases the risk of genetic disease such as Down syndrome.
As a community health nurse it is necessary to understand the prevailing marriage system in the community.
  • Birth control: The aim of birth control measures as eugenics is to reduce the frequency of hereditary disease and disabilities in the community to the low level due to adoption of birth control measures. So as no child born with defective genotype.
    • Community health nurse teaches the community for adoption of birth control measures (temporary/ permanent) to limit size of family.
  • Early diagnosis and treatment: Some of the genetic diseases which has diagnosed earlier can be corrected such as congenital hip dysplasia.
    • Early diagnosis can be made by identifying the carriers of genetic disorders by investigations, such as serum creatinine kinase level to identify the carriers of muscular dystrophy.
    • It assists the community health nurse for teaching the appropriate measures for correction of some of hereditary diseases among community.
  • Segregation of mentally ill from normal: There is need to segregate mentally ill from normal so as to prevent birth of mentally ill child in community. For example, a mentally ill person who is living in community gets married to either a mentally ill or a normal genetically healthy person. In such case the offspring will have abnormal genes and if this continued it will lead to more of hereditary diseases in the community.
Methods of Application of Eugenics
  • At government level: Government should make policies and legislation to achieve healthy community.
  • At population level: Eugenics should be promoted among general population through education using democratic approach
  • At individual level: Eugenics should be practiced by individual on the basis of decision so as to reduce economic burden of disease in the family.
Role of Community Health Nurse
  • Nurse's knowledge on genetic diseases will be helpful in identification of hereditary diseases, need of care to be provided to family and to provide support to the persons affected by or at risk of genetic diseases.
  • She provides education to people about risk factors for hereditary diseases such as DM, HTN which occur due to multifactorial reason. She should provide information about diseases which occur due to chromosomal abnormalities.
  • She must identify the hereditary diseases among the population, refer and motivate them to seek medical treatment.
  • She informs the community about risk and benefits associated with genetic testing.
  • She analyses the data and develops plan to address the genetic concerns
  • Plan to manage the hereditary diseases, to control and reduce the chances of genetic diseases and will prevent further occurrence of abnormality in family.
  • She teaches the people about eugenics methods such as birth control, genetic counseling, etc.
  • She identifies the carriers and diseased person in the community and refers them.
Prevention is always better than cure. As per the natural history of disease, epidemiology has derived four levels of prevention.
Primordial Prevention
Primordial prevention is defined as prevention of risk factors themselves, beginning with change in social and environmental conditions in which these factors are observed to develop, and continuing for high risk children, adolescents and young adults. It is a relatively new concept, is receiving special attention in the prevention of chronic diseases. For example, many adult health problems (e.g. obesity, hypertension) have their early origins in childhood, because this is the time when lifestyles are formed. General access to energy-dense diets coupled with typically sedentary urban lifestyles creates a trend toward obesity and chronic disease. It is important to change the milieu that promotes major risk factor development. Primordial prevention calls for changing the socioeconomic status of society. A better socioeconomic status correlates inversely with lifestyle factors like smoking, abnormal food patterns and exercise.21
Primary Prevention
Primary prevention is true prevention—it precedes disease or dysfunction and its applied to clients considered to be physically and emotionally healthy. It includes all health promotion efforts as well as wellness activities that focus on maintaining and improving the general health of individuals, families and communities. Health promotion includes: Health education programs, Immunization, Physical and Nutritional fitness activities. Primary Prevention means measures designed to promote positive general health: —development of good health habits and hygiene—proper nutrition—proper attitude towards sickness—proper and prompt utilization of available health and medical facilities. Primary Prevention also includes Specific protection which means the use of measures adopted against specific disease agents like protection of the individual by increasing resistance of the individual through specific immunization, the establishment of barriers against agents in the environment, i.e. control of means of spread of vector such as control, sanitation of food, milk, water, and air, proper sewerage disposal, proper disposal and or disinfection of soiled articles or clothing, eradication of animal reservoir, Handwashing technique, etc.
Secondary Prevention
Secondary prevention includes early diagnosis and prompt treatment. Regular health checkup of community, check up of children, pregnant mothers and elder people. Health checkup of high risk groups like smokers, obese, alcoholic, sedentary worker and factory workers. Examples of secondary prevention include Public education to promote breast self examination, use of home kits for detection of occult blood in the stool specimens, Screening programs for hypertension, diabetes, uterine cancer (Pap Smear), breast cancer, glaucoma and sexually transmitted diseases. Focuses on individuals who are experiencing health problems or illness and who are risk for developing complications or worsening condition. Activities are directed at diagnosis and prompt intervention thereby reducing the severity and enabling the client to return to a normal level of health as early as possible. Includes screening techniques and treating early stages of disease to limit disability.
Tertiary Prevention
Tertiary prevention means disability limitation and rehabilitation. Tertiary prevention begins early in the period of recovery from illness. It consists of such activities as consistent and appropriate administration of medications to optimize therapeutic effects moving and positioning the patient to prevent complications of immobility and active and passive exercises to prevent disability, minimizing residual disability and helping the client learn to live productively with limitations through proper exercise, physiotherapy and occupation therapy and corrective, plastic surgery can improve mobility, which is otherwise known as rehabilitation. Rehabilitation may be Physical mental and Occupational which make the individual productive. Occupational therapy depending on the nature and extend of disability can provided. By rehabilitation clients achieve as high a level of functioning as possible, despite the limitations caused by illness or impairment. It involves preventing further disability or reduced functioning.
Community means a group of people living in a certain locality such as a village, who have common interests. They meet and react with one another. A community consists of people living together in some form of social organization and cohesion. Its members in varying degrees share political, economical, social and cultural characteristics as well as interests and aspirations including health.
In biological terms, a community is a group of interacting organisms sharing a populated environment. With regard to humans, a ‘community’ is understood as a group of interacting people, possibly living in close proximity, and often refers to a group that shares some common values, and is attributed with social cohesion within a shared geographical location, generally in social units larger than a household. The word can also refer to the national community or international community.
The origin of ‘community’ is from the Latin word, ‘community’ is derived from the Old French communité which is derived from the Latin communitas (cum, ‘with/together’ + munus, ‘gift’), a broad term for fellowship or organized society.’ (http://en.wikipedia.org/wiki/Community).
‘Community: The origin of the word ‘community’ comes from the Latin munus, which means the gift, and cum, which means together, among each other. So community literally means to give among each other’ (http://www.seek2know.net/word.html).
Communities are the building blocks that allow us to make sense of the world in which we live, participate 22and share experiences. They provide a sense of identity and purpose, a sense of being a part of and belonging.
The WHO expert committee on Community Health Nursing in their report agreed in following definition ‘A community is a social group determined by geographical boundaries and or common values and interest. Its member know and interact with each other. Its function within a particular structure and exhibits and create certain norms, values and social institutions. Many authors have tried to analyze various definitions to identify common aspects and those common factors are highlighted. Those are:
Community as Collection of People
Community is collection of people who are social interact with each other within same type of organized structure for mutual benefit. It is collection of people where the people identify themselves as a separate group and the people included both healthy and sick. The people may be a from a small hamlet to a large metropolitan city implying the variability size of community.
Community as Place
Community as a place refers to specific location, geographical area and boundaries within which group of people with common culture, beliefs values, and customs, etc. are live together, the geographical area comprise the physical and biological; environment, housing and transportation, etc.
Community Social System
Community as a social system organize itself to meet the needs of its members by the joint efforts of the members of specific community. It is the combination of all social units and systems which have been developed to carry out its major functions by interaction. A number of ways to categorize types of community have been proposed; one such breakdown is:
Geographic communities: Range from the local neighborhood, suburb, village, town or city, region, nation or even the planet as a whole. These refer to communities of location.
Rural community is a simple community of primary relation with low population based on primarily on agriculture life. The village socially did not spring all of a sudden, so they developed slowly and adjustment with society. Property is likely to be thought as a family possession. The second control in the rural community is exercised with minimum of formally and maximum command. The groups are more reflecting a commonly share of values, they effective themselves with social pressure by the support of specialized agencies.
Urban community: It is different from village rural community. The social control system is urban or cities life the social behavior complex are informal. The relation are contractual. The mechanism of social control are largely legal and exercised by state and secondary institution.
Communities of culture: Communities of culture range from the local clique, subculture, ethnic group, religious, multicultural or pluralistic civilization, or the global community cultures of today. They may be included as communities of need or identity, such as disabled persons, or frail aged people.
According to the bonding relation with the community people the community is classified as:
  • Gemeinschaft: Characterized by implicit bonds that relate all community members to each others.
  • Gesellschaft: Characterized by bonds that are both formal and specific.
Now a day's different communities are formed to fulfill different needs of the peoples:
  • The spiritual community
  • The family community
  • The living community
  • The recreational community
  • The learning community
  • The employment community
  • The health community
  • The internet community.
Communities have Various Roles/Goals
Each community has a particular role that fulfills a particular need.
The role of the community provides the members with a sense of belonging and purpose. Community roles can be active in providing a service, supportive, where the members support the activities of another community, or a mixture where the members share experiences, resources, skills and knowledge with each other. Communities can be recreational, and provide a social role in enabling its members to participate in various activities, or provide an educational role in providing its 23members with knowledge, skills and resources, or fulfill any other role that is valued in society as well as other communities that it is a part of.
Valued community roles provide a common cause or focus for the community. The members develop a sense of pride and purpose in being a part of the community that bond and strengthen the community. The role is valued in a sense that it brings something to the wider community that it is a part of, as well as the members of the community. Valued roles are also about community leadership that is in touch with the community and can create a feeling of importance within the members.
Community is an Institution
Community is compared with an institution as it is having all characteristics of an institution. Institution define the way we interact with each other within the community. They are determined by the formal and informal cultures and values of the society in which the community participates, and provide order and stability within the community. Social role valorization provides valued roles for ALL members of the community. In doing this, a positive environment is created where all members have valued roles in supporting each other as a group. The characteristics of an institution are Culture, Values, Hierarchy, Roles, Expectations and Behaviors.
‘The set of shared attitudes, values, goals, and practices that characterizes an institution, organization or group’ is termed as culture.
The culture of the institution is the way the institution is organized. This is generally determined by its role in society. For example, while the institutions of a hospital, nursing home or prison are simular, the culture of each is quite different.
Institutional values (or social values) are different to our personal values in that they allow the members to function within the institution.
Institutions are all about a means of coordination and cooperation. The hierarchy defines the agenda and purpose, and the way things get done.
Leadership is probably the most important role, and provides the identity and purpose within the institution. Other roles are determined by the hierarchy and the members in fulfilling the agenda and purpose of the institution.
The members are expected to fulfill their assigned role within the institution.
The way the members treat each other or interact with each other is determined by the culture, values, hierarchy, roles and expectations of the members within the institution.
Community have Geographical Boundaries
All communities need a way to determine what the community does and how it does. Boundaries can be physical, virtual or psychological. They define the identity of the community. Without boundaries, the roles of the community become meaningless. Does a sporting community focus on transportation or scientific research? While transportation or scientific research may be a part of the community, they are not a part of the role of the community in society.
Without boundaries the community may:
  • Become unfocused
  • Become too diversified and uncoordinated
  • Not adequately provide for its own needs, or the needs of its members
  • Create tensions within communities that it is a part of, or a part of it
  • Create layers of bureaucracy that become communities in their own right.
Boundaries are often defined by the:
  • The institutions of the community
  • The members of the community
  • The settings (physical, virtual or psychological)
  • Government (local state and federal) policy and practice
  • Other communities that it is a part of, or are a part of it.
Communities are about caring and sharing. All members share a common cause and have a sense of identity. A sense of belonging is created where the members are connected to, and interact with each other.
Just as the members of the community have ownership of their lives and property, the community 24has ownership of its members and property through the various mechanisms put in place by the community.
The community has ownership of its members through:
  • May involve some formal/informal induction or rite of passage.
  • Commitment: Members have a sense of obligation towards the community.
  • Loyalty: Members give up a certain amount personal autonomy for the greater good.
  • Respect: Members have respect for each other.
  • Responsibility: Members take on responsibilities (and feel responsible for others) within the community.
  • Safety and security: Members feel that they can call on other members in times of need or when threatened.
  • Resources: Community resources are owned by the community on behalf of its members. Personal resources are sometimes shared between the members.
  • All members have the opportunity to participate in the activities of the community.
Social Role Valorization Provides Valued Roles for All Members of the Community
The community needs to be able to communicate with its members in order to achieve its goals.
The members communicate with each other to share thoughts, feelings, experiences, skills and knowledge. Clear thinking and expression of thoughts are essential to effective communication.
The community also needs to communicate with others outside the community. To function effectively as a community, the community needs to be able to respond to events that are outside the community and have an impact on the community.
‘Communication is the process of exchanging information, beliefs and feelings among people; it may be oral, written, or nonverbal. Information may travel up, down, or horizontally.’
The Skills and Resources of the Community Provide for the Needs of its Members
A community needs a set of skills and resources in order to achieve its goals. They provide an available source of wealth that can be drawn upon when needed.
If the community does not have the skills and resources to look after the needs of its members, those skills and resources need to come from somewhere else.
Balance the needs of the community with the needs of its members.
Community Leadership
  • Understanding the changing internal and external environments and how they relate to the community
  • Involving all members
  • Effective communication between all members
  • Understanding what members need
  • Aware of relevant research and the evidence base for practice
  • Data gathering, analysis and reporting mechanisms
  • Informed decision making processes
  • Coordinating internal and external services.
Teams and Groups
Teams and groups are an important part of any community in providing for the needs of its members.
Communities have rights and responsibilities:
  • The right to its own identity
  • The right to set its own agenda, constitution and institutions
  • The right to participate within the wider community
  • The right to access skills and resources within the wider community
  • The right to support its members within the wider community
  • The right to protect its members from influences that disadvantage its members
  • The right to refuse entry to members that do not fit into the community
  • The right to evict members that do not accept the agenda, constitution and institutions of the community
  • The right to refuse skills and resources to the wider community, where its members are disadvantaged
  • The right to determine its own destiny.
  • Ensure the agenda, constitution and institutions of the community, protect and support its members, as well as other communities and their members. Provide a safe, secure environment for its members, as well as other communities and their members
  • Facilitate the development of valued roles and relationships for the community, its members, as well as other communities and their members25
  • Ensure that the community communicates with its members as well as other communities and their member
  • Ensure the community does not disadvantage other communities or their members
  • Responsibility use, and share, skills and resources to the advantage of its members, as well as other communities and their members
  • Respect, protect and promote the rights, cultures and institutions of other communities and their members
  • Engage with other communities in an interdependent relationship.
The concept of community is defined as ‘a group of people who share some important feature of their lives and use some common agencies and institutions.’ The concept of health is defined as ‘a balanced state of well-being resulting from harmonious interactions of body, mind, and spirit.’ The term community health is defined by meeting the needs of a community by identifying problems and managing interactions within the community.
The healthy community is one that makes wide use of its resources and is prepared to meet threats and dangers. In assessing the health of any community, it is necessary to collect information not only about variables specific to location but also about relationships between the community and its location. Do groups cooperate to identify threats? Does the community make certain that its members are given available information about resources and dangers? The location perspective of the community profile inventory, including the six location variables: community boundaries, location of health services, geographic features, climate, flora and fauna, and the human-made environment.
Every physical community carries out its daily existence in a specific geographic location. The health of a community is affected by location, because placement of health services, Geographic features, climate, plants, animals and the human made environment are intrinsic to geographic location. The location of a community places it in an environment that offers resources and also poses threats (Skelly, et al, 2002; Neuman and Fawcett, 2001).
Community health is a field of public health, is a discipline which concerns itself with the study and improvement of the health characteristics of biological communities. While the term community can be broadly defined, community health tends to focus on geographical areas rather than people with shared characteristics. The term ‘community health’ refers to the health status of a defined group of people, or community, and the actions and conditions that protect and improve the health of the community. Those individuals who make up a community live in a somewhat localized area under the same general regulations, norms, values, and organizations. For example, the health status of the people living in a particular town, and the actions taken to protect and improve the health of these residents, would constitute community health. In the past, most individuals could be identified with a community in either a geographical or an organizational sense. Today, however, with expanding global economies, rapid transportation, and instant communication, communities alone no longer have the resources to control or look after all the needs of their residents or constituents.
The actions and conditions that protect and improve community or population health can be organized into three areas.
  • health promotion
  • health protection
  • health services.
This breakdown emphasizes the collaborative efforts of various public and private sectors in relation to community health. Health promotion may be defined as any combination of educational and social efforts designed to help people take greater control of and improve their health. Health protection and health services differ from health promotion in the nature or timing of the actions taken. Health protection and services include the implementing of laws, rules, or policies approved in a community as a result of health promotion or legislation. An example of health protection would be a law to restrict the sale of hand guns, while an example of health services would be a policy offering free flu shots for the elderly by a local health department. Both of these actions could be the result of health promotion efforts such as a letter writing campaign or members of a community lobbying their board of health.
Concept of Community Health Nursing
Definition of community health nursing must be based on an understanding and appreciation of the whole spectrum of nursing and its contribution to the 26individual sickness and health, to his family and to his community with this change of thought, the role of community health nurse has became complex and dynamic. Every nurse should be a community health nurse in practice.
Community health nursing is concern with the people who are sick as well the healthy, young and old, male and female. At the same time from the above points it is clear that community health nurse is responsible for family centered care rather than an individual oriented one. Community health and community health nursing draw knowledge and practices from other disciplines such as medicine, surgery, pediatrics, obstetrics, dentistry, health education and vital statistics.
  • Community health nursing has been defined by the Division of Community Health Nursing Practice of ANA as a field of nursing practice for which there exists a body of knowledge and related skills which is applied in meeting the health needs of communities, families and individuals in their normal environment such as at home, at school and at place of work.
  • As defined by Ruth Freeman, service rendered by a professional nurse with the communities, groups, families, individuals at home, in health centers, in clinics, in schools, in places of work for the promotion of health, prevention of illness, care of the sick at home and rehabilitation.
  • 1982, APHA (American Public Health Association) defines public health nursing as follows: Public health nursing synthesizes the body of knowledge from the public health sciences and professional nursing theories for the purpose of improving the health of the entire community. This goal lies at the heart of primary prevention and health promotion and is the foundation for public health nursing practice. To accomplish this goal, public health nurses work with groups, families, and individuals as well as in multidisciplinary teams and programmes. Identifying subgroups within the population which are at the high risk of illness, disability or premature death, and directing resources towards these groups, is the most effective approach for accomplishing the goal of public health nursing.
  • As explained by ANA (American Nurses Association) 1980, The community health nursing is defined as a synthesis of nursing and public health practice applied to promoting and preserving the health of people. The practice is general and comprehensive. It is not limited to a particular age group or diagnoses and is continuing, not episodic.
Goals of Community Health Nursing
  • To increase the capability of families, groups and communities to cope with health and illness problems.
  • To support and supplement the efforts of other professional restoration and preservation of health.
  • To control or counteract as much as possible physical and social environmental conditions that threaten health or decrease the enjoyment of life.
  • To contribute to the refinement and improvement of nursing practice and of public health practice and service.
Scope of Community Health Nursing
  • Home care
  • Nursing homes
  • MCH and Family Planning
  • School health nursing
  • Community health nursing services
  • Industrial nursing services
  • Mental health nursing services
  • Rehabilitation centers
  • Geriatric nursing service
To accomplish community health goals and its aim the following aims are to be utilized by community health professionals, i.e.
Persuasive approach: The presuasive approach implies convincing people through dialogue and educate them to change or modify their health behavior. Community health nurse make use of this approach in all types of nursing interventions related to health promotion and specific protection, early recognition, diagnosis and treatment and disability limitation and rehabilitation. It is through education that self care competencies of individual, family and community can be developed which is essential to achieve the goal of health for all.
Enforcement: The enforcement implies the use of more coercive measures such as use of legislation, e.g. prohibition of drug abuse, child abuse, immunization as a condition to school admission, etc. and the use of authority, e.g. giving strict instructions or orders to do certain things especially when it is a question of life and death during emergency situations such as child labor, acute bronchopneumonia, etc. Community health nurses make use of such measures in life threatening emergency situations.27
Team approach: Community health is a problem solving process and a team approach is very necessary to deal with varied and complex health needs and problems at large. It is just not possible for any one profession or discipline to provide such care. Community health nursing is one of the professions and community health nurses along with auxiliary nurses and female health supervisors help to meet nursing needs of the community as a whole. Other members of the team who are usually there include physicians, clinical specialists, public health engineers, health statistians, epidemiologists, health educationalists, counselors, social workers, clinical psychologists, pharmacologists, lab technicians, village health workers. Community health nurses working in the community health settings needs to identify the health teams and their roles, functions and team dynamics so as to participate effectively in providing compressive health care services to people in the community and accomplish community health goals and aims.
Community involvement: Health of individual living in a defined community is not only their ‘right’ but also their ‘responsibility’ to take of their own health and also of community at large. Without people's help, participation or cooperation, it is neither possible to make health care services accessible and acceptable to them nor it is feasible to achieve community health goals and aims. Community involvement and participation is recognized as one of the crucial supportive approach for successful implementation of community health care services. But it is all the more important for the primary health care component which is given greatest emphasis at the grass root level. The extent of community involvement may vary from one community to another. It may depend upon their socioeconomic and cultural aspects, health attitude, health knowledge, etc. It ranges from true or active participation, i.e. people are knowledgeable and have a positive attitude and get involved in planning and implementing their health care to passive recipient of care provided, i.e. the major responsibility of community involvement lies with health personnel who directly deal with people at the community level. They need to encourage and promote them for their participation. Community health nurse working with individuals, families, groups within the community as a whole for community health nursing services need to mobilize, encourage, organize and prepare them to take greater interest and responsibilities, develop self-reliance for their own health matters.
Intersectorial approach: Health of people at large cannot be attained by health sector alone because there are many factors which affect people's health but they are not under the purview of the health sector, e.g. food production and distribution, water, sanitation, housing, environmental protection and education, etc. each one is dealt by separate sector and socioeconomic development and health. It is felt necessary to have proper coordination between the health and all other sectors concerned at all levels. Health workers including community health nurses working at the grass root level for primary health care need to identify these sectors and coordinate with them to provide desired services which serve as entry points for the development and implementation for primary care services. Community health nurses can also educate on nutritional status of the family, food storage through programs in the agriculture and health economics, proper use and maintaince of houses and the areas surrounding them through respective programs, etc. Health workers including community health nurse who can also involve personnel from these sectors at community level to promote health activities, e.g. agricultural workers can promote production of appropriate food stuff and their consumption by families; teachers in schools can promote good sanitation, encourage healthful behavior in students, conduct courses on nutrition and first aid; mass media personnel can popularize various primary health care services by disseminating authentic in different communities, etc. Evidence-based practice (EBP) entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected. This is done in a manner that is compatible with the environmental and organizational context. Evidence is comprised of research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses.
Epidemiological approach: Epidemiological analysis and measurement allow reaearchers to measure health status and measurement of disease occurrences in a population. Surviellance of disease yields epidemiological intelligence data by providing systematic count of disease frequency. These data can be in turn used to estimate the magnitude of health problems in the community, detect epidemics and understand natural history of a disease or detect potential emerging infectious disease threats. Another use of this approach is case finding to identify health status of people who are at risk.
Nursing Process Approach
The nursing process is a modified scientific method. Nursing practice was first described as a four stage 28nursing process by Ida Jean Orlando in 1958. The nursing process uses clinical judgement to strike a balance of Epistomology between personal interpretation and research evidence in which critical thinking may play a part to categorize the clients issue and course of action. Nursing offers diverse patterns of knowing. The nursing process is goal-oriented method of caring that provides a framework to nursing care. It involves five major steps: A - Assess (what data is collected?) D - Diagnose (what is the patient's problem) P - Plan (how to manage the problem) I - Implement (putting plan into action) E - Evaluate (did the plan work?). Assessing phase: The nurse completes an holistic nursing assessment of the needs of the individual/family/community, regardless of the reason for the encounter. The nurse collects subjective data and objective data using a nursing framework, such as Marjory Gordon's functional health patterns. Nursing assessments provide the starting point for determining nursing diagnoses. It is vital that a recognized nursing assessment framework is used in practice to identify the patient's problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern. Diagnosing phase: Nursing diagnoses represent the nurse's clinical judgment about actual or potential health problems/life process occurring with the individual, family, group or community. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly identify and link to the defining characteristics, related factors and/or risk factors found within the patient's assessment. Multiple nursing diagnoses may be made for one client.
Nursing Theories Approaches
A nursing theory is a conceptualization of some aspects of nursing communicated for the purpose of describing, explaining, predicting, and or prescribing nursing care. There are a lot of theories had identified by different theorist which can be applied in community field during providing care, developing IPR and giving health education. Health belief model can be applied to change behavior during community education programme to motivating the people.
The home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities. In performing this activity, it is essential to prepare a plan of visit to meet the needs of the client and achieve the best results of desired outcomes. It is a purposeful interaction in a home (or residence) directed at promoting and maintaining the health of individuals and the family (or significant others). A major distinction of a home visit is that the health professional goes to the client rather than the client coming to the health professional. Home visiting involves a process of initiating relationships with family members, negotiating and implementing a family-focused plan of care, and evaluating health outcomes and family satisfaction.
The home visit is a family-nurse contact which allows the health worker to assess the home and family situations in order to provide the necessary nursing care and health related activities.
A home visit is a purposeful interaction in a home directed at promoting and maintaining the health of individuals and the family. Home visit is the process of providing nursing care to the client's own setting. The setting may be in a single or multiple unit structure and may be located in a rural or urban setting.
A comprehensive range of community nursing services is provided by Community Health. The main focus of this service is to enable people to be cared for in their own homes rather than as patients in hospitals.
Aims of Home Visit
  • To Assess the family
  • To provide Nursing care
  • To Treat according to the need
  • To rendered Health education
  • To provide Referral services (if care fails).
  • Promoting support systems that are adequate and effective and encouraging use of health-related resources.
  • Promoting adequate, effective care of a family member who has a specific problem related to illness or disability.
  • Encouraging normal growth and development of family members and the family and educating the family about health promotion and illness prevention.
  • Strengthens family functioning and relatedness.
  • Promoting a healthful environment.
  • A home visit must have a purpose or objective.
  • Planning for a home visit should make use of all available information about the patient and his family through family records.29
  • In planning for a home visit, we should consider and give priority to the essential needs if the individual and his family.
  • Planning and delivery of care should involve the individual and family.
  • The plan should be flexible.
  • The physical needs, psychological needs, and educational needs of the individual and family.
  • The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
  • Take into account other health agencies and the number of health personnel already involved in the care of a specific family.
    • Careful evaluation of past services given to the family and how the family avails of the nursing services.
    • The ability of the patient and his family to recognize their own needs, their knowledge of available resources and their ability to make use of their resources for their benefits.
Procedure of Home Visit
Greet the patient and introduce yourself.
  • State the purpose of the visit.
  • Observe the patient and determine the health needs.
  • Put the bag in a convenient place.
  • Perform the nursing care needed and give health teachings.
  • Record all important date, observation and care rendered.
  • There is no easy access to emergency equipment or consultation with.
  • These visits cost less than hospital care, with better outcomes, especially when chronic health issues are involved.
  • Clients have greater control over their health and lives.
  • The community health nurse gains access to families to provide health education and other prevention strategies. Individuals and family members may be more receptive to learning because they are less anxious in their own environment and because the immediacy of needing to know a particular fact or skill becomes more apparent.
  • Home visits allow for primary intervention, to prevent disease or injury from occurring.
  • Home setting provides more opportunities for comprehensive care.
  • Most people prefer to be cared for at home for getting better psychological support.
  • Environmental factors impinging on health, such as housing condition and finances, may be observed and considered more readily.
  • Information collection and understanding lifestyle values are easier in families’ own environment.
  • Participation of family members is facilitated.
  • Care to ill members in the home can reduce overall costs by preventing hospitalizations and shortening the length of time spent in hospitals or other institutions.
  • A family focus is facilitated.
  • The nurses skills, personality, or physical ability may not be compatible with providing home visit.
  • Home visits are time consuming; travel time is required to get to the persons needing care.
  • There is no easy access to emergency equipment or consultation with other health professionals if needed.
  • Home visits may present issues regarding the nurse personal safety in some community or family settings.
  • The nurse has less control over the care setting (for example, cleanliness, noise, privacy, or distractions).
Bag Technique
Home visiting is very essential and back bone of public health nursing because majority of client are found in the home. While home visit community health nurse should carry community health bag. The community health bag is designed to carry equipments and material needed during a visit to the home, school or factory. Equipment and materials are needed to make test, demonstrate patient care and perform dressing, etc.
The bag should be made up of canvas, leather or light metal. This is stitched in such a way that it can be carried either by hand or over shoulder.
Ideally the community health nursing bag should have four pockets, 2 outer pocket and 2 inner pocket.
1st outer pocket: 1st outer pocket contained Hand washing articles (soap, soap dish, towel, nailbrush) Note book, pen, plastic sheet and news paper, etc.
2nd outer pocket: 2nd outer pocket is used to keep used articles.
N.B: Ideally it should be opposite to first outer pocket.
1st inner pocket
1st inner pocket contain:
  • The articles for physical assessment such as torch, 30spring balance, weighing cloth, BP instrument, stethoscope, fetoscope, tape measure, thermometer.
  • Articles for urine testing such as Test tube, test tube holder, match box, litmus paper, dropper, filter paper, Benedict's solution, spirit lamp.
  • Articles for dressing such as Betadine solution, adhesive tape, gloves, spirit.
  • Articles for injection like syringe and needle cotton swab, gauze piece, etc.
  • Other articles like Slides, lancet, drugs, ORS, contraceptives.
2nd inner pocket
  • 2nd inner pocket contains all sterile materials (dressing instruments, sterile instrument and swab stick for culture, Sterile artery forcep.
Principles of Bag Technique
  1. Cleanliness: The bag and its contents are all designed for efficiency and cleanliness. The content and bag also must kept clean and ready to use for all time.
  2. The hand should be washed every time before touching the bag.
  3. For doing any dressing the surgical aseptic technique should follow.
  4. During giving care or doing any procedure the name most avoid to touch the bag.
  5. Contaminated article should be separately properly.
  6. Sterilized articles aseptic principle should be maintained.
  7. Maintain bag technique properly.
  8. Bowl contaminated instrument and equipment before returning them to the bag. The article should be autoclaved.
  9. Protect and take care of the bag.
Preprocedural Responsibility
  • Check the bag before leaving for home visit.
  • Bag should be kept at proper place, out of reach of children.
  • Personal equipment should not be kept inside the bag.
After Procedure
  • Wash hand with soap under tap water
  • Return articles to the bag. Use a cotton must and swab with spirit wipe out side used bottles
  • Washable articles should be properly washed
  • Fold used proper with used side inside and ask the family members for next visit
  • Closed the bag
  • Write the report of what are observed and what are done, etc.
Table 1.1   Steps of procedure of bag technique
S. No.
Select a work area where the bag may be set up without danger of being contaminated by children or domestic animal
Children and domestic animal can contaminate the bag.
Spread a plastic sheet or new paper on surface to place the bag
For creating clean surface area
Remove hand washing material and wash hand under tap water with bacteria static soap if available
Running water help to remove dirty easily and antiseptic soap reduce the bacterial growth
Remove apron from the bag put it on grasp the apron at the neck line and shake out.
For less contamination
Set up paper bags
For collecting dry wastes
Remove basin, scale, thermometer, dressing cotton swabs, urine and kit dressing sets as per needed and place on clean area.
Removing all needed articles at a time to save time
Wash hands again if you are going to do any surgical procedure
For creating or maintaining surgical Asepsis
Close the bag securely
Some time small children can take article and handle it
Give nursing service as indicated
To fulfill our purpose
When the procedure in over wash the hands over soap under top or poured water
For keeping own free from danger.
Community health nursing has evolved into a focus on care of individuals, families and communities. The focus and orientation are different to other nurses in their work areas.
Community health nursing is a specific and specialized orientation to the care that embodies principle of public health as guiding concepts.
Primary health care is one aspect of community health nursing. Community health nursing focuses on the physical, biological, social, psychological and environmental health of a population group. While primary care is a ‘coordinate system of personal health care, emphasizing first contact care and continuously’ (Ruth, 1978).31
Primary care emphasizes ambulatory care that addresses total client needs both for curative and preventive services. Community health nursing is population based.
School nurses have played a significant part in school health programs. They need to be flexible, creative, and involved in revising their role to fit with new directions, otherwise, the role of the school nurse may be jeopardized. Economic justification for services is necessary and therefore, the value of the school nurse must be ascertained.
National health objectives for the year 2000 seek to increase school based education to prevent human immunodeficiency virus infection, alcohol and other drug use, tobacco use, injury and sexually transmitted diseases.
Health education has proven to be effective at reducing risk behaviors associated with the leading causes of death that is heart diseases, cancer stroke, COPD, unintentional injuries, AIDS, etc. responsibility needs to be a fundamental components of health care reform.
Trends Influencing Community Health Nursing
Community Health Nursing practice today has been affected by several newer developments in the field of medicine, nursing and other scientific disciplines. Several trends currently influencing community health and nursing. They are:
Demographic trends: Increase population, greater percentage of elderly people, suburbanization of society, etc.
Technological trends: Knowledge explosion, environmental pollution, use of nuclear energy, etc.
Sociocultural trends: Woman liberalization, health insurance, mass communication techniques.
Economic trends: Rising cost of health care, independent nurse practitioner, self-care by individuals.
Political trends: Research in Community Health Nursing field, more specialization in community health.
Principles of Community Health Nursing
  • Community health nursing is an established activity based on recognized needs and functioning within the total health programmes.
  • The community health nursing agency has clearly defined objectives and purposes for its services.
  • An active organized citizens group, representative of the community is an integral part of the community health programme, e.g. mandals, school teachers act as the community representative to share in the health programmes. Their knowledge and experience shared with professional workers.
  • Community health nursing services are available to the entire community regardless of origin, culture or social and economic resources and also it should be available to people irrespective of age, sex, creed, nationality, political affiliation.
  • Community health nursing recognized the family and community as units of service.
  • Health education and counseling for individual, family and community are the integral part of community health nursing.
  • Recipients of health care should participate in planning relating to goals for the attainment of health.
  • The community health nurse is a qualified as a full-fledged nurse.
  • The community health nursing service should be based on the needs of the patient and there will be proper continuity of services to patients. Periodic and continuing appraisal and evaluation of the health situation of the patients are basic to the community health nursing.
  • The community health nurse should function or serve as an important member of the health team.
  • The community health nurse does not provide material relief to patients, but directs the patient to appropriate community resources for necessary financial and social assistance.
  • The community health nurse should not accept gifts or bribes from the patients.
  • The community health nurse should not belong to any one section or any political group.
  • The nurses assume responsibilities of their own continuing professional development through acquiring higher and higher education and forming and strengthening the professional associations.
  • The community health nursing services must develop proper guidelines in maintaining records and reports which are very essential for community health.
  • There must be proper facilities and job conditions.
  • The community health nurses will maintain professional relationship with all the leaders in the community and maintain ethics at all times.
  • Community Health Nursing is based on recognized needs of communities, families, groups and individuals.
  • The community health nurse must fully understand the objectives and policies of the agency she represents.32
  • Community Health Nursing must be available to all regardless of race, creed and socioeconomic status.
  • Health Teaching is a primary responsibility of community health nurse.
  • Community health nurse works as a member of the health team.
  • There must be provision for periodic evaluation of Community Health Nursing services.
  • Opportunities for continuing staff education programs for nurses must be provided by the Community Health Nursing agency. She has a responsibility for his/her own professional growth.
  • The community health nurse makes use of available community health resources.
  • Community health nurse utilizes the already existing active organized groups in the community.
  • There must be provision for educative supervision in Community Health Nursing
  • Clients of the Community Health Nurse are Individual, family and community.
Ethics Involved in Community Health Nursing
Every profession makes provision to raise its status and to safeguard its own interest and that of its clients there is no legal binding for the acceptance of a particular ethic. It is a self-imposed discipline. There are some moral rules and principles adopt in nursing profession after conducting many conferences and meetings from time to time professional ethics governing community health nursing practices are essentially the same as applied to nursing in other fields.
In 1973 The International Council of Nurses Code of Ethics had resulted in clear and broader standards which can be applied in any culture and anywhere in the world. Some of the standards given in the code for nurses are also stated in the Nightangle Pledge which is universally known and used in the nursing profession.
  • The fundamental responsibility of the nurse is fourfold: to promote health, to prevent illness, to restore health and to alleviate suffering.
  • Inherent in nursing is respect for life, dignity and rights of man.
  • It is unrestricted by considerations of nationality, race, creed, color, age, sex, politics or social status.
  • Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups. These are discussed in the following order:
Nurses and People
  • The earlier term patient has been replaced by client. The code directs the nurse to respect a person's values, customs and religious beliefs. Each country and different areas within a country has certain values and customs. The nurse is expected to learn the accepted patterns of behavior of the community and not insult the people knowingly or unknowingly by behavior that is not acceptable to them. Any personal information must be held in confidential or shared only with careful judgement. Careless talk about a person is always unethical conduct. The religious beliefs must be respected and spiritual advisers should be provided.
Nurses and Practice
  • The nurses must maintain at all times the highest standards of nursing care and professional conduct.
  • She should maintain at all times the highest standards of nursing care and of professional conduct.
  • She should maintain up to date scientific knowledge and skills and have the right attitude in using this knowledge.
  • She must give medical treatment without medical orders only in emergency and reports such action to the physician at earliest possible movement.
  • She must carry out the physicians orders intelligently and loyally and to refuse to participate in unethical procedures.
  • A nurse is entitled to just remuneration and accepts only such compensation as the contract, actual or implied, provides.
  • She should not permit her name to be used in connection with the advertisement of products or with any form of self-advertisements.
Nurses and Society
  • Nurse should participate and share responsibility with other citizens and other health professions in promoting efforts to meet the health needs of the public, local, state, national and international.
  • The code states the responsibility of the nurse for positive promotion of health for the community by birth initiating and supporting action to meet the health and social needs. Social needs are closely link with the health needs. Poor housing, sanitation, nutrition, unemployment and illiteracy affect the health of the people.
  • The nurse has an important role to play in education and referral work.33
Nurse and Coworkers
  • The nurse should cooperate with and maintain harmonious relationship with members of other professions and his nursing colleagues.
  • The nurse is one member of the health team who can serve and meet the health needs of the people.
  • She should understand her own responsibilities on the health team with others.
Nurses and Profession
  • The code points out the role of a nurse as a leader and active participant.
  • The nurse should take the leadership role in setting up desirable standards of nursing education and practice.
  • She should enlarge the care of professional knowledge and take interest in research.
  • She should setting up and maintaining fair social and economic working conditions in nursing. This should be done in the right way by peaceful negotiations and not by means of strike which is very unethical. Action should be initiated through professional organizations.
Application of Ethics to Community Health Nursing Practice
The priority of ethical principles in community health nursing, ethical principles direct and guide nursing actions with individuals and aggregate groups. The professional ethic, in general, places a greater emphasis on the observance of the principles of autonomy and beneficence than the principles of justice in most nursing actions but in community action is directed towards group, that is why autonomy of individual has less importance. The ethical principle of beneficence is given slightly less emphasis in the code for nurses but it is given more importance in community health nursing. The principle of justice is also not strongly emphasized in the professional code of ethics but justice can strongly emphasized in community Health Nursing it is noted in passing that nursing practice is not influenced by age, sex, race, color, personality or other personal attributes or individual differences in customs, beliefs, or attributes. The code estates that nursing care is delivered without disease detection and prevention and in health maintenance. Accountability: In Community Health Nursing Moral accountability in nursing practice means that nurses are answerable for how they promote, protect, and meet the health needs of clients while respecting individual rights to self-determination in health care. She should accountable for client and employing agency. In community health nursing, where the greater emphasis is on aggregates rather than individual clients, moral accountability means being answerable for how the health of aggregate groups justice are still important in community health nursing. Yet they are less important than the principle of beneficence in community health nursing the emphasis of the professional ethic is slanted toward benefit to aggregates, which implies following a rule of utility in planning, implementing, and evaluating community health nursing services.
The definition of sociocultural is something that involves the social and cultural aspects. Social problems are the general factors that affect and damage society. A social problem is normally a term used to describe problems with a particular area or group of people in the world. Social problems often involve problems that affect real life even though world advances a lot, people in the community still have lot of social issues.
Major Social Issues
  • Child abuse
  • Elderly abuse
  • Female feticide
  • Prostitution
  • Food adulteration
  • Substance abuse
  • Women abuse
  • Women Empowerment.
There is clear evidence that child abuse is a global problem. It occurs in a variety of forms and is deeply rooted in cultural, economic and social practices. It has observed that two out of every three children were physically abused. Out of 69% children physically abused, 54.68% were boys and among them physically abuse in family situations, 88.6% were physically abused by parents. Before defining ‘child abuse’ it's crucial to get informed about ‘children's rights’ in the first place because so many children prohibited to enjoy their rights.
Right to Education
  • Access to quality, free, compulsory primary education.
  • Non-Discrimination in access to education (gender gap).
  • Right to leisure, recreation and cultural activities.34
Right to Health
  • Access to quality health services
  • Rights of children with disabilities
  • Adolescents and reproductive health knowledge
  • Right to benefit from social security
  • Right to an adequate standard of living.
Right to Special Protection
  • Protection from all forms of exploitation (economic, sexual).
  • Violence against children (physical, psychological and sexual).
  • Female Genital Mutilation and early marriage.
  • Torture and deprivation of liberty for juvenile in conflict with the law
  • Hazardous occupations.
  • Smoking, substance abuse, and trafficking.
  • Protection of Street children.
Child abuse can be defined as a variety of abnormal behaviors directed against children which can take many forms.
Types of Child Abuse
Physical Abuse
Physical abuse is any non-accidental injury to a child under the age of 18 by a parent or caretaker. These injuries may include beatings, shaking, burns, human bites, strangulation, or immersion in scalding water or others, with resulting bruises and welts, fractures, scars, burns, internal injuries or any other injuries. The term ‘battered child syndrome’ was coined to characterize the clinical manifestations of serious physical abuse in young children. This term is generally applied to children showing repeated and devastating injury to the skin, skeletal system or nervous system. It includes children with multiple fractures of different ages, head trauma and severe visceral trauma, with evidence of repeated infliction.
Another form is the ‘The shaken infant’. Shaking is a prevalent form of abuse seen in very young children (less than 1 year). Most perpetrators of such abuse are males. Intracranial hemorrhages, retinal hemorrhages and chip fractures of the child's extremities can result from very rapid shaking of an infant.
Corporal Punishment
In the form of hitting, punching, kicking or beating is socially and legally accepted in most countries. In many, it is a significant phenomenon in schools and other institutions and in penal systems for young offenders.
Emotional Abuse
It includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child. Such acts include restricting a child's movements, denigration, ridicule, threats and intimidation, discrimination, rejection and other nonphysical forms of hostile treatment. The consistent failure of a parent or caretaker to provide a child with appropriate support, attention, and affection also act as emotional abuse. It also include a chronic pattern of behaviors such as belittling, humiliating, and ridiculing a child.
It refers to the failure of a parent to provide for the development of the child where the parent is in a position to do so in one or more of the following areas: health, education, emotional development, nutrition, shelter and safe living conditions. Neglect is thus distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver.
Child Sexual Abuse
Child sexual abuse is the exploitation of a child or adolescent for the sexual gratification of another person, e.g. child prostitution, pornography, intercourse.
Risk Factors for Child Abuse
Individual Risk Factors
  • Parents’ lack of understanding of children's needs, child development and parenting skills
  • Parents’ history of child maltreatment in family of origin
  • Substance abuse and/or mental health issues including depression in the family
  • Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
  • Nonbiological, transient caregivers in the home (e.g. mother's male partner)35
  • Parental thoughts and emotions that tend to support or justify maltreatment behaviors.
Family Risk Factors
  • Social isolation
  • Family disorganization, dissolution, and violence, including intimate partner violence
  • Parenting stress, poor parent-child relationships, and negative interactions.
Community Risk Factors
  • Community violence
  • Concentrated neighborhood disadvantage (e.g. high poverty and residential instability, high unemployment rates, and high density of alcohol outlets), and poor social connections.
Indicators of Child Abuse
Type of abuse
Physical indicators
Behavioral indicators
Unexplained bruises, welts, burns, fractures, or bald patches on scalp
Wary of adult contact, frightened of parents or afraid to go home, withdrawn or aggressive, moves uncomfortably, wears inappropriate clothing for weather
Difficulty walking or sitting; torn or stained/blood underclothes; pain, itching, bruises, swelling in genital area; frequent urinary or yeast infections
Advanced sexual knowledge, promiscuity, sudden school difficulties, self-imposed social isolation, avoidance of physical contact or closeness, depression
Speech or communicative disorder, delayed physical development, exacerbation of existing conditions, substance abuse
Habit disorders, antisocial or destructive behaviors, neurotic traits, behavior extremes, developmental delays
Consistent hunger, poor hygiene, inappropriate dress, unattended medical problems, underweight, failure to thrive
Self-destructive behaviors, begging or stealing food, constant fatigue, assuming adult responsibilities or concerns, frequently absent or tardy, states no caretaker in home
Role of a Community Health Nurse
Identification of Child Abuse: The Community health nurse can identify by observing the child in day to day life their Normal childhood development, Conditions that may be confused with abuse, Unintentional vs intentional injury, Human Bite Marks, Hair Loss, Falls, Head, facial, oral injuries, Shaken baby Syndrome, Abusive Burn Patterns, Scald, Flexion Burns, Contact Burns or Pseudoabusive’ Burns, etc. When observing injury she should check the color of the injury. Or any other indicators of psychological or sexual abuse. The Community health Nurse can report to child abuse help line.
Educating the family: She can educate the family regarding:
  • Nurturing parenting skills
  • Stable family relationships
  • Household rules and child monitoring
  • Parental employment
  • Adequate housing
  • Access to health care and social services.
Her Supportive Role is also:
  • Strengthen family and community connections and support.
  • Treat parents as vital contributors to their children's growth and development.
  • Create opportunities for parents to feel empowered to act on their own behalf.
  • Respect the integrity of the family.
  • Enhance parents’ capability to foster the optimal development of their children and themselves.
  • Establish links with community support systems.
  • Provide settings where parents and children can gather, interact, support and learn from each other.
  • Enhance coordination and integration of services needed by families.
  • Enhance community awareness of the importance of healthy parenting practices:
Elderly abuse has been discussed in the chapter 13 (geriatric care)
Female feticide is the abortion of a female fetus outside of legal channels. It occurs in India for assumed cultural 36reasons that span centuries. Ultrasonography and Fetoscopy helps determine abnormalities in the fetus. But it is misused to find out sex of the fetus and abortion is done if it is a girl. The child sex ratio is calculated as number of girls per 1000 boys in the 0–6 years age group. According to 2011 census the girls sex ratio is 940/1000 boys. Though the condition is improving still it needs special attention to stop Female feticide.
Causes of Female Feticides
  • Strong male child preference
  • Gender inequity
  • Easy availability of sex determination test, abortion services
  • Child marriage
  • Economic dependence
  • A low status of the women in the family
  • Dowry system
  • Cultural preference (One male child must)
  • Illiteracy.
Preventive Measures
Legal Initiatives
The Prenatal Diagnostic Test Act (PNDT Act): The Prenatal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994, was enacted and brought into operation from 1st January, 1996, in order to check female feticide. Rules have also been framed under the Act. The Act prohibits determination and disclosure of the sex of fetus. It also prohibits any advertisements relating to prenatal determination of sex and prescribes punishment for its contravention. The person who contravenes the provisions of this Act is punishable with imprisonment and fine.
The Medical Termination of Pregnancy (MTP) Act: This act was enacted by the Indian Parliament in the year 1971 and came into force in 1972. As per India's abortion laws only qualified doc stipulated conditions, can perform abortion on a woman in an approved clinic or hospital. The Medical Termination of Pregnancy (MTP) Act of India clearly states the conditions under which a pregnancy can be ended or aborted.
The Dowry Prohibition Act, 1961: As dowry is considered to be an important cause of female feticide, the Dowry Prohibition Act should be made more stringent by proper amendments and should be implemented strictly. According to this act, if any person, after the commencement of this Act, gives or takes or abets the giving or taking of dowry, he shall be punishable with imprisonment for a term which shall not be less than five years, and with fine which shall not be less than fifteen thousand rupees or the amount of the value of such dowry, whichever is more.
Other Measures
  • The related social malaises such as dowry, poverty, women's unemployment and exploitation, lack of proper education to girl child and their dropouts, early marriage, etc. are to be dealt with sternly by enacting proper laws and implementing them in true spirit.
  • Affirmative action on part of the government and the corporate sector by providing security for parents and granting financial aid to the girl child can help in changing the mindset of the society of treating the girl as a burden.
  • Corporate initiatives, such as ‘Beti Ek Anmol Ratan’ scheme in which the donations are invested in mutual funds, Kisan Vikas Patras and National Savings Certificates in the name of new born girls and on maturity (Age of 21 years) to be utilized for higher education or marriage; has found favor with the parents and the scheme is yielding positive results.
  • Government schemes like ‘LADLI’ have created gender revolution in national capital, and impacted sex ratio in favor of the girl child. Banks need to be encouraged to give loans for female child's higher education at lower rates of interest.
  • Awareness programs should be launched to make the woman aware about their rights and about the ill effects of abortions. Women should know their rights regarding adoption, maintenance, marriage, property, employment, education, etc.
  • In order to make the females independent, women should be imparted skill and training through various vocational programs. Free and compulsory education should be provided to female children so that they can support themselves during exigency. Also it would remove the attitude that investing in girls is unnecessary.
  • Medical termination of pregnancy should only be permitted after approval of PNDT authority/committee/gazetted female officer/Mahila Panchayat members/NGOs on proof of the existence of medical condition necessitating such termination.
  • A social audit of all documents received from sonography clinics and making the data regarding sale of ultrasound machines, which are used for illegal sex determination tests, should be made available online. Information received will help governmental and non-governmental organization in estimating the targets for proper implementation of the Acts and for suggesting remedial measures to combat the problem. By involving all the stakeholders, a 37comprehensive social audit can be conducted to launch a crusade against female feticide.
Prostitution is the sale of sexual services, such as oral sex or sexual intercourse for money. Prostitution the word itself speaks about the plight of a women. It is not a problem which exists in India but exists throughout the world. Prostitution was a part of daily life in ancient Greece. In the more important cities, and particularly the many ports, it employed a significant proportion of the population and represented one of the top levels of economic activity. In the ancient city of Heliopolis in Syria, there was a law that stated that every maiden should prostitute herself to strangers at the temple of Astarte.
A prostitute may be defined as an individual (male or female) who for some kind of reward (Monetary or otherwise) or for some other form of personnel satisfaction and as a part of full time profession engage in normal or abnormal sexual intercourse with various persons who may be of the same sex or opposite sex to the prostitute.
Causes of Prostitution
  • Poverty
  • Broken homes
  • Mental illness
  • Uneducated women
  • Widows and divorces
  • Easy way to income money
  • Over sexual desires
  • Indebtedness
  • False hope of marriage
  • Influence of peer group.
Types of Prostitution
Street Prostitution
Street prostitution who typically find their customers, or are found by their customers, somewhere on a street. They then have a quick act of sex in the customer's car, in an alleyway or other secluded spot, or in a cheap hotel.
Escort or Out Call Prostitution
Call girls work as independent operators in their homes or fairly fancy hotels and charge a lot of money for their services, which include sex but also talking and dining. Their clients are typically businessmen or other wealthy individuals. Many call girls earn between $200 and $500 per hour, and some earn between $1,000 and $6,000 per hour or per session. Call girls and escorts rank at the top of the prostitution hierarchy.
Brothel Workers
As the name implies, are prostitutes who work in brothels. The only legal brothels in the United States today are found in several rural counties in Nevada, which legalized prostitution in these counties in 1971. Workers in these brothels pay income tax. Because their employers require regular health exams and condom use, the risk of sexually transmitted disease in Nevada's brothels is low.
Massage Parlor Workers
Massage parlor workers, as their name also implies, work in massage parlors. Many massage parlors, of course, involve no prostitution at all, and are entirely legal. However, some massage parlors are in fact fronts for prostitution, where the prostitute masturbates a man and brings him to what is often termed a ‘happy ending.’
Bar or Casino Workers
A final category of prostitution involves prostitutes who work in bars, casinos, or similar establishments (bar or casino workers). They make contact with a customer in these settings and then have sex with them elsewhere.
Theoretical Perspective
Prostitution is functional for several parties in society. It provides prostitutes a source of income, and it provides a sexual alternative for men who lack a sexual partner or are dissatisfied with their current sexual partner. According to Kingsley Davis, prostitution also helps keep the divorce rate lower than it would be if prostitution did not exist.
Conflict theory Prostitution arises from women's poverty in a patriarchal society. It also reflects the continuing cultural treatment of women as sex objects who exist for men's pleasure.
Symbolic Interactionism
Prostitutes and their customers have various understandings of their behavior that help them justify why they engage in this behavior. Many prostitutes believe they are performing an important service for their customers, and this belief is perhaps more common among indoor prostitutes than among street prostitutes.38
Impact of Prostitution
Personal disorganization: Prostitutes are almost social outcast. Though men use them in order to satisfy their lust they are otherwise looked down upon and condemned. The prostitute losses all their self-respect and acts merely as a machine. They lack normal emotions and moral value.
Family Disorganization
The person habitually visit to a prostitute loses interest in his own family. Harmonious relationship with his family affected. Husband wife relationship scattered. If the father behavior is known to the children he loses esteem in their eyes too. Similarly the family life of the women also affected. If a married women entered also to prostitution by the permission of her husband then also tensions and conflicts can be un avoidable.
Economic Problem
The man who goes to a prostitute regularly loses a lot of money in this manner.
Health Hazards
Both the prostitution and customer are at a risk of Sexually transmitted diseases including HIV AIDS.
Moral Degradation
Prostitution defines their results in moral degradation of the entire society.
Degradation of Women
With increasing trend of prostitution women are losing respect in the society. Women are more and more looked upon as sex symbols. The unhealthy environment in which the prostitute are living are demoralizing.
Community Disorganization
The prostitute community will may have different types of STI or STDs which is created in sanitary condition in the community. The general people will hate that community and may be isolate that.
Children Born to Prostitute
The children born to prostitute are called offspring of unwanted mother. Generally they are not accepted in society. Such type of children in later life turn to anti- social works.
Prevention and Control of Prostitution
The measures against this can be grouped under four heading:
  • Preventive
  • Prohibitary
  • Prophylaxis
  • Legislation
  • Facilitate vocational or moral training to lower socioeconomic groups
  • More job facility and vocational training
  • Rescue home, selter home or other facility should be provided to the poor and destitute women
  • Male should be taught to respect women folk not explore them sexually
  • Unhealthy social custom ‘devdasi’ should abolish completely
  • Social education propaganda are important measure
  • Pornographic literature or obscene film should be completely banned.
  • Medical examination of all prostitute.
  • Segregate the infected person.
  • Medical personnel dealing with them should be specially trained sympathetic, efficient and free care should be provided.
  • Many brothels are situated near the market place or industrial area. In such cases no prostitute should allowed in or near the residence of men or educational institutions.
  • The term brothel should be adequately defined in order to facilitate the enforcement of law.
The prophylactic measure include prevention of communicable diseases and improvement of hygienic condition. It can be possible by using condom, isolation of infected person and sex education in the brothel.
According to law, prostitution is legal where both parties to the acts are adult and no fraud or force has been used, but a number of related activities, including soliciting in a public place, kerb crawling, owning or managing a brothel, prostitution in a hotel, pimping and pandering, are crimes. Prostitution is legal only if carried out in the private residence of a prostitute or others. The Immoral 39Trafficking Prevention Act, 1956 can help in preventing prostitution.
The Immoral Trafficking Prevention Act, 1956 (‘ITPA’)
The main statute dealing with sex work in India, does not criminalize prostitution or prostitutes per se, but mostly punishes acts by third parties facilitating prostitution like brothel keeping, living off earnings and procuring, even where sex work is not coerced.
Section 3: Punishment for keeping a brothel or allowing premises to be used as a brothel.
Any person who keeps or manages, or acts or assists in the keeping or management of a brothel, shall be punishable on first conviction with rigorous imprisonment for a term of not less than one year and not more than three years and also with fine which may extend to two thousand rupees and in the event of a second or subsequent to conviction with rigorous imprisonment for a term of not less than two years and not more than five years and also with fine which may extend to two thousand rupees.
Any person who:
  • Being the tenant, lessee, occupier or person in charge of any premises, uses, or knowingly allows any other person to use, such premises or any part thereof as a brothel, or
  • Being the owner, lessor or landlord of any premises or the agent of such owner, lessor or landlord, lets the same or any part thereof with the knowledge that the same or any part thereof is intended to be used as a brothel, or is willfully a party to the use of such premises or any part thereof as a brothel, shall be punishable on first conviction with imprisonment for a term which may extend to two years and with fine which may extend to two thousand rupees and in the event of a second or subsequent conviction, with rigorous imprisonment for a term which may extend to five years and also with fine.
Section 5: Procuring, inducing or taking person for the sake of prostitution.
  • Any person who:
    • Procures or attempts to procure a person whether with or without his/her consent, for the purpose of prostitution; or
    • Induces a person to go from any place, with the intent that he/she may for the purpose of prostitution become the inmate of, or frequent, a brothel; or
    • Takes or attempts to take a person or causes a person to be taken, from one place to another with a view to his/her carrying on, or being brought up to carry on prostitution; or
    • Causes or induces a person to carry on prostitution; shall be punishable on conviction with rigorous imprisonment for a term of not less than three years and not more than seven years and also with fine which may extend to two thousand rupees, and if any offence under this sub-section is committed against the will of any person, the punishment of imprisonment for a term of seven years shall extend to imprisonment for a term of fourteen years:
Provided that if the person in respect of whom an offence committed under this sub-section:
  • Is a child, the punishment provided under this sub-section shall extend to rigorous imprisonment for a term of not less than seven years but may extend to life; and
  • Is a minor; the punishment provided under this sub-section shall extend to rigorous imprisonment for a term of not less than seven years and not more than fourteen years.
So it can be seen that both the sections namely section 3 and section 5 punishes only the acts of the 3rd party and same does the other sections in the Act and so new legislation shall be passed as to punish the client who are visiting the prostitutes.
Explained in separate chapter in chapter number 5 (Nutrition)
Substance abuse refers to the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. Psychoactive substance use can lead to dependence syndrome—a cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. Drug abuse is also inextricably linked with adverse effects such as infectious diseases, crime, accidents, and teenage pregnancies. Approximately half of those suffering from a chronic alcohol or drug disorder also suffer from a chronic psychiatric disorder.40
Substance abuse can be defined as using a drug in a way that it is inconsistent with medical or social norms and despite negative consequences.
Using of substances for pleasure is increasing day by day in the modern society, as a mark of fashion.
The chronic usage of addictive substances creates chronic physical and psychological problems among individuals and also has an impact on society.
Causes of Substance Abuse
  • Biological causes
  • Psychological causes
  • Social causes
Biological Causes
  • Family history of Substance abuse
  • Personality disorders
  • Co-morbid medical disorders
  • Re-enforcing effects of drugs
  • Withdrawal effects and craving
  • Biochemical factors.
Psychological Causes
  • Curiosity
  • Poor impulse control
  • Low self-esteem
  • Poor stress management skills
  • Childhood trauma
  • Psychological distress
  • Reaction to neglect
Social Causes
  • Peer group pressure
  • Modeling
  • Easy availability of alcohol and drugs
  • Familial conflicts
  • Religious reasons
  • Unemployment
  • Poor social support
Consequences of substance abuse: Substance abuse leads to disturb marriage/relationships, home/family life, poor performances in education and also leads to confusion, mental tension, shoplifting, violence, stealing and trafficking, etc. The health effects of substances abuse are unsafe sex, sex in exchange of substances, unwanted pregnancy, depression and other psychiatric diseases, co-morbid illnesses, self-injurious behavior and suicidal ideation and suicide.
Commonly used Substances
  • Alcohol
  • Opioids
  • Cannabinoids
  • Cocaine
  • Amphetamine
  • Hallucinogens
  • Barbiturates
  • Inhalants
  • Nicotine
  • Other stimulants.
Control of Substance Abuse
Primary prevention
  • Provision of happy and healthy family life
  • Establishment of healthy parent-child relationship
  • Provision of love and care to the children
  • Show interest towards the child's activities
  • Offer counseling to the teenagers
  • Reduce the availability of drugs
  • Legislation.
Secondary prevention
  • Closely monitor the changes in the behavior of an individual.
  • Early detection and treatment of addicts.
  • Establishment of de-addiction centers, after care centers and day care centers.
  • Proper treatment and specific therapies should be given to prevent complication of disease.
Tertiary prevention
  • Provision of treatment in the state of severe dependence.
  • Provision of rehabilitation measures for the drug addicts.
  • Involvement of family in the restorative and rehabilitative activities.
  • Involvement of social agencies for the rehabilitation.
Women abuse is define as any act of gender based violence that result in, as is likely to result in physical, sexual as psychological harm, as suffering to a women, whether occurrence in public or private life. (cited by Gomez, 1996)41
Forms of Women Abuse
Physical Abuse
Physical abuse is the intentional infliction of pain or injury by:
  • Slapping, shoving, punching, strangling, kicking, burning, stabbing and/or shooting
  • ‘Caring’ in an abusive way including giving too much medication, keeping confined, neglecting or withholding care
  • Using a weapon or other objects to threaten, hurt or kill
  • Sleep deprivation—waking a woman with relentless verbal abuse
  • poisoning.
Sexual Abuse
Sexual abuse is any form of forced sexual activity, including unwanted sexual touching, sexual relations without voluntary consent and the forcing or coercing of degrading, humiliating or painful sexual acts, including:
  • Rape
  • Forcing a woman to watch or take part in pornography
  • Forcing a woman to watch partner engage in sexual acts with others
  • Being compared to other lovers
  • Ridiculing sexual performance or sexual organs
  • Using weapons or other objects to penetrate
  • Touching or acting in any way that a woman does not want
  • Forcing or pressuring a woman into sexual acts
  • Forcing a woman into prostitution
  • Preventing a woman from receiving information or education about sexuality
  • Forcing a woman to become pregnant, have an abortion or have an operation to prevent pregnancy
  • Infecting a woman with HIV or other sexually transmitted diseases (STDs).
Psychological/Emotional Abuse
Psychological or emotional abuse is the use of systematic tactics and behavior intended to control, humiliate, intimidate, instill fear, or diminish a person's sense of self-worth, including:
  • Verbal aggression
  • Forcing a woman to do degrading things (e.g. eating cigarette butts or licking the floor)
  • Forcibly confining a woman against her will
  • Stalking or harassing
  • Threatening to harm or kill children, other family members, pets or prized possessions
  • Threatening to remove, hide or prevent access to children
  • Threatening to commit suicide
  • Controlling a woman's time, actions, dress, hairstyle, etc.
  • Preventing a woman from seeing a dentist or doctor
  • Not respecting a woman's privacy
  • Denying affection or personal care
  • Belittling a woman through name-calling or descriptions such as ‘stupid,’ ‘crazy’ or ‘irrational’
  • Accusing a woman of cheating or being promiscuous
  • Leaving a woman without transportation or any means of communication, especially in isolated or rural communities
  • Attacking a woman's self-esteem in other ways.
Social Abuse
  • Putting her down or ignoring her in public
  • Not letting the woman see her friends or family, making a scene, being charming with others and aggressive with her
  • Embarrassing the woman in front of her children, using children as a weapon, not taking responsibility for children
  • Placing limits on a woman about the people with whom she can talk on the phone or visit
  • Cutting a woman off from friends and family
  • Forcing a woman to be part of illegal/criminal acts (e.g. welfare fraud, drug operations, etc.)
Stalking includes repetitive harassing or threatening behavior done in a way that creates physical or emotional fear or apprehension in the person being stalked. A stalker may be trying to get his partner back or may wish to harm her as punishment for her departure. Regardless of the form, the victim fears for her safety or even her life.
Stalking includes:
  • Harassing her at work
  • Repeated phone calls, sometimes with hang-ups
  • Following, tracking (possibly even with a global positioning device)
  • Finding her through public records, online searching, or paid investigators
  • Watching with hidden cameras
  • Suddenly showing up where she is, at home, school, work, in the grocery store, at a movie, or in a restaurant
  • Sending emails, communicating in chat rooms, or with instant messaging
  • Sending unwanted packages, flowers, cards, gifts, or letters42
  • Monitoring her phone calls or computer use
  • Contacting her friends, family, coworkers, or neighbors to find out about her
  • Going through her garbage
  • Threatening to hurt her or her family, friends or pets
  • Damaging her home, car or property
  • Using the children as an excuse to repeatedly contact the woman or to show up where she and the children are (at the children's school or day care, at their extracurricular activities)
  • Engaging in legal bullying during family court proceedings.
Legal Bullying
Legal bullying is a very common kind of separation violence since this is one of the few remaining ways he can attempt to control and harass her. Legal bullying includes dragging out support and custody proceedings, refusing to pay support or alimony, withholding assets, and fighting for custody solely to maintain control over the woman. The abuser may:
Economic Abuse
Economic abuse includes any act or behavior that maintains control of financial resources or maintains a woman's financial dependence. It can include the following:
  • Withholding money for basic necessities (e.g. food, clothing, diapers, medication, transportation, etc.) or for emergencies
  • Forcing her to pay a disproportionate share of household expenses
  • Preventing a woman from getting to work, controlling where she works, not allowing a woman to work, forcing her to work
  • Spending or mismanaging family income, including a woman's earned income and/or savings, and leaving her and the children with little or no money
  • Controlling a woman's spending, including where purchases are made, what is purchased, etc. and forcing her to account for and justify all spending
  • Using credit cards without her permission and destroying her credit rating
  • Obtaining credit or incurring bills in her name without her knowledge or consent
  • Forcing her to turn over benefit payments or entitlements
  • Denying access to education/training opportunities (e.g. upgrading, ESL) that may lead to increased earnings or employment
  • Threatening to make false allegations about fraud to Ontario Works.
Spiritual Abuse
The use of a belief system to control, degrade or punish a woman. Spiritual abuse may include:
  • Using religion to control a woman's behavior
  • Punishing or ridiculing a woman for her religious beliefs
  • Preventing a woman from practicing her religious beliefs
  • Forcing a woman to practice certain beliefs and engage in rituals
  • Putting down or attacking her spiritual beliefs
  • Preventing a woman from going to church, synagogue, temple or other religious institution of her choice
  • Forcing a woman to join and/or stay in a cult.
Prevention of Women Abuse
Violence against women and girls is rooted in gender-based discrimination and social norms and gender stereotypes that perpetuate such violence. Given the devastating effect violence has on women, efforts have mainly focused on responses and services for survivors. However, the best way to end violence against women and girls is to prevent it from happening in the first place by addressing its root and structural causes. Prevention should start early in life, by educating and working with young boys and girls promoting respectful relationships and gender equality. Giving importance on woman empowerment can helps in prevention and control of women abuse.
Domestic Violence Act
The Protection of Women from Domestic Violence Act 2005 is an Act of the Parliament of India enacted to protect women from domestic violence. It was brought into force by the Indian government from 26 October 2006. The Act provides for the first time in Indian law a definition of ‘domestic violence’, with this definition being broad and including not only physical violence, but also other forms of violence such as emotional/verbal, sexual, and economic abuse. It is a civil law meant primarily for protection orders and not meant to penalize criminally. The act does not extend to Jammu and Kashmir, which has its own laws, and which enacted in 2010 the Jammu and Kashmir.
Over the past decade, gender equality and women's empowerment have been explicitly recognized as key, not only to health of Nations, but also to social and economic development. India's National Population 43Policy 2000 has ‘empowering women for health and nutrition‘ as one of its crosscutting strategic themes. Additionally, the promotion of gender equality and empowering of women is one of the Millennium Development Goal (MDG) to which India is a signatory. MDG recognizes that gender equality and women empowerment are two sides of the same coin.
Empowerment: Development must be by people, not only for them. People must participate fully in the decisions and processes that shape their lives. Investing in women's capabilities and empowering them to exercise their choices is not only valuable in itself but is also the surest way to contribute to economic growth and overall development.
Women empowerment means strengthening the capacity of women in order to identify, understand and control their lives. Women due to lack of control have little to say in decisions, so they need to be empowered to achieve control and to participate in decision making related to their health matters.
According to Arrow (1995) women empowerment is the process by which women strengthens their capacity individually and collectively to identify, understand and overcome gender discrimination, thus taking control of their lives.
Women empowerment can be achieved by changing policy and programs of actions and directing these policies and programs that will improve women's access to secure livelihood and economic resources, alleviating their extreme responsibility with regard to house work, remove legal impediments to their participation in public life and raising social awareness through effective programs of education and mass communication. Even improving the status of women also enhances the decision making capacity at all levels in all spheres of life.
The women need to be developed socially, educationally and economically in order to achieve empowerment among them.
Social Development
Social of women development of women means raising the status of women in society. Women in male dominating society, i.e. patriarchal form of society do not get the same status as men especially in decision making. As a result, they are facing threats to their lives, health and well-being.
Social legislation has brought a change by developing the women socially. Nowadays, if women compared with the women of earlier ages, they are having more privileges. This is due to certain social legislations.
  • In 1950, New constitutions of India accorded equal rights to women. All women now enjoy political equal rights with men. They have the right to vote and have right to hold public offices.
  • In 1955, Hindu marriage Act and Divorce Act have removed several disabilities. No Hindu can marry second time unless wife or husband is dead or divorced.
  • In 1976, the equal remuneration Act,1976 provide for equal payment of remuneration to men and women workers.
  • In 1978, the child marriage restraint amendment Act , has raised the marriage of girls from 15 to 18 years of for boys 18 to 21 years.
All the legislative measures help in bringing awareness among women and removing social prejudices and inequalities; thereby bringing social development.
Educational Development
Women need to be educationally developed. It has been seen that women receive less formal education than men and at the same time, women's knowledge, abilities and coping mechanisms often go unrecognized. Education will help them in creating awareness regarding demerits and merits of large and small family size as well as other aspects of health. If she is educated, then she can educate the whole family and can care the family adopting appropriate measures.
Lack of education has been an obstacle in the development of women. So there is need to take all special efforts to raise the literacy rate among women and girl's education. Government is making the efforts to raise the educational level of women. The Central Govt. is providing financial assistance under the plan schemes to establish schools and colleges exclusively for girls in backward states. Special programs have been started for improving girl's education level. Other incentives are also provided such as clothing, free tuition.
Eliminating gender differences in access to education and educational attainment are key elements on the path to attaining gender equality and reducing the disempowerment of women.
The grants are provided by central social welfare board to voluntary organization to conduct courses of two or three years duration for having education. In order to achieve increased literacy rate, there is need to bring changes in policies and programs.
Economic Development
Educational development and social development will bring a change in economic condition of the women. Women can be empowered economically by:44
Implementing Income Generating Schemes
By these schemes rural and poor women come together and develop an understanding of their problems and fulfill their need. Under these schemes:
  • Technical information is imparted and strategies to plan action towards development and against injustice.
    • Vocational courses for women
    • Opening of women polytechnics
    • Rehabilitation of women by providing vocational training cum employment and residential care to old widows, deserted women.
To raise the economic level of women, women's development corporation are plying an important role in providing employment opportunities to women so it is essential for the sustainable development of community that the women should be empowered and developed socially, educationally, politically and economically. Experience shows that population and development programs are effective if overall development occurs in women.
In 2000, the govt. of India adopted a national policy for the empowerment of women. This was to bring about gender justice. National Health Policy was under consideration in 2005 for implementation and it to be reviewed twice a year. The aims of the policy are:
  • Women equality in power sharing and active participation in decision making.
  • Comprehensive economic and social empowerment of women.
  • The advancement, development and empowerment of women in all spheres of life.
  • Strengthening and formation of relevant institutional mechanisms.
  • Partnership with community based programs.
  • Implementation of international obligations and co-operation at international, regional and sub-regional levels.
  • More responsive judicial legal systems that are sensitive to woman's need.
To review laws and legislation related to women, a task force for women headed by deputy chairperson of planning commission has been constituted. The laws related to divorce, marriage and succession were amended to empower the women. National Commission on women has formulated a code of conduct for preventing sexual harassment at place of work. Tenth five year plan (2002–2007) is concerned towards promotion of gender equality and empowering women which include three strategies of empowering women. These are social empowerment, economic empowerment and gender injustice.
Programs and Schemes for Women Empowerment
The ministry of women and child development launched different schemes for over all empowerment of girls and women. They are listed as follows:
  • Beti Bachao Beti Padhao Scheme
  • One Stop Centre Scheme
  • Women Helpline Scheme
  • UJJAWALA which is a comprehensive scheme for prevention of trafficking and rescue, rehabilitation and re-integration of victims of trafficking and commercial sexual exploitation
  • Working Women Hostel
  • Rajiv Gandhi National Creche Scheme for the children of working mothers
  • SWADHAR Greh (A scheme for women in difficult circumstances)
  • Revision under IGMSY in accordance with national Food Security Act, 2013 in12th Plan
  • Support to Training and Employment Programme for Women (STEP)
  • Nari Shakti Puraskar
  • Rajya Mahila Samman and Zila Mahila Samman awards
  • Indira Gandhi Matritva Sahyog Yojana (IGMSY) - A conditional maternity benefit scheme
  • Release of 2nd installment of grant for 2015—2016 for all the States under IGMSY.
Historical Development of Public Health in India
Ancient India (3000 BC): Ancient India was among the pioneer countries where knowledge of public health existed. As early as 3000 BC Indus Valley Civilization showed practice of public health. The relics excavated at the site of two cities Mohenjodaro and Harappa showed water supply, public baths and drainage system. It was also found that these cities were built with adequate planning.
Vedic Period (1400 BC–600 BC): People during Vedic period were conscious of health and hygiene. The book Manu Samhita written during this period. This book prescribed rules for personal hygiene, diet and rituals to be followed during birth and death. Susruta, who is considered as the father of surgery in India lived during this period.
600 BC–600 AD: During this period there were two famous universities namely Nalanda and Taxila, which started systematic medical education. Buddhism became popular during this period and these universities came out of Buddhist religious movement.45
Ayurvedic system of medicine which originated in India, was widely accepted during this period. Charak, who has been considered as the father of Indian medicine, also practiced during this period.
268 BCE–232 BCE: King Ashok ruled, during which period, prevention of disease was given importance and hygienic practices were adopted. Cleanliness of body considered as a religious duty. Doctors and midwives were to be trustworthy and skillful. Lying in room for delivery was kept clean and it was well ventilated.
Mughal Period (1650–1857 AD): The Mughal emphasis on physical fitness and encouragement of out-of-door mainly games for maintaining their general standard of health. Though the medical services were inadequate for the people, still the local physicians were able to deal with normal problems. Public hospitals had been provided in Muslim India, at least since the days of Firuz Tughluq (1351–1388). As early as 1616 they knew the important characteristics of the bubonic plague and suggested suitable preventive measures. A crude form of vaccination against smallpox seems to have been employed by Eastern doctors, for it was vaguely realized that the introduction of a mild form of cowpox prevented the virulent form of smallpox. In this period the use of medicines had been well developed among the Hindus, but dissection was considered to be irreligious. The Muslims, who did not have this restriction, performed a number of operations. With the invasion of Mughals, Unani system of medicine, which originated in Arab countries, also came to India.
During British Rule (1757–1947): Concern for public health was established in India with commencement of British rule. British soldiers stationed in India, died in large numbers due to unhygienic conditions and contagious diseases prevailing at that time. So the British Government felt concerned about the poor condition of public health in the country.
1825 – Quarantine Act was promulgated.
1839 – A Royal Commission was appointed to investigate the causes of death of British Soldiers in India. Florence Nightangle who had experience in Military Barracks of Scutari and recommended corrective measures for improvement of sanitary conditions in India. The Royal Commission recommended supply of safe drinking water, construction of proper drainage system and prevention of epidemics among the civil population where British soldiers are stationed.
1864 – Sanitary Commissioners were appointed in Bombay, Madras, and Bengal. At the same time many actions were initiated and public health acts were passed to improve the existing condition of health in India. Some of these are:
1869 – Public Health Commissioner and a Statistical Officer were appointed with the Government of India.
1873 – Birth and Registration Act. The different phases of public health
1880 – 1920 Disease Control Phase
1880 – Vaccination act was passed.
1881 – First Indian factories act was passed and first All India Census was taken.
1885 – Local self government act was passed.
1886 – The idea of training females for maternity care came. Missionaries felt the need of training the Dais who assisted in the delivery of mothers at home.
1888 – Government of India directed that local bodies should be responsible to look after the sanitation but no local public health staff was appointed to carry out that task.
1891 – First All India Census
1896 – Government of India awoke to improve the public health of India, subsequent to an outbreak of plague. The Plague Commission was appointed.
1897 – The Epidemic Disease Act was promulgated.
1904 – Plague Commission recommended in its report that:
  • Public Health Departments should be reorganized and expanded
  • There should be laboratory facilities established for purposes of research and production of Sera and Vaccine.
1907 – Central Malaria Bureau at Kasavli was established.
1911 – Indian Research Fund Association was established for the purpose of research.
1917 – Government of India sanctioned the appointment of Deputy Sanitary Commissioners and Health Officers. Also grants were sanctioned to local bodies.
1918 – Lady Reading Health School In Delhi was established.
The Nutrition Research Laboratory at Coonoor was established.
1919 – The Public Health sanitation and vital statistics responsibilities were transferred to provinces under the control of an elected minister. This is the first step taken in decentralizing the health administration of India.46
1920 –1960 Health Promotional Phase
1920 – In several provinces, Municipality and Local Boards Act were passed.
1921 – The act providing legislation for the advancement of public health was passed. First confined their efforts to control of small pox, cholera and plague. Priority was given to small pox vaccination.
1924 – A subsidized rural practitioner scheme was introduced.
1926 – Madras Nursing Council was the first one to pass the act to train nurses in midwifery to replace the dais in 1926 – Missionaries established the Lady Reading Health School for training the health visitors to carry out public health nursing along with midwifery care. Then few other states also established schools for health visitors.
1930 – At Calcutta, an All India Institute of Hygiene and Public Health was established with aid from the Rockefeller Foundation.
1931 – A Maternal and Child Welfare Bureau was established by Indian Red Cross Society.
1935 – The health activities in the country were grouped as under the control of Central or Central-cum-provincial or Provincial government.
1937 – A Central Advisory Board of Health was set up. The public health commissioner was the secretary and states were members to coordinate the public health activities in the country.
1939 – Madras Public Health Act was passed. Indian Tuberculosis Association was established.
1940 – The Drug Act was passed and for the first time were brought under control.
1943 – In October 1943, Bhore Committee was appointed by the Government of India to make survey of the existing health conditions and to formulate a comprehensive plan for administration.
1946 – Bhore Committees’ report was submitted and recommended the establishment of health centers for providing integrated curative and preventive services. Recommended the posts of PHN in PHC. So two colleges of Nursing at Vellore and New Delhi were established to train graduate nurses undergoing an integrated course of theory and practice of public health nursing along with GNM.
One of the main objectives of preparing B.Sc. Nurses was to prepare PHN to function with a high level of efficiency in the community health set up. But due to shortage of teachers in newly opened schools of nursing, most of the B.Sc. Nurses were absorbed as teachers.
Post Independence Era
1947 – India established the concept of Welfare State at the time of independence. The National Government took up the responsibility of improving the health of people by covering all aspect of community, i.e. administration, training, expansion of health services, research.
1948 – India joined as a member state of World Health Organization. Employees State Insurance Act was passed. Report of environment hygiene committee was published.
1950 – The Constitution of India came into force in 1950. The Planning Commission was set up by the Government of India, which immediately drafted the first five year plan.
1951 – Beginning of First Five Year Plan. BCG vaccination programme was launched. Central Drug Research Institute launched at Pune.
1952 – Constitution of Central Council Health. Primary Health Centers set up. To train the GNM Nurses as Public Health Nurse, however, a diploma course of one academic year was introduced and started at College of Nursing, New Delhi. The training was transferred to All India Institute of Hygiene and Public Health, Calcutta, Lady Reading Health School in Delhi, LHV training was also started. GNM Nurses were given theory and practical training in public health to become PHN.
1953 – National Malaria Control Programme was initiated. Nationwide family planning research and programme committee was set up.
1954 – contributed health services scheme was initiated in Delhi. Central social welfare board was set up.
  • National water supply and sanitation scheme was inaugurated
  • National leprosy control programme was started
  • VDRL Antigen production was set up in Calcutta
  • Food adulteration act was passed by Parliament.
1955 – National Filaria Control Programme was started. Central Leprosy Training and Research Center was established at Chengelpet in Tamilnadu. National Tuberculosis survey commenced.
1956 – Second Five Year Plan begun. Central Health Education bureau was established. Director for family planning was appointed at the Union Ministry of Health.
Chemotherapy center at Madras was started.
1958 – National Malaria Control Programme was changed to National Malaria Eradication Programme. National Tuberculosis survey was completed.47
1959 – Mudaliar Committee was appointed to review the progress made in health since the Bhore Committee recommendation. The National Tuberculosis Institute at Bangalore was established. The Nutrition Research Lab. At Coonoor was shifted to Hyderabad.
1960-1980 Social Engineering Phase
1960 – Mudaliar Committee report was published and recommended. Training of auxiliary nurse midwives should be continued and extended to have a second line of trained personnel to meet the needs of the country and one auxiliary nurse will be for 500 population by the end of 15 years. There should be a public health nurse with a basic nursing qualification and one year training in domiciliary care and other public health aspects of community work.
Male nurses should be trained only for certain types of work, i.e. mental hospital, army hospital, etc.
1962 – The central family planning institute was established. National smallpox eradication programme, national goiter control programme, national school health programme and district tuberculosis programme were established.
1963 – Applied nutrition programme started by Government of India and WHO. National Institute for Communicable Disease was established in Delhi. The Chadha committee was established a norm of one Basic Health Worker for every ten thousand people. A drinking water board was set up.
1964 – National Institute for Health Administration and Education was established in Delhi.
1965 – IUCD was introduced. Direct BCG vaccination programme without tuberculin test was introduced.
1966 – Minister for Family Planning was appointed under Ministry of Health. A separate department of Family Planning was constituted to coordinate family planning programme at central and state.
1968 – Medical Education Committee was appointed by Government of India.
1970 – All India Hospital Family Planning Programme was started. Birth and death registration act came into force.
1971 – Medical Termination of Pregnancy bill was passed by Parliament.
1972 – Medical Termination of Pregnancy bill was came into force. National Institute of Nutrition was set up at Hyderabad.
1973 – Government plans to set up 30 bedded rural hospital one for every four primary health centers.
A new cader of health workers called multipurpose health workers was formed on the basis of the recommendation of Kartar Singh Committee report who will eventually replace auxiliary nurse midwives, family planning workers and basic health workers.
1974 – The fifth five year plan came into operation. It was the year of world population by the United Nations. The term community health is replaced in place of public health.
1975 – India was declared as smallpox free in July. Integrated Child Development Scheme was launched in India. National Children's Welfare Board was set up.
1976 – A three tier plan of health care delivery system to rural areas was proposed by Central Council of Health. National Programme for Prevention of Blindness was formulated. The Prevention of Food Adulteration Act of 1975 was amended and passed.
1977 – International Commission declared that India has eradicated smallpox. National Institute of Health and Family Planning was formed. Community Health Workers Scheme was begun by the Union Ministry of Health.
1978 – The slogan Health for All by 2000 AD came into light by the International Conference on Primary Health Care in Alma Ata Declaration in USSR.
1979 – The year, was observed a The Year of Child all over the world.
1980 – Small pox was officially declared eradicated worldwide by WHO.
Health for all Phase (1981-2000 AD)
1981 – The 1981 census was taken up. India is committed to the goal of providing safe drinking water and adequate sanitation for all by the year 1990. Emergence of AIDs as a life threatening infection. First recognized in United States of America. AIDs had already appeared in several areas of the world by late seventies posing a serious international health problem of extraordinary urgency.
1982 – The new 20-point programme was announced. The Government of India announced its National Health Policy. WHO experts committee meeting organized in Geneva on the training of nurse teachers and managers with special regard to primary health care.48
1983 – Common Wealth Nurses Federation South Asian Seminar on the Role of Nurse in the Delivery of Primary Health Care Programme was conducted in the college of Nursing, Madras, Tamilnadu from 5th to 7th December. This was organized by Trained Nurses Association of India and Tamilnadu State branch was the hot. Nurses from India and other countries participated. This was the first of its kind in India. The TNAI was initiated various programmes for primary health care at National, Regional level.
1984 – Bhopal Gas Tragedy was occurred on the night of December. The ESI Amendment Bill, 1984 was passed by Parliament.
1985 – Seventh Five Year Plan was launched and universal immunization programme was launched. A separate department of women and child development was set up under Ministry of Human Resource Development. INC prescribed a Diploma in Nursing Education and Administration Course for General Nursing and Midwifery nurses with 2 years experience. This courses along with teachers training and administration course curriculum also includes training in public health to make them suitable to act as public health nurse as well as PH instructors in schools of nursing. The introduction of MPHW scheme.
1986 – The Environment Protection Act, 1986 promulgated.
1987 – The Government of India appointed a High Power Committee on Nurses and Nursing Profession to go into the working conditions of nurses, nursing education and other related matters.
1988 – New 20-Point Programme was launched. India Standards Institution was renamed as Bureau of Indian Standards. Safe motherhood programme was launched. National Diabetes Control Programme and National AIDs control programme was initiated.
1989 – Blood Safety Programme was launched.
1990 – Control of Acute Respiratory Infections Programme was initiated.
1992 – Eighth Five Year Plan was launched. Child Survival and Safe Motherhood Programme was launched.
1993 – Revised National TB Programme with DOTS was introduced.
1995 – ICDS was renamed as Integrated Mother and Child Development Services.
1996 – Pulse Polio Immunization was initiated.
1997 – Reproductive and child health programme was launched. Ninth five year plan was launched.
1998-99 – National Family Health survey was undertaken. National Malaria Eradication Programme was renamed as National Antimalaria Programme.
2000 – Government of India announced National Population Policy.
2002 – National Health Policy (2002) was announced. Government announced National AIDs Prevention and Control Policy.
In September 2000, Representatives from 189 countries met at the millenium summit in New York to adopt the United Nations Millenium Declaration. The leaders made specific commitments in seven areas: peace, security, disarmament, development and poverty eradication, protecting our common environment, human rights, democracy and good governance, protecting the vulnerable, meeting the special needs of Africa and strengthening the United Nations. The Road Map established goals and targets to be reached by year 2015 in each of seven areas. The goals in the area of development and poverty eradication are known as Millenium Development Goals.
When a person in a community is sick or ill, the people are able to find the illness and take steps to help his get well. Similarly, can we tell when, a community is ill, the question that naturally arises whether a community can get ill. What do you mean by the health of a town or a community? In a community at any point in the same persons are ill and others are well. If many persons are ill, we say that the health of the community is poor. If many persons are well, we say that the health community is good. On the other hand in a ‘healthy’ community there will be ill and in ‘sick’ community there will be some persons who are healthy. Can anyone find out the total numbers of ill persons in a community? How does one identify any measure of health diseases? It also involves the social, economical, political living conditions and the attitude and beliefs of people on their health status. A person will be found ill when he is diagnosed by the doctor. In the same way community diagnosis will help in identifying the health status of a community.49
Community diagnosis is a comprehensive assessment of the state as an entire community in relation to its social, political, economic, physical and biological environment, A process by which the nurse collects data about the community in order to identify factors which may influence the deaths and illnesses of the population, to formulate a community health nursing diagnosis and develop and implement community health nursing interventions and strategies.
The purpose of this diagnosis is to determine problems and to set priorities for planning and developing programmes of care for the community.
The Purpose of Community Diagnosis
  • It helps to identify community needs and problems
  • It is a prerequisite for planning, implementing and evaluation of successful community-based health and development programmes
  • It helps to decide strategies for community involvement
  • It helps to match project organizations and services with community needs
  • It can be used to help the community become conscious of its existing problems and finding solutions.
Assessing the Health Status of the Community
The process of community diagnosis is critical for the following reasons:
  • It is an opportunity for the community to learn about itself
  • It is an opportunity for outsiders, such as health workers and personnel from other sectors, to learn about the community
  • It will generate information to be used for planning.
Ideally, the process of community assessment should aim to find out all information relevant to the health and all information relevant to health and well-being of entire community nor the health workers may have sufficient time available to devote to data collection. Another important reason is that the community may not at first see the need for detailed collections of information. They may feel, with justification that they know all by virtue of their day-to-day experiences. For this reason it may be a better approach to begin by asking the community, through its leaders, to describe its present circumstances in the following terms:
All of this information can usually be obtained at least roughly through conversation. It should be recorded systematically, in writing, in terms that the people can understand and constantly refer to. Any gaps should be noted for future information gathering. This initial conversation is also good means of assessing the knowledge of the leaders concerning their community, which in turn is a useful indication of their or concern with community as a whole.
Objectives of Community Diagnosis
  • To find about all information relevant to the health and well-being of the community
  • To identify and quantity of the health problems in a community in a term of mortality morbidity
  • To evaluate health services
  • The qualification of health problems can be a source of new knowledge about disease distribution, causation and prevention
  • To understand about the social, cultural and environmental characteristics of the community.
Content of Community Diagnosis
A programme coordinator should know the following facts about the community:
Hard Measurable Facts
  • Age
  • Sex distribution
  • Literacy status
  • Prevalence of disease
  • Land holdings
  • Sanitary conditions
  • Irrigation facilities
  • Others
Overall organization pattern of the community within which there are several suborganizations, e.g. castes with their own values and pattern of conduct. Each sub organization is intricately interrelated to the other and to the overall community, thereby affecting its entire behavior.
The process of community diagnosis is a continuous learning experience both for the programmer and community, when considered in all its aspects community. Diagnosis a simple process that develops gradually and only requires keen perceptiveness, observations and study of the facts obtained.
Steps in Community Diagnosis
  • Defining area–who and what: This is an area of intensive study from which it is gathered the data for community diagnosis and in which health action is 50most easily evaluated. The data should be gathered and health action evaluates unless it is limited and defined in this way.
  • Identifying the needs from the community perspective: The identification of needs as perceived by the community is a useful means of assessing the priorities and values of the people. It is quite possible that directly health related needs may not feature high on a list of overall community needs in order to obtain such information, it is important that the outsiders enquires about needs do not pressurize the community, to include health needs they do not consider important.
    Numbers of approach are needed to elicit reliable data. In other cases an additional enquiry will be usually required, either as apart of a community survey on all respect of the community or as a separate enquiry.
  • Specifying priority health needs of the community: Specifying priority health needs is a delicate process requiring a lot sensitivity on the part of the health worker who may be receipted to regard this as his particular field of expertise with the consequence danger of dictating to the people what their problems are. This must be registered at all costs and genuine community involvement is to succeed.
  • Identifying community resources for facilitating health problems: Resources available for health care, particularly in developing countries, are limited. It follows that countries must strive to identify and then to mobilize all potential resources and ensure that they are used as effectively as possible. Community involvement in PHC makes possible the mobilization of plenty of resources, which might otherwise remain unutilized.
    The individual and collective actions of the people constitute one of the most important types of community resources for achieving better health. The people should be motivated to provide facilities such as drugs, building, equipment, money, or contributions in terms of money and materials.
  • Setting priorities for action: The priorities may vary greatly, reflecting local judgement as far as possible. However, it must be recognized that certain national health priorities already, have been established, for example with respect to immunization and control of malaria, TB and AIDS/STD. The health consequences for the country as a whole may be such that these cannot be postponed until all communities have explicitly endorsed the national programmes. Thus, communities are likely to be faced with a number of health's initiators which are already being implemented their approval being sought. It will be important for the local health workers, to explain the existence and relevance of such initiatives, so that communities can incorporate them into their agreed priorities for action.
  • Community needs in proportion to national capacity: Closely associated with the setting of priorities at community level is the capacity of the country as a whole to support this implementation. One striking example is the construction of a clinic or health center rather common community felt need. In almost all countries, there are insufficient resources. To finance such projects every community taking into account not only the costs of constructions but of training staff, paying their salaries and keeping them supplied with medicines and equipment. In such circumstances, where community felt needs cannot be met, it is as possible to prevent to be building up and enable them to adjust their expectations to realistic levels.
  • Mechanisms for intersectional co-operation in planning: ‘No sector involved in community development can work effectively in isolation. Interdependence in such those activities in one sector have an impact on the goals of another. For maximum benefit it is essential that all sectors fully appreciate their roles in overall community development and their relationships with one another. Thus, there is an essential need for effective coordination at all levels between health and all other sectors.’
At local level the mechanism established for adequate in providing for intersectional cooperation, for example, the CD committees just like the local health worker, the school teacher, the agricultural worker, and the social worker will act as a technical adviser to the community as well as provider of logistical support where appropriate.
Health for all has been defined as attainment or a level of health that will enable every individual to lead a socially and economically productive life. Health for all means simply the realization of WHO's objective of attainment by all people the highest possible level of health. HFA means that health is brought within reach of everyone in a given country. It enables a person to lead a socially and economically productive life. The stress is on the provision of the treatment, promotion and prevention to the people representing a shift from medical care to health care and from urban population to rural population.
HFA is thus a holistic concept calling for efforts in agriculture, industry, education, housing and communications, 51medicine and public health. The basis for HFA strategy is primary health care (Halfdan Mahler 1981).
History and Evolution of HFA
In 1977, the World Health Assembly decided that the major social goal of governments and WHO should be the attainment by all people of the world by the year 2000 of a level of health that would permit them to lead a socially and economically productive life.
In 1981, the Assembly unanimously adopted the global strategy for health for all by the year 2000. This was the birth of the ‘Health for All’ movement.
‘Health for All’ does not mean an end to disease and disability, or that doctors and nurses will care for everyone. It means that resources for health are evenly distributed and that essential healthcare is accessible to everyone.
It also means that health begins at home, in schools, as well as the workplace, and that people use better approaches for preventing means that people recognize that ill health is not inevitable and that they can shape their own lives and those of their families from the avoidable burden of disease.
In 1994, WHO's member states acknowledged that significant global changes had occurred since that time, and called for a strategy renewal to meet challenges, expand opportunities, and overcome obstacles at the dawn of the 21st century.
The concept of HFA conceived and practiced in India during Vedic civilization in the cherished value of health is enshrined in an ancient Sanskrit verse ‘SARVE SANTU NIRAMAYAH’ which means ‘let all be free from disease.’ Let all be healthy used to express good wishes. Factors led to the evolution of goal for HFA – 2000:
  • Inaccessibility of and nonequitability of essential health care of life saving measures to majority of people in developing countries.
  • Gross inequalities in health care system and distribution of health facilities.
  • Failure of existing health care system to cope with primary health care problems.
  • Unresolved emerging health care problems in developed countries.
The term primary health care was first used to mean the care given to the patient by health worker who saw him first. It was also called FIRST CONTACT CARE.
Central Theme for HFA
  • Universal coverage with primary health care that is relevant effective, acceptable and affordable in terms of the need, culture interest and resources of each community.
  • Community participation in the planning, provision and evaluation of health services.
  • Integration between health and other health related sectors.
Global Targets for HFA
  • All people in every country will have at least a ready access to essential health care and to first level of referral facility.
  • All people will be actively involve in care for themselves and their families as far as come in first level of care and in community action for health.
  • Countries throughout the world will share with government responsibility for health care of the members.
  • All government will have assumed overall responsibility for the health of their people.
  • Availability of safe drinking water and basic sanitation for all.
  • Adequate nourishment for all people.
  • Full coverage of children for vaccine prevented diseases.
  • Communicable disease in the developing countries will be of no greater significance in the year 2000 than they are in developed countries in the year 1980.
  • All possible ways will be applied to prevent and control on communicable diseases and promote mental health through influencing lifestyle and control of physical; and psychological environment.
  • Provide essential drugs for all.
In September 2000, representatives from 189 countries met at the millennium summit in New York to adopt the United Nations Millennium declaration. The leaders made specific commitments in seven areas; peace security and disarmament, development and poverty eradication; protecting our common environment, human rights, democracy and good governance, protecting the vulnerable; meeting the special needs of Africa and strengthing the United Nations.
Government set a date of 2015 by which they would meet the Millennium development goals. The Millennium Development Goals place health at the heart of development and represent commitments by government throughout the world to do more to reduce poverty and hunger, and to tackle ill-health, gender inequity, lack of education, access to clean water and environmental degradation.
Millennium development goals have been set by the United Nations and health has been identified as a significant area of concern. MDGs are as follows:52
  • Goal 1: Eradicate Poverty and Hunger
    • Target-1: Halve hunger between 1990 and 2015 the proportion of people whose income is less than one dollar a day.
    • Target-2: Achieve full and productive employment and decent work for all, including women and young people.
    • Target-3: Halve between 1990 and 2015 the proportion of people who suffer from hunger.
  • Goal-2: Universal Primary Education
    • Target-1: Ensure that, by 2015 children every where boys and girls a like, will be able to complete a full course of primary schooling.
  • Goal-3: Promote Gender Equity and Empower Women
    • Target-1:Eliminate gender disparity in primary and secondary education, preferably by 2005 and to all levels of education no later than 2015
  • Goal-4: Reduction of Child Mortality
    • Target-1: Reduce under five mortality by two third.
  • Goal-5: Improve Maternal Health
    • Target-1: Reduce maternal mortality by three quarters.
  • Goal-6: Combat HIV/AIDs, Malaria and Other Diseases
    • Target-1: Have halted by 2015 and began to reverse the spread of HIV/AIDS.
    • Target-2: Have halted by 2015 and begun to reverse the incidence of Malaria and other major diseases.
  • Goal-7: Ensure Environmental Sustainability
    • Target-1: Integrate the principles of sustainable development in to country policies and programs and reverse the loss of environmental resources.
    • Target-2: Reduce biodiversity loss, achieving by 2010 a significant reduction in the rate of loss.
    • Target-3: Halve by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.
    • Target-4: By 2020, to have achieved a significant improvement in the lives of a least 100 million slum dwellers.
  • Goal-8: Development of a Global Partnership for Development
    • Target-1: Develop further an open, rule based, predictable, nondiscriminatory trading and financial system.
    • Target-2: Address the special needs of the least developed countries.
    • Target-3: Address the special needs of the land locked countries and small island developing states.
    • Target-4: Deal comprehensively with the debt problems of developing countries through national and international measures in order to make debt sustainable in the long term.
    • Target-5: In cooperation with the developing countries, develop and implement strategies for decent and productive work for youth.
    • Target-6: In cooperation with pharmaceutical companies provide access to affordable, essential drug in developing countries.
    • Target-7: In cooperation with the private sector make available the benefits of new technologies especially information and communication.
Societal Influences
Many factors influenced the growth of community health nursing. These are:
  • Advanced technology shaping the practice of health care, nutrition, lifestyle transportation, job mobility, free products, equipments, computer technology and treatment for other technology.
  • Progress in causal thinking. In the health science, particularly in epidemiology significantly affected the nature of community health nursing.
  • Changes in education
  • Changing role of women has profoundly affected community health nursing – nurse still struggle for equality.
  • Consumer movement – demanding their rights in many areas.
  • Economic forces.
CH nursing has evolved into a focus on care of individuals families and communities. The focus and orientation are different to other nurses in their work areas. CHN is a specific and specialized orientation to the care that embodies participles of public health as guiding concepts.
Primary health care is one aspect of CH nursing. CH nursing focuses on the physical, biological, social, psychological and environmental health of a population group. While primary care is a coordinated system of personal health care, emphasizing first contact care and continuously. Primary care emphasizes ambulatory care that addresses total client needs both for curative an preventive services. CH nursing is population based.
Primary health care is the first level of contact between the individual and the health system where ‘essential’ health care (primary health care) is provided. A majority 53of health complaints and problems can be satisfactorily managed. This level of care is closest to the people. This care is provided by the primary health centers and their subcenters, within community participation.
Primary health care is a practical and key approach to making essential healthcare accessible to all in the universe and helping them to attain acceptable of health. It is equally valid for all the countries from most developed to the least developed countries.
Primary health care addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly within the economic conditions.
Concept of Primary Health Care
After three decades of trial and error and dissatisfaction in meeting peoples’ basic health needs, the World Health Assembly, in May 1977, the Government of India launched a Rural Health Scheme, based on the principle of ‘placing people's health in people's hands. It is a three tire system of health care delivery in rural areas based on the recommendation of the Shrivastav committee in 1975. Close on the heels of these recommendations, an international conference at Alma-Ata in 1978; jointly WHO and UNICEF introduce primary healthcare approach to achieve the goal of an acceptable level of Health for All the people of the world by the year 2000 AD.
The conference declared (PHC) as the key approach to achieve the ‘HFA’ goal. It also stated that PHC shall be the part of overall development of the nation and should be the spirit of social justice.
The Alama Ata Conference defined Primary Health Care as:
‘Primary health care is essential health care made universally accessible to individual and acceptable to them, through their full participation and a cost the community and country can afford’.
History of Primary Health Care
The concept of primary health care was born in India during postindependent era. In 1947 the Bhore Committee recommended for the integration of preventive health services along with the curative services in offering health care to the people in rural and remote area through the organization of health center. The Bhore committee recommendation highlighted on:
  • To provide comprehensive and preventive, curative and promotive health services to the people in the rural areas through the network of PHC and the health care to be accessible to all.
  • Another short term plan was proposed to establish a PHC for a population of forty thousand and a secondary unit to supervise thirty PHC with 650 bedded hospital. A distinct hospital which will serves as a referral center with specialties. These recommendations were not satisfactorily implemented because (1) distance from PHC to District Hospital became greater from 8 km to 160 km which become impossible for the people to get immediate medical help. Now there are nearly 5886 PHC operating in India.
  • The health needs of the people in India are varied. The population is increasing at the rate of 18 million annually. MMR (3-4) and IMR (120) are very high. Nutritional status and hygienic conditions are very poor and all these may vary from urban to rural areas state to state, religion to religion and region to region, etc. life expectancy was low. Literacy rate was only 30%. The PHC was not covered with doctor with all regions. The health services is mostly urban oriented only curable in nature since 1952. The emphasis was on preventive concept which integrated in GNM curriculum to prepare nurses for health orientation in meeting the need of the people. But in many states the thought are not implemented and lost gradually.
Now the concept of Primary Health Care has become a global level with Alma Atta declaration at the USSR to the grassroots level with increasing recognition of failure of existing health services to provide health care. Alternative ideas and methods have been tried.
In 1947 the world health assembly gave the call for HFA by 2000 AD. Health for all basically meant that individual should attained a level of health which will enable them to earn their livelihood and lead a socially congenial life. So, at the joint venture of WHO and the UNICEF executive in the national conference at Alma Atta USSR, the capital of Kazakhstan from 6–12 September, 1978 with the Governments of 134 countries and many volunteer agencies called for a revolutionary approach to healthcare and the topic was the existing gross inequality is the health status of the people particularly between developed and developing countries as well as within countries politically, socially and economically unacceptable. The conference emphasizes that the key to attain the HFA by 2000 AD was through implementation of primary health care and this is put forcefully in the declaration of Alma Atta to which all the participating countries were signatory and India was one of these countries.54
zoom view
Fig. 1.12: Concept of primary health care
The 30th health assembly decided in 1977 May that the main social target of government and WHO should be the attainment of HFA by 2000 AD, i.e. the attainment by all the people of the world of the level of health that will permit them to lead socially and economically productive life.
In 1978 an international conference on PHC held at Alma Ata USSR issued a declaration which stated that PHC is key to attaining the HFA by 2000 AD.
In May 1979, the World Health Assembly endorsed declaration of Alma Ata on Primary Health Care and invited member states to proceed immediately to formulate their own national policy strategy and plan to attain the target the HFA by 2000 AD.
The global strategy of WHO for the goal of health for all was endorsed by the WHO in 1981. There is now a growing national and international movement to attain HFA.
Planner in every countries have develop their own strategy for achieving the goal. Milestones set by the WHO for achieving the goal for HFA are:
  • Right kind of food for all by 1985
  • Provide essential drugs for all by 1986
  • Providing an adequate supply of safe drinking water and basic sanitation by 1990
  • Immunizing children against six killer diseases by 1990
  • Other cardinal features of movements are to ensure.
Concept of Primary Health Care
The Alama Ata Conference defined Primary Health Care as:
‘Primary health care is essential health care made universally accessible to individual and acceptable to them, through their full participation and a cost the community and country can afford’.
Primary health care form an integral part of the country's health system and overall social and economic development of the community. It is the first level of contact of individual, family, and community with the national health system bringing health care as close as possible where people live and work. It constitute the first element of a continuity health care process. A vital feature of primary health care is that it is based upon participation of the people themselves. Many health programs have failed because they were perceived by the people not as their own programme but rather as government program primary health care is equally valid for all countries though the problems would differ between the developing and developed countries. Primary health care is concerned with the main health problem of the country providing promotive, preventive, curative and rehabilitative services as required (Fig. 1.10).
Characteristics of Primary Health Care
It is the essential health care based on practically sound and socially acceptable technology
  • It should be rendered universally
  • Acceptable by individual and form in the community by their full participation
  • Its availability to a cost which the community and country can afford to maintain in a spirit of self reliance and self develop55
  • It requires joint efforts of health sector and other health related sectors like education, food, agriculture, social welfare, animal husbandry and housing, etc.
Elements of Primary Health Care
  • Education regarding existing health problems and methods of preventing and controlling them. Health education is an integral part of all health services and all health personnel, including nurses and nurses are responsible for educating people as to how they can improve their own health. Public education is the first, and one of the most essential, component of primary health care. By educating the public on the prevention and control of health problems, and encouraging participation, the World Health Organization works to keep disease from spreading on a personal level. The community health nurse has to play an important role in organizing appropriate health educational programs according to the needs of the community, collaborating and coordinating with intradisciplinary and inter disciplinary teams. The promotion, maintenance and restoration of health requires that patient understand health care requirements.
  • Promotion of food supply and proper nutrition. Nutrition is another essential component of health care. In India, available statistics indicate that 65% of our children are malnourished about 1 lakh die due to it every year, dominating among under fives. Vitamin A deficiency increases vulnerability to respiratory infections, gastrointestinal infections and xeropthemia, iodine deficiency resulting in hypothyroidism is another common deficiency disease. Nutritional deficiency states are particularly noticeable among pregnant and lactating mothers and in infants and children. This may be due to sociocultural/economic factors prevailing in the community. WHO works to prevent malnutrition and starvation and to prevent many nutritional deficiencies diseases and afflictions though promotion of food supply.
    The responsibility of community health nurse in this regard is to provide essential health services. This include surveillance and case finding through use of growth charts in children, making provisions for supply of iodized salt. Vitamin A supplements, food supplements in collaboration with other members of the health team for prevention and treatment of malnutrition. She takes suitable measures for prevention and treatment of diarrheal diseases, intestinal parasites and other diseases affecting ability to utilize food.
  • An adequate supply of safe water and basic sanitation. In India, safe and potable water is not available to a major section of the population. Many water borne diseases prevalent in the country are preventable, but the importance of the use of pure and safe water as well as the personal hygiene do not properly appreciated. The environmental sanitation also is very poor due to so many reasons, particularly in rural areas and in urban slums. There are no proper arrangements for disposal of human excreta and animal wastes, sewage, garbage and sullage, etc. A supply of clean, safe drinking water, and basic sanitation measures regarding trash, sewage and water cleanliness can significantly improve the health of a population, reducing and even eliminating many preventable diseases.
  • Maternal and child health care, including family planning. In India maternal mortality rate is quite high as compared to other countries. The main causes for increased MMR are sepsis, hemorrhage, toxemia, illegal abortions and malnutrition. Maternal morbidity is also increasing for malnutrition, anemia, infections, malaria, hepatitis, urinary tract infections, tuberculosis, etc during the child bearing year. Ensuring comprehensive and adequate health care to children and to mothers, both expecting and otherwise, is another essential element of primary health care. By caring for those who are at the greatest risk of health problems, WHO helps future generations have a chance to thrive and contribute to globally. Sometimes, care for these individuals involves adequate counselling on family planning and safe sex. CHN are assigned to carry out maternal and child health care, which includes antenatal, prenatal perinatal and postnatal care.
  • Immunization against major infectious diseases. Immunization is to prevent endemic and epidemic diseases. India has a long history of vaccination programmes. In the sixties, this vaccination against smallpox and tuberculosis was started. Now universal immunization programme is in operation in India. Nurses and nursing team plan immunization programmes for adults and children, particularly infants and pregnant women. Encouragement and persuasion are strategies in monitoring and scheduling immunization. By administering global immunizations, WHO works to wipe out major infectious diseases, greatly improving overall health globally.
  • Prevention and control of locally endemic diseases. In India, the government has launched various 56national programmes for the control or eradication of these endemic diseases like leprosy eradication programme, tuberculosis control programme for controlling TB, malaria, eradication programme and others prevention and control of local diseases is critical to promoting primary health care in a population. Many diseases vary based on location. Taking these diseases into account and initiating measures to prevent them are key factors in efforts to reduce infection rate. Nurses and nursing team collect data care of the ill, offer health education, visit and follow up cases, and provide surveillance over the target population to ensure that communicable diseases are eradicated or controlled.
  • Appropriate treatment of common diseases and injuries Another important component of primary health care is access to appropriate medical care for the treatment of diseases and injuries. By treating disease and injury right away, caregivers can help avoid complications and the expense of later, more extensive, medical treatment. First aid measures may be taken at village level. Treatment of common diseases and injuries are to be provided at the subcenter, and primary health center and appropriate referral services are to be organized. Nurses have been trained to treat patient under a doctor's standing order. The emergency treatment and primary care provided by nurses help to reduce morbidity and mortality rates.
  • Provision of essential drugs. By providing essential drugs to those who need them, such as antibiotics to those with infections, caregivers can help prevent disease from escalating. This makes the community safer, as there is less chance for diseases to be passed along. The community health nurse has to procure, keep and also utilize whenever necessary essential drugs to treat minor ailments, etc. Also she should be aware of the resources and facilities for getting essential drugs to inform the client within a short distance.
Principles of Primary Health Care
Equitable Distribution
Equitable distribution means health services must be shared equally by all people irrespective of their ability to pay (rich or poor, urban or rural must have access to health services).
Previously health services mainly concentrated major towns and cities resulting in a inequality of care to the people in rural areas. The worst hit are the needy and vulnerable groups of the population in rural areas and urban slums. This is termed social injustice. Primary health care aims to redress this imbalance by shifting the center of gravity of the health care system from cities (where three quarters of the health budget was spent) to the rural areas (where three quarters of the people lived) and bring these services to the door step level.
Community Participation
The involvement of individuals, family and communities in promotion of their own health and welfare is an essential ingredient of primary health care. Countries are now conscious of the fact that universal coverage by primary health care cannot be achieved without involvement of the local community. There should be continuing effort to involve the community in the planning implementation and maintenance of health services, maximum reliance on local resources such as man power, money and materials. Primary health care must be built on the principle of community participation.
One approach that has been tried successfully in India is by health guides and trained dais, being selected and trained by local community in delivery of primary health care free of charge. By overcoming cultural and communication barrier they provide primary health care in community acceptable way.
Focus on Prevention
Vigorous action to be taken to ensure availability of adequate number of appropriate self health personnel required to devise and implement plan of action, preventive measures such as safe water, sanitation, immunization was emphasized. The focus is on disease prevention.
Intersectoral Coordination
The declaration of Alma Ata states that primary health care involves in addition to health sector, all related sectors and aspects of national and community development, such as agriculture, animal husbandry, food, industry, education, housing, public works, communication and other sectors.
Agricultural policies can help improve nutritional status of vulnerable sections. Appropriate agricultural technology can lighten the work load and increase work productivity. The person from agriculture, irrigation and engineering can help farmers grow more food (cereals, pulses, oil seeds, vegetables, fruits, etc.) locally, can provide seeds for kitchen garden and community garden, can educate people for composting, can also motivate people in family welfare activities, etc.57
Animal Husbandry
The personnel from animal husbandry can help people to develop farms for poultry, fisheries, fruits, vegetables, etc. can help in immunization of domestic animals, and can also help in prevention of Zoonotic diseases, etc.
Housing structure need to be built up considering the climatic and environmental conditions; the basic facilities, etc. so as to have wholesome effect on health; and be easy to clean and maintain. Education is very important to ensure healthful living in the house. Housing department can play an important role in this to promote healthy house/building structure, etc.
Water Supply
Adequate safe drinking water supply need to be there both in urban and rural areas within easy reach of people to reduce morbidity, mortality due to water born diseases.
Sanitary facilities are equally important to control such problems. It is also necessary to educate people regarding the proper use and maintenance of water and sanitary facilities.
Public Works
For public workers, it is very important to have good roads connecting villages with each other and the town and cities to have easier reach to villages, market places, health agencies, etc. It requires coordination with departments which deals with these services.
Communication: (Education and Mass media)
Mass media, two way radio communications can help in disseminating valid primary health care information to people living in remotest areas. It can also help in establishing contacts between isolated areas and centrally located administrative levels.
Education sector can play a very important role in developing instructional material on primary health care aspects to educate people at large in the communities. Primary health care activities can be planned and organized by the teachers and parents—Teachers Association in the school for school children and also in the community for different groups.
Social and Women's Welfare
The personnel from social and women's welfare can help in: mobilizing women, mahila mandals, etc. for propagation of various aspects of healthy living in the community, education of mothers regarding maternal and child care, prevention and control of locally endemic diseases, etc.
Panchayats can play very important role in providing funds and administrative support for infrastructure, various health programs, health education, propagating messages, mobilizing transport, etc.
Cooperatives and Banks
Cooperatives and banks can provide funds for community garden, community composting, soak pit etc. making farms for poultry, fisheries, vegetables, fruits, milk, etc. health insurance.
Appropriate Technology
Appropriate technology has been defined as technology that is scientifically sound, adaptable to local needs, and acceptable to those who apply it and those for whom it is used, and can be maintained by the people themselves, in keeping with the principle of self reliance with resources the community can afford is emphasized. The term appropriate because in some countries, large luxurious hospitals that are totally inappropriate to the local needs, are built, which absorb a major part of the national health budget, effectively blocking any improvement in general health services.
This also applies to using costly equipment, procedures and techniques when cheaper, scientifically valid and acceptable ones are available, viz. oral rehydration fluid, stand pipes which are socially acceptable, and financially more feasible than house to house connections, etc.
Primary health care is qualitatively a different approach to deal with the health problems of community. Unlike the previous approaches, e.g. Basic health services, integrated health care, vertical health services to the doors of the people, primary health care approach starts with the people themselves. This approach signifies a new dynamism in health care and has been described as health by the people, placing peoples health in people hands.58
The ends of the primary health care approach are the same of those of earlier approaches (i.e. attainment of an acceptable level of health by every individual) but the means adopted are different that is more equitable distribution and nationwide coverage, more intersectoral coordination and more community involvement in health related matters. Primary health care forms part of the larger concept of human resources and development.
WHO strategies of primary health care:
  • Reducing excess mortality of poor marginalized populations: PHC must ensure access to health services for the most disadvantaged populations, and focus on interventions which will directly impact on the major causes of mortality, morbidity and disability for those populations.
  • Reducing the leading risk factors to human health: PHC, through its preventative and health promotion roles, must address those known risk factors, which are the major determinants of health outcomes for local populations.
  • Developing Sustainable Health Systems: Primary health care as a component of health systems must develop in ways, which are financially sustainable, supported by political leaders, and supported by the populations served.
Primary Health Care Approach
In 1978 WHO at a meeting at Alma Ata, Russia declared the new concept of primary health care PHC. India being a member country of WHO was committed to implement the new method of approach. The approach came into existence in 1978. Primary health care delivery first proposed by Bhore Committee in 1946 and before Alma Ata Primary Health Care was regarded as synonymous with Basic Health Care Services, First Contact Care, Health Accessible Care, Services provided by Generalists, etc.
Although specific services provided will vary in different countries and communities, the Alma Ata Declaration has 8 essential components for patient care.
Roles of Nurse in Primary Health Care
In 1981 International meeting was convened by WHO to consider the role of nursing in contributing to the achievement of the goal of HFA – 2000 through primary health care. The development in each country of a corps of nurses that is well informed about health care and ready to bring necessary changes in the nursing system. The inclusion of nursing personnels at all levels of policy making and administration so that the profession can contribute to determine the action plan. The involvement of nurse and use of their skills in initiating an extending primary health care. Fundamental changes at all levels of nursing education, basic, post-basic and continuing to ensure that priority needs of population are functionally integrated into the education and in the nursing practice. Research into nursing administrations, practice and education that will demonstrate nurses contribution to primary health care. The focus and core of all registered nursing practice is to provide care to patients/clients. Using the nursing process of assessment, diagnosis, planning, implementation and evaluation registered nurses are skilled and competent professionals who provide holistic nursing care to individuals, families, communities or populations. The registered nurse's practice is guided by essential interventions that are considered fundamental to primary health care and can occur in any practice setting from acute care to community care to continuing care. WHO study group 1985 identified four main self-explanatory role of nurse including the eight essential elements.
  1. Nurse as a direct care provider
  2. Nurse as a teacher and educator
  3. Nurse as a supervisor and manager
  4. Nurse as a researcher and evaluator health promotion
Nurse as a Direct Care Provider
Nurse as a direct care provider provide curative service at clinic camp in the home also provide emergency service first aid during disaster. The care should be client as the center of care using community involvement approaches. As a direct care provider, she can provide maternal and child healthcare, i.e. antenatal care delivery care, postnatal care, managing complication during pregnancy, delivery or postnatal period. In home or clinic she is providing direct care to the people who are sick or ill. She will assist in the arranging of, and participate in specialty clinics with physician specialists or other health care provider whenever needed and maintain client and administrative records following professional and legal guidelines in a confidential, concise and accurate manner. Assist patients to achieve their optimum level of health in situation of normal health, illness, injury, or through the process of dying. Assess the patient for physical and psychological needs, knowledge of their health, disease process and learning needs during giving care. Apply and promote principles of equity and fairness to assist patients in receiving unbiased treatment and a share of health services and resources proportionate to their needs.59
Nurse as a Teacher and Educator
Nurse as a teacher and educator should not miss any opportunity to provide health education. As primary health care main focusing preventive approach rather than curative approach the nurse can use health education as a weapon to achieve her goals. Provide counseling during any personal or family problems, teaching patient and family, providing guidance for restoration and maintenance of their health. She can educate the people regarding a safe and healthy environment in homes, schools and throughout the community. Not only this in every home visit she can educate the pupil regarding existing health problems and methods of preventing and controlling them MCH and family planning hygiene, proper nutrition safe water and basic sanitation prevention of common communicable diseases.
The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. ‘The nursing process provides the basis for critical thinking in nursing’ (Alfaro-Le Favre, 1998, p.64). The nursing process is dynamic and requires creativity for its application. The steps remain the same, but the application and results will be different in each client situation. It can be applied to individual family and community. Based on its application in hospital and community it is classified as Individualized nursing process, family health nursing process and community health nursing process. Though the same steps of Nursing process (assessment Nursing diagnosis, planning, implementation and evaluation) can be followed at each level (Individual, family and community) but there is a vast difference between the institutional level and community level of nursing process. The steps of family health nursing process and community health nursing process are same but the main variation is in nursing diagnosis.
Community is the client or target of service in community health nursing practice. The focus is on the health of community at larger rather than an individual or family health. The community directly influences the health of individuals, families, groups, subpopulations, and populations who are a part of it. The individual's families are the units of services. The services are rendered not only to any specific individual families but to the whole community. For example, for eradication of malaria we are changing the whole environment of the community. provision of most health services occurs at the community level. Community agencies help develop specific health programs and disseminate health information to many types of groups and populations. In community the community health nurse giving care to the whole community not particular individual or group. The services pertaining to primary, secondary and tertiary level of prevention are rendered to entire community and not to any selected individuals/families or groups in the community.
Nursing process: Nursing process generally defined as a designated series of actions intended to fulfill the purposes of nursing to maintain the patient's wellness and, if this state changes, to provide the amount and quality of nursing care the situation demands to direct the patient back to wellness, and if wellness cannot be achieved, then contribute to the patient's quality of life, maximizing his resources as long as the life is a reality.’
Community health nursing process: Community health nursing process is a problem-solving process that addresses community health problems at every aggregate level with the goals of preventing illness and promoting public health.
It is a management process that requires situational analysis, decision-making, planning, organization, direction and control of services, and outcome evaluation.
It is a process for implementing changes that improve the function of various health-related systems and the ways that people behave within those systems.
Community health nurse, must consider community as the client. Understanding of the community is a prerequisite for providing effective services to the community as the client. Community identification is the first phases of community assessment. Through community identification the community health nurse can assess the size of the population, density of the population, composition of the population, rate of growth or decline, cultural characteristics, social class and educational level mobility pattern of the population.
Community identification is the beginning of community health and nursing care process. It refers to 1st level ‘Assessment Phase’. This phase is fundamental to ‘Planing of Community Health Actions’ which is followed by ‘Implementation of Plan’ and ‘Evaluation of Actions and Outcomes’. Altogether there are four phases of the community health nursing practice process which have been discussed.60
The nursing process is a series of steps or acts that lead to accomplishment of some goal or purpose. The purpose of the nursing process is to provide care for clients that is individualized, holistic, effective, and efficient but in community health nursing process the whole community is an individual. The steps of the nursing process are same like general nursing process which build upon each other, but they are not linear. There is overlap of each step with the previous and subsequent steps.
Assessment phase
Community identification
Date review and update
1st Level
  • Planning of data collection; categories of information Method and techniques
  • Data collection
  • Data analysis
  • Community profile and diagnosis
Planning phase
Community health planning
  • 2nd level assessment
  • Analysing Health problems Establishing priorities
  • Setting goals and objectives
  • Formulating community health actions
Goals and Objectives and Actions
Action phase
Implement actions plan
  • Considering nursing interventions.
  • Review and revise if needed
  • Mobilization of resources-health Facilitating working environment.
  • Implementing and documentation.
Evaluation phase
  • Concurrent quantitative
  • Terminal qualitative
A community assessment is basically a description of a community and its people. The purpose is to identify the needs of a community in order to provide services appropriate to those needs. Community identification refers to ‘systematic process of knowing and exploring the defined community for assessing its health status and determining the possible factors affecting the health of people in the community.’
It helps to know all the three dimensions of community, i.e geographical area, the people and the social system and also helps to identify determinants of community health (biological characteristics of people, their lifestyle, the environment in which they live and the resources available to them) which affect their health. Community identification is the first step of community health nursing practice process and it is also otherwise termed as the first level of assessment or initial assessment.
Benefits of Community Identification
  • Provides comprehensive knowledge about the profile of the community: Community identification provides information about health status of community, its health problems and the factors that interfere to their health. These information form the baseline date for planning community health services and determining their effectiveness.
  • Helps to develop good working relationship with the community: Community identification provides opportunity for establishing working relationship and gaining acceptance of the community. The community health nurse is a part of health care system. Some of the people may not accept this system or some of its health services. So the community health nurse should work in coordination with various formal and informal leader in the community for implementation of health care activities. She talks to them about her functions and explains to them about her willingness to help in meeting their health needs/health problems as perceived by them. Hence she gain entry in the community and be accepted by the leaders and people.
  • Make community Diagnosis: This is a statement that defines the health strength, health problems or health risks of the community. The community health nurse arrange and analyse the collected data and make community diagnosis and organize community development programmes. The problems could be with reference to people, their environment, lifestyle and resources. For example, inadequate ANC r/t inadequate health information or service accessibility as evidenced by 70% of female delivering at hospital with no antenatal care.
  • Designing community health actions plan: Community identification act as an instrument for community health planning. Community identification forms community diagnosis which forms the basis for designing community health actions plan according to priorities and goals and objectives and available resources/health services.
  • Promotes community participation: Community identification improves community participation. It gives an opportunity to mix with people and the 61leaders informally and meet them formally. As we mix and meet with the people and leaders, we come to know each other, get informed about each other's intentions and expectations, strengths and weaknesses, etc. This will help not only in developing confidence, trust and faith in each other's abilities but also help in communicating people's contributions in dealing with their health needs/health problems individually and unitedly.
    The other benefits are:
    • There is increased understanding within the community about its needs, why they exist, and why it is important for the needs to be addressed.
    • Community members have the opportunity to share how the needs impact the quality of life for the larger community.
    • Community engagement is increased because members from different parts of the community are included in discussions about needs, assets, and the community's response.
    • The community's strengths and weaknesses are identified.
    • There is an inventory of the resources currently available within the community that can be leveraged to improve the quality of life for community members.
    • Communities identify the asset gaps that exist in their communities.
    • Community members have an increased awareness of how they can contribute to their community's assets.
    • Community organizations can use the information about community needs to assess their service delivery priorities.
    • There is data for making decisions about the actions that can be taken to address community needs and how to use the available assets.
    • Data can be used to inform strategic planning, priority setting, program outcomes, and program improvements.
Planning of Data Collection
Before data collection understanding the community is very important in community health nursing process. Understanding the community means what a community is, and the specific nature of the communities we work in. Anything we do in a community requires us to be familiar with its people, its issues, and its history. Carrying out an intervention or building a coalition is far more likely to be successful if they are informed by the culture of the community and an understanding of the relationships among individuals and groups within. Understanding the community entails understanding it in a number of ways. Whether or not the community is defined geographically, it still has a geographic context, a setting that it exists in. Getting a clear sense of this setting may be key to a full understanding of it. At the same time, it's important as a community health nurse to understand the specific community she is concerned with.
After understanding the community, the community health nurse will plan to collect the data by deciding what type of data will be collect, where to collect data, what are the major source of information. It is impossible for a community health nurse to get all the information from a single source or one method. Therefore different methods will be used to collect data from different source. For collecting data establishing working relationship is very essential.
Establishing Working Relationship
Building and sustaining relationships are at the heart of organizing community development program. The strength of community lies in the strength of the connections that we have with each other. With strong connections, people have the power to make real change. Building these connections takes time. But it is worth it.
A working relationship makes the client and nurse to know each other and work together, by this the problems can be easily identified and solved. Community involvement is the main aspect of community care for that a good trusting working relationship is essential. It promote the acceptance and interest by the client to accept things and also asking questions. Some tips to develop good interpersonal relationship are described below.
  • Be friendly and tactful: A community health nurse should be friendly with the community people for developing working relationship. She should have a smiling face and tactfully she should try to develop good IPR.
  • Ask people to questions: People love to talk about them and about what they think. If a community health nurse ask people about themselves and then take time to listen attentively, they can become her fast friend.
  • Tell people about yourself: People will not trust you unless you are willing to trust them. Tell them what you genuinely care about and what you think. Explain the benefits of your care.
  • Accept people the way they are: Before going to modify their behavior we should be accept them the way they are. If they are doing wrong also first we should be non judgmental.62
  • Overcome your fear of rejection: Before development of trust among community people the chance of rejection is more. A CHN should be mentally prepared for that and plan how to overcome it and develop trust among community people.
  • Be persistent: People are often shy and suspicious. It takes a while to win trust. A health worker can almost always form a relationship if he/she stick with it.
  • Invite people to involved: During organizing any community development program more participation from the people should be initiated. The CHN should encourage more involvement of the people by which the program will be fruitful.
  • Learn about the person's culture: Learning about the person's culture is very much essential because for providing comprehensive care not only learning about the person's culture is sufficient. The CHN should put herself at the center of another. person's culture for developing a strong IPR.
  • Hang in there even if you feel rejected: It means sometimes people do not accept us and trust us. In that case we should not lose our hope and we will stick with them to make them understanding even if we feels rejected also.
The community assessment is required at all levels of its geographical organization and set up, because assessment and planning of health services are necessary at each level. According to the definition of community, a community can be very small as like small helmet or as large as the state, country, etc. Republic of India has a federal structure consisting of 30 States and 7 Union Territories. Each state and union territory has a number of districts. Each district is organized into a number of blocks depending upon the population and the area coverage. Altogether there are 466 districts and 6000 blocks. Each block has 80–100 villages and a population of 80,000–1,00,000 or even more in some places.
For community identification a variety of information required like geographical characterstics, population composition, environmental and social factors. Community organization, communication pattern etc. The information needs to be collected for community assessment are described below. A community health nurse should have detail idea about her community.
Geographical Characteristics
Every physical community carries out its existence in a specific geographic location. The health of a community is affected by this location including the placement of health services, the geographic features, plants, animals and animals and the human made environment.
  • Geographical area: Every community has a defined geographical area in which people live and carry out their existence. It is very important for the community health nurse to study and familiar with the topography of any community which includes the study of its location and geographical boundaries; physical setup, natural resources such as land area, forest and jungles, minerals, water; important landmarks, important institutions, etc. The geographical area only does not reflects, geographical location and geographical boundaries physical setup, etc. but also it depicts the followings
    • Levels of population density in different parts of a city
    • Where different ethnic or racial groups are concentrated
    • Income levels in different areas
    • Increases in housing starts for various areas
    • Current ranges of endangered species
    • The frequency of particular diseases or conditions in various regions, towns, neighborhoods, or even city blocks
    • The proportion of children under 18 in different school districts.
  • Geographical location/boundary of a community: Geographical location of a community determines its climate, resources, health threats and dangers, e.g. communities in the mountain areas in the Northern India will be entirely different from communities in Southern India. The most obvious type of geographical boundary is a physical boundary which is a naturally occurring barrier between two areas. Rivers, mountain ranges, oceans, and deserts can all serve as physical boundaries.
    The incidence and prevalence of various diseases, mortality and morbidity of a community is measured and compared with other community locally, nationally or internationally and sometimes with whole world. Which determines health action to be taken for the community.
  • Physical set up: Each community has its own physical setup which includes pattern of settlement, arrangements of dwellings and other buildings, streets, connecting roads, important landmarks and institutions, etc. It is important to know the community's size, its topography (the lay of the land– the hills, valleys, rivers, roads, and other features you would find on a map), and each of its neighborhoods. Also you would important are how various areas of the community differ from one another, and the 63CHN should assess whether the community is one of clean, well-maintained houses and streets, or one of shabbiness, dirt, and neglect.
    The physical set-up of a town is differ from the physical set up of a village. If it is a city or a town, the community health nurse have to see whether the facilities of the town are sufficient to meet their need, town is properly planned, housing structure, overcrowding, drainage facility, water supply and presence of industries, etc. If it is a village, the CHN should have to find out the arrangement of houses, the type of houses, facilities available, whether the village is self-sufficient in fulfilling the basic needs of the people or not.
    The pattern of settlement and arrangement of dwellings and the basic amenities available will influence the environment and the lifestyle of the people which will have an impact on the health status of the community. The people of urban community are exposed to stress, overcrowding, pollution, development of slum beggary, poverty, crime, prostitution, delinquency, alcoholism, air and water born diseases, etc. in the other hand in rural community they are exposed to agricultural environment, lack of electricity and potable water facility. So the community health nurse must study the physical set up, boundaries, draw a map of a community and identify factors that influences their health status influences on the health status of the people.
  • The natural resources: Natural resources are also very important to the economy of a community. A natural resource is anything that people can use which comes from nature. People do not make natural resources, but gather them from the earth. They are useful raw materials that we get from the Earth. we use and modify natural resources in ways that are beneficial to us. Different communities around the world use the natural resources around them to make their lives better. Natural resources are trees, minerals, water, and animals. Without them, we would have no food, clothing, or shelter.
    Land area (cultivable and noncultivable) determines the bulk of crops and types of crops as a source for self consumption and for generating income which is sufficient or not.
    Water is the most important natural resource and is vital for life. The CHN has to see thet the water should be safe and potable because there are so many water born diseases are there.
    Flora and fauna: Poisonous plants and disease carrying animals can affect community health.
    Forests, jungles and animals: Plays very important role in maintenance of ecosystem.
    Minerals are good source of income for the community
    So the community health nurse also have to identify the availability of natural resource in that area which can helps to make solution of so many problems. Natural resources are the foundation from which rural poor people can overcome poverty.
  • Important landmarks and institutions: It is very important to know the important landmarks and institutions such as community centre, panchayat ghar, school, post office, anganwadi, religious centres, village pond, bank, health center, etc. These places will be helpful in searching and locating the houses, etc.
  • Environmental sanitation: Environmental sanitation as defined by WHO refers to ‘control of all those factors in man's physical environment which exercise or may exercise a deleterious effect on his physical development, health and survival’. It includes control of housing, food, water, refuse and excreta, waste water, air, soil, vectors, insects and rodents etc. Environmental sanitation is one of the essential measures of health care service to promote the health of the people. It is essential for community health nurse to identify factor that alter environmental sanitation which will help her to implement health community health actions.
  • Climate: Climate has a direct effect on health of a community, e.g. extreme heat and cold).
Population Characteristics
The total number of inhabitants living in a particular geographical area called as population. Population is another very important component of the community which influence there health. Health in the group depends upon the dynamic relationship between the member of people, the space they occupy and the skill that they have acquired in meeting their need. The scientific study of human population is termed as demography. It focuses attention on population size, composition and distribution of population in space. These demographic characteristics of people helps to identify their health problems and needs and helps health planner for selection of health services.
The size of the community refers to the total number of people staying in that community. The size of a population influences the number and size of health care institutions and bulk of health services need to be 64rendered. The smaller the size, the easier it will be to identify cases, trace the source of infection and causes of infection and plan and provide the services and the same will be difficult if the size of the community will be large. Knowing community size provides important information for planning.
Thus it is very important to study the size of the population and its impact on the health of the community.
It refers to number of persons living per square kilometre of area. It is the ratio between total population and surface area. The more the people, the more dense it becomes. For the year 2014 the density of population per square kilometre in India was 394. It is very high especially in towns and cities. The increased population density may increase stress and so many health problems like development of slum, insanity, water and air born diseases. Similarly when people are spread out health care provision may become difficult. The rural areas are much less dense than urban areas which affect allocation of health resources in these areas.
It refers to distribution of population by age, sex, education and occupation etc. Understanding of population's composition is very important because it helps in assessing health problems and health needs by different age groups, sex, occupation and education. There may be some common health problems for all the people by virtue of common environmental factors, resources and lifestyle. But, there are specific health problems and health needs of each age group by virtue of their growth and development and physiological status. Health needs and health problems also vary in males and females, more so during various stages of child bearing period in women. A healthy community is one that takes full account of and provides for differences in age, sex, educational level, and occupation of its members, all of which may affect health concerns. Determining a community composition is an important early step in determining its level of health.
Occupation is another variable which influences the health status of people depending upon its nature and risk involved e.g. industrial occupations, agriculture, managerial occupations, health and science related occupations etc. Education and literacy level is still another variable of population composition which would determine health related attitude, behaviour and competency and in turn affect the health status of people.
Vital Events
Some of the vital events which determine community health status are live birth, death, fetal death, marriage, divorce, adoption, legal separation etc. These are like vital signs of human being as it serves as a reliable source of community helth information. Death rates and morbidity rate are the most easily available and accessible indicators which can be used to determine health status of community and plan for services. Morbidity refers to the state of being diseased or unhealthy within a population, In addition to mortality and morbidity statistics, it is important to study the growth in population. Community population changes over time. It changes in size and composition. Some communities grow rapidly and place great demands on the provision of health services whereas some others may grow very slowly or some may even decline because of socioeconomic developments and changes. Any significant change in population can affect the health of community.
Vulnerable/High-Risk Groups
Vulnerable population includes the economically disadvantaged, racial and ethnic minorities, children, elderly, homeless person with HIV, those with other chronic conditions like mental illness, one living in abusive family, the homeless, immigrants and refugees. So, it is important to identify high-risk groups in the community as they form the target group for providing health service.
Social Structure
The notion of social structure as relationship between different entities or groups or as enduring and relatively stable pattern of relationship. According to social science, social structure is the patterned social arrangements in society that are both emergent from and determinant of the actions of the individuals. On the macro scale, social structure is the system of socioeconomic stratification (class structure), social institution or other patterned relations between large social group. On the macro scale, it is the structure of social network ties between individuals or organizations. On the micro scale, it can be the way norms shape the behaviors of individuals within the social system. So it include social stratification, social control system, community organization and group dynamics, leadership pattern, sociocultural practices (lifestyle) and communication system. The community health nurses need to study these elements of social structure of the community as it will help to understand attitude, health behaviour and health competencies and 65abilities to deal with health situations. These structural elements are social stratification, social control system, community organization and group dynamics, leadership pattern, lifestyle and communication system which are briefly discussed here.
Social Stratification
Social stratification is a division of society into permanent or temporary groups or categories. The group are interlinked with each other by the relationship of superiority and subordination. Social class is determined on the basis of certain acquired characteristics, e.g.: economic condition, individual attainment, wealth and social status, or derived power. Traditionally stratification is done on the basis of caste system. There are four such classes: Brahmins, Kshatriyas, Vaishyas and Shudras. Each caste is governed by certain rules and regulations relating to cultural practices. The caste system is on the basis of occupation and each caste group is supposed to provide specific services to the community.
People also have been grouped into three classes on the basis of income they have. These are upper income, middle income and lower income groups. This can determine standard of life.
It is important for the community health nurse to know the social stratification of community because each social group will have some different health problems, resources to cope with health problems and ways of using health services. In general, people in lower classes have poor health and multi health problems because of lack of education, poverty and ignorance. Health services are mostly needed by this strata of population but, services should be available to all social groups.
Social Control System
Social control is a concept that refers to the ways in which people's thought, feelings, appearance and behavior are regulated in social systems. It mainly consists of formal and informal rules and regulations. Informal means of control is Internalization of norms and values by a process known as socialization, i.e the process by which an individual born with behavioral potentialities and formal means of social control is by external sanctions which is enforced by government to prevent the establishment of chaos or anomie in society. The social control system may vary from one community to another community and from one social strata to another in the same community. Community health nurse must try to know the social control system as it may be helpful in carrying community health programmes.
Community Organization and Group Dynamics
Community organization covers a series of activities at the community level aimed at bringing about desired improvement in the social well-being of individuals, groups and neighborhoods. It is being often used synonymous to community work, community development and community mobilization. Every community has social groups based on a variety of common factors such as culture, beliefs, mores and codes, religion, caste, occupation, political beliefs, functions, common ailments etc. Each group has a leader members work together under the leadership. Each group has definite goals and objectives and program activities which are taken care of by members working together in the group.
Community health nurse needs to identify such groups in the community, their integrating and disintegrating factors.
Leadership Pattern
For organizing a community health program the community health nurse should organize formal meetings with the leader because by this it will become for a CHN to enter the community easily. So it is very important for a CHN to know the leadership pattern of the allotted community. Leader means not only formal leader like Sarapancha or ward members but also informal member like priest, school teacher, lawyers, doctors or the people who will be accepted and obeyed in the community. They may help in approaching the community, developing and maintaining working relationship with the people, organizing them into working groups, seeking their help and cooperation in dealing with their health needs and health problems and mobilizing community resources etc.
Lifestyle is a way of living of individual, families and societies which they manifest in coping with their physical, psychological, social and economic environment on a day to day basis. Lifestyle is expressed in both work and leisure behavior pattern and attitude, opinion, values, beliefs and attitude; religion, education, political and administrative system, socioeconomic status, caste, interest and allocation of income. Lifestyle varies from community to community and sometime from one social strata to another strata in a same community.
Lifestyle has a strong association with health status of people. Healthy lifestyle promotes optimum health. Unhealthy lifestyle and behaviors like smoking, excessive alcohol consumption, misuse of elicit drugs, 66excess consumption of sugary foods, rituals and taboos during illness, pregnancy, natal and postnatal period alters health. Other factors like social norms, price and legality promotes good lifestyle. Community health nurses need to study the lifestyle of community and identify health practices, unhealthy practices that affect their health.
Communication System
Communication is the process by which ideas, facts, impression, feelings, informations and knowledge facilitate through the process of social interaction. It helps the individual to understand various forms of social relationships and to make necessary adjustments. It moulds personality of individual, fullfils need, exchange information through the process of social interaction and the person develops bondage and leads effective social life. The ultimate aim of communication is to socialize its members, make them knowledgeable, inculcate positive attitude in them and develop behavior which is useful and acceptable by the society.
As a community health nurse, it is very essential to identify their channel of communication (formal and nonformal), common meeting places for the people in the community; informal communicators like barbers, numberdar etc.; mechanism of communication of cultural heritage e.g. fairs and festivals, political and religious gatherings etc. and modern media of communication. The community health nurse can use these communication channels for dissemination of health information and motivation of people for acceptance of healthy behavior.
Social System
Social system is an orderly and systematic arrangement of social interaction. The entire community is organized into a sociopolitical system which is governed by formal and informal laws, rules and regulations. The people will interact with each other according to shared cultural norms which influence their behavior and their behavior also controlled by social institution. Formally, the social system is organized into various sociocultural, political and administrative subsystems which perform various functions and help in serving Maslow's hierarchy of needs of people in the community. These subsystems include; housing, food, education, health, environment protection, recreation, communication, transportation, welfare, law and order, economic, political and legal systems etc.
Each subsystem has an organizational setup, goals, objectives, belief and infrastructures and/or institutions to perform specific functions. These infrastructures/institutions include households, families, schools, colleges, health centres, hospitals, banks, cooperatives, post offices, public distribution shops, temples, recreation and sports clubs, etc.
Community health nurse needs to identity these facilities and their functioning, cultural norms, so that she can mobilize for health promotional activities.
Sources of Information
These are various sources for attaining information relevant to three dimensions of community.
  1. The sources of information regarding geographical aspects of the community are Maps; local administrative bodies like municipalities, panchayati raj organizations; development department, like block development office, area development committees, school, temple, flora and fauna, minerals, etc.
  2. The source of information relevant to population aspects: Census, registration of vital events, notifications of diseases, health survey, records of hospitals and health centers, sample registration system (SRS), record linkage, epidemiological surveillance, other health service records, environmental health data, health manpower statistics. The department of health intelligence and annual reports; the epidemiological surveillance and notification records and reports at the local health departments; health service records and reports maintained at the center and other allied agencies if any in the community.
  3. Sources of information about social system are: Local, political and administrative bodies; local development departments; local directory and organization literature if available; key informants from various systems.
    In addition to these specific sources for each category of information there are common sources for all these categories of information. These include community environment; community people in general and formal and informal leaders in particular; village level workers like birth attendants, village health guides, anganwadi workers; health officials and officials from other organizations, health records and reports.
  4. Community people: Community people are also a major source of information in all aspect. The can provide information about their lifestyle, customs, culture, environmental data etc. The data can be collected from them is mainly survey method
Community identification is done by descriptive survey approach. This approach provides broad range of data about all the dimensions of community, community health problems and the associated factors. But it is neither feasible nor advisable to gather all possible data because it is laborious, time consuming, expensive and is not required. It needs to be planned carefully. There are various methods to get informations about the community. These are as under:
Listening Sessions and Community Forum
Listening sessions are forums used to learn about the community's perspectives on local issues and options. They are generally fairly small, with specific questions asked of participants. The CHN can get a sense of what community members know and feel about the issues, as well as resources, barriers, and possible solutions. Public forums tend to be both larger in number of participants and broader in scope than listening sessions. They are gatherings where citizens discuss important issues at a well-publicized location and time. They give people of diverse backgrounds a chance to express their views, and are also a first step toward understanding the community's needs and resources. A good public forum informs the group of where the community is and where the members would like to go. By this method a CHN can arrange formal and informal meeting with community people, leaders and organized groups which may include panchayat members, school teachers, mahila mandals, youth club/groups, young innovators, traditional leaders, professionals etc.
The initial meetings need to be organized properly. One needs to spell out the purpose and specific objectives indicating the informations to be sought or issues to be discussed. Invitation should be given ahead of the time in person. Date, time and vanue should be fixed which is convenient to all. All the principles of conducting group meetings should be considered. Keep in mind the agency's policies, goals and objectives.
Community forum approach is useful and relatively less expensive method of gathering data.
Observation Method
Observation offers a distinct way of collecting data. It does not rely on what people say they do, or what they say they think. It is more direct than that. Instead, it draws on the direct evidence of the eye to witness events first hand. It is a more natural way of gathering data. Whenever direct observation is possible it is the preferable method to use. Here the CHN gathering data by watching the physical characteristics of community in their natural setting. More over observation is a method of data collection that can be used together either information or characteristics and conditions of individual. This method depends upon nonverbal communication. Observation visits to community can help gain a lot of information about geographical area of the community, environmental sanitation, socio-economic conditions, population density, population stratification and their interaction, social mobility etc. These observatory visits can be informal and formal.
Informal visits are done to get familiar with the area, to know its general pattern of setup whereas the formal observation visits are done with specific objectives to attain specific data e.g. mapping of the area, observation of land area, the natural resources, pattern of settlement, environmental sanitation, health problems, contributing factor and uses of health services etc. These visits need to be planned, specific objectives need to be outlined and an observation check list required to be prepared to collect and record information.
Interviews are an attractive proposition for collection of data. Interviews are something more than conversation. They involve a set of assumptions and understandings about the situation which are not normally associated with a casual conversion. Interviews are also referred as an oral questionnaire by some people. Interview data is collected directly from others in face to face contact. It is a method to elicit needed information by asking relevant questions. In community interviews can be in the form of informal conversation with people; face to face interview of key informants, the entire population, sample population Informal conversation with people can provide many information which can be validated through other methods. A carefully planned conversation can be very useful.
The face to face interview of key informants can provide valuable information about social structure, lifestyle, health problems, health services and allied services. The key informants can be formal and informal leaders and the representatives from social system's organizations and institutions in the community. The interviews can be formal and informal. These interviews need to be planned properly like community forum meetings. Generally the interview method may be structured or unstructured. Structured interview involves fight control over the format of questions and answers. It is like a questionnaire which is administered face to face with a respondent. The researcher has a predetermined list of questions. Each respondent is 68faced with identical questions. The choice of alternative answers is restricted to a predetermined list. This type of interview is rigidly standardized and formal.
The unstructured interviews are sometimes referred to as ‘discovery interviews’ and are more like a ‘guided conservation’ than a strict structured interview. They are sometimes called informal interviews. An interview schedule might not be used, and even if one is used, they will contain open-ended questions that can be asked in any order. The questions can be changed to meet the respondent's intelligence, understandings and beliefs. Hence, the interviewer encourages the respondents to talk freely about given topic with minimum prompting. In this, no preplanned schedule is used. These interviews are also known as non-standardized interview generally this method is used in community setting.
Self-answering questioning is useful for collecting data from a large sample but it is feasible for literate population only. Moreover, the return rate is very less. Hence, it has its limited use in the community health settings.
Physical Examination
Just as physical examination is important to individual patients, so is examination of the community physical environment. Five senses are used in physical assessment: inspection, auscultation, vital signs, system review, and laboratory studies. Inspection uses all sense organs and is done by walking survey in the community, or micro-assessment ofhousing, open spaces, boundaries, transportation service centers, markets places, meeting street people, signs of decay, ethnicity, religion, health and morbidity, political media. Auscultation is listening to the community residents about the physical environment. Vital signs can be observed the climate, terrain, natural boundaries such as rivers and hills. Community resources can assessed by looking the signs of life such as notices, posters, new housing and buildings. System review can done on housing age, architecture, building materials used, signs of disrepair, running water, plumbing, sanitation, windows (glasses) etc. Also business facilities and churches. Laboratory studies depicts the census data or planning studies for community mapping.
Record Review Method
It is one of the important means to gather data in short period of time. Data can be gathered from secondary sources like records, documents, and other previously collected information from schools, departments of health at the city and state levels, county data, private foundations, and state universities. Secondary data provides the statistics that are the vital signs of the community. Much of community identification informations such as housing conditions, vital events, morbidity, health services etc. are available in the records maintained in health agencies. These informations can be collected by record review through the use of record review check list. Record review check list needs to be developed based on the informations to be obtained from records.
Conversation/Discussion Method
Conversation/Discussion with health personnel can generate information on community health problems in the past and present, services rendered, difficulties encountered, etc. Similarly discussion with representatives from other organizations can help to attain information about functioning of their organizations and about establishing working relationships etc. Like community forum method, these meetings need to be planned and informed and guidelines are to be prepared to conduct discussion session.
It is done by asking formal questions. It may be informal conversation or face to face interview. Question method requires the well planned interview schedule and questionnaire to obtain proper information.
Case Study
The case study is a way of organising social data for the purpose of viewing social reality. It is an in depth study of social unit. It examines a social unit as a whole. The unit may be a person, a family, a social institution or a community. It analyses limited number of events or conditions and their interrelations. Main advantages of this method is; it enables to understand the total behavior pattern of the concerned unit, it helps to obtain real record of personal experience and great number of interesting insight can be developed. But it has also some drawback like; it is expensive, time consuming, generalization and comparison may not be possible and subjective bias may be there.
Other Methods
Other methods which can be used for data collection clinical examination, investigation etc. These methods involve the use of standard screening instrument like sphygmomanometer, audiometer, weighing scale, snellel's chart, thermometer, laboratory test protocol etc.
Listening is yet another very good method of data collection in community health. Attentive listening can help to gather many information which otherwise might 69not have been possible. It gives many verbal and non-verbal clues.
No single method can be used for gather information rather a combination of techniques required to be used to get complete data. The instruments which need to be developed and procured are: community forum guidelines, observation check list, interview schedule, questionnaire, opinionnaire, record review check list, discussion guidelines, health record form, screening instruments and laboratory test protocol.
Data collection is a systematic approach to gather information from a variety of sources to get a complete and accurate picture of an area of interest. The community health nurse must possess strong cognitive, interpersonal, and technical skills to gather appropriate information and make relevant observations during the data collection process. This process often begins prior to initial contact i.e. plan for data collection, development of tool/checklist etc. The community identification survey needs to be planned carefully to ensure systematic and appropriate collection of valid information.
The following steps need to be considered.
  • Define the community to be studied: Mention the name of community, address, level of community i.e. whether it is a village, villages under subcenter or primary health center or community health center, whole area or part of the area covered by maternal and child health and family welfare center etc.
  • Set tentative community goal: This is where the community planning process begins to bring a real road map for the future. Determine the general goals first before getting bogged down in wordsmithing.
  • Determine specific information: Determine specific information/data to be collected and identify the sources from where these information can be obtained. Specify the measurement of data.
  • Identify the population and sampling unit under study: It will depend upon the sources of information. These can be: people in the community, key informants, health and allied officials, records etc. or all of these. Identify the sampling unit e.g. when study-population is ‘people’ in the community, the sampling unit could be an individual, family or a house hold. Select the respondent when family and household is the sampling unit.
  • Decide on the sample size and sampling method: As we know the size of the community may vary from a small hamlet to a big metro politian city. During data collection sometimes the CHN has to select sample to collect the data. In this stage the CHN will decide what type of sampling technique will be followed to collect the data.
  • Decide on the methods and instruments of data collection: This will depend upon nature and sources of information and population under study etc. It is advisable to work out the blue print based on these steps which can serve as guidelines for collection of desired data.
  • Develop the instruments decided: These may include interview schedule, observation check list, community forum guidelines etc.
  • Organize and conduct survey: Organize and conduct survey by collecting data using various methods as decided and planned. In order to gain acceptance, cooperation and confidence of people it is important to follow the principles of community approach and data collection.
    Some of the tips which are important from practical point of view are listed here.
    • Before visiting a community find out any kind of customs which are expected from a visitor. Develop working relation sheep with them
    • Identify leaders, develop a good relationship make them understood the purpose of your visit.
    • Dress up appropriately in a manner acceptable by the local people.
    • Do not act as a stranger or a superior. Empathize with them. Appreciate what they are and their cultural practices and customs.
    • Mix up with the people, accept their hospitality. Participate in their cultural events. Play and joke with them as and when necessary.
    • Watch and listen to them attentively, answer their que ries and consider their point of view.
    • Make only those commitments which can be fulfilled.
    • Avoid unnecessary arguments, criticism and comments.
    • Be neutral in any kind of dispute in the family or in the village.
    • Maintain confidentiality.
It is very important to hold initial informal and formal meetings with community people and their representatives. These meetings help in gaining entry in the community, earning their trust, confidence and co-operation. The people get involved and informed about what is happening or going to happen etc.
It is not difficult to arrange such meetings. Thematic film is a film on relevant subject (10-15 mts.) can precede the meeting to draw and sensitize the people. 70The meeting should not be too long and be arranged at a time and place convenient to them. Agenda must be drawn. Guidelines must be prepared to steer the discussion towards the purposes i.e. community identification, its purposes, strategy their help and cooperation etc.
Community identification requires collection of large and variety of data from various sources using variety of methods and instruments. It will be difficult for any one health worker to carry on such huge task.
It requires the efforts of health team to share the task. The team members need to be trained in data collection and recording information. Confidentiality of the date collected from individual/family needs to be maintained. Schedule for data collection needs to be worked out and implemented as feasible.
Data Analysis
Data analysis is a process of extracting, compiling and modelling raw data for purposes of obtaining constructive information that can be applied to formulating conclusion, predicting outcome or supporting decision. It provides a way of drawing inductive inferences from data and distinguishing the signal (the phenomena of interest) from noise (statistical fluctuation) present in the data. Analysis of data consists of putting all the factual information collected into an order, compile and summarize according to variables studied. It reveals relationship, trends This step is very important and essential to make the collected data meaningful, understandable and be able to describe the community profile, identify health problems and their possible associated factors.
The phases of analysis include:
  • Data categorization (demographic, geographic, socioeconomic, health resource and services…etc) then organizing by Coding, key punching then arranging of data for tallying.
  • Data summarization (rates, charts graphs…etc.)
  • Comparing data (compared with similar data, identification of data gaps, incongruence…etc)
  • Draw inferences (draw logical conclusions from the evidence) that lead to community diagnosis.
  • Reporting of the findings: It includes describing the community profile, making community profile, making community diagnosis i.e. stating health problems and their associated/underlying possible causes, implications and recommendations.
Community Profile and Diagnosis
Community identification process helps to determine community profile and helps in drawing conclusions or make diagnosis of its health needs and health problems from interpretation of data collected. The health problems during community assessment can be identified from their lifestyles (e.g. poor dietary habits, sedentary lifestyle, substance abuse), environmental condition, (e.g. unsafe drinking water, substandard housing conditions), inadequate health care system (e.g. insufficient primary care providers, lack of prenatal care services etc. The community health nurse can identified possible risk factors as high infant mortality rate, lack of prenatal care and delivery services, available care not affordable/accessible, available care not culturally sensitive, lack of transportation to health care, high percentage of teenage mothers, low education levels of mothers (high school drop outs), poor maternal nutrition, maternal smoking during pregnancy, family and neighborhood stress, multiple pregnancies (twins, triplets, etc), high unemployment incomplete immunization, early marriage high fertility and growth, malnutrition, unsafe water supply, improper collection and disposal of garbage, field defection, prevalence of communicable diseases, nutrition deficiency diseases, poor personal practices, traditional cultural practices regarding antenatal, postnatal and child rearing practices regarding antenatal, postnatal and child rearing practices etc.
A nursing diagnosis has three parts
  • Description of the problem (specific target or groups)
  • Identification of factors/etiology related to (r/t) the problem
  • The sign and symptoms (the manifestations) that characteristics of the problem.
Example: Poor nutritional status of under five children in the community r/t knowledge deficit regarding weaning diet as evidenced by growth monitoring chart.
In general planning is the third step of the nursing process and includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client's plan of care. Once the nursing diagnoses have been developed and client strengths have been identified, planning can begin. The planning phase involves several tasks. Here the plan will be developed for a community or country Community health planning is very important to determine the course of action to be implemented to meet community health needs and resolve community health problems. It is based on community diagnosis. Community health planning is a systematic process and involves logical decision making at each step of its process. The process includes four steps. These are as under:71
  1. Analyzing health needs/health problems.
  2. Establishing priorities.
  3. Setting goals and objectives.
  4. Formulating community health action plan to achieve the objectives.
Community health planning process requires collaborate functioning of the team including community people so that they get interested, informed, involved and feel responsible.
Analysis of Health Problems
A problem is the difference between what and what should be. The cause of community problem may be inside or outside the community. The identified problems of community required to be analyzed further to clarify the nature and extent of problems, the factors associated with problems and its consequences. It may required further collection of some specific information regarding identified problems (if already collected data does not provide such information), e.g. health and illness status etc. This is known as problem oriented assessment and it is second level of assessment. After further assessment it is required to find out the community's comprehension of problems, perception and evaluation of the problems in terms of seriousness and urgency of attention needed and resources available to resolves the problems.
Why to analyze a problem:
  • To know facts about a disease
  • Helps in making specific diagnosis which becomes the basis for setting goals and objectives
  • To formulating community health action plan
  • To credible communicate this information to other
  • To raise community awareness of the importance and seriousness of this health issues.
  • To able to compare the data with local, state, national and with the world.
Establishing Priorities
Establishing priorities refers to ranking of health problems identified by determining their relative importance on the basis of predetermined criteria.
Prioritization is necessary because of limited resources available and many problems to deal with which is not feasible. Priorities require consideration of nature of problems, their impact and consequences, community's readiness to resolve the problems and the resources available to deal with the problems. The criteria must be decided by the team. The following criteria have been suggested by many Public Health Nursing experts and may be used to rank the problems:
Type of Health Problems
According to Ruth Freeman, there are three types of health problems which can be grouped as:
  • Health deficits: It is the gap between actual and achievable health status. For example, illness state, failure to thrive, disability, amputation.
  • Health threats: Conditions that are conducive to disease, accident or failure to realize one's potential. For example, family history of hereditary disease, faulty eating habits, unhealthy lifestyle, threat of cross infection etc.
  • Foreseeable crises or stress points: i.e. anticipated periods of unusual demands on the individual or family in terms of adjustment/family resources. For example, marriage, pregnancy, parenthood, divorce, loss of job, death etc.
Extent of Problems (Who all in the community are affected?)
This refers to the extent of prevalence of the problems. This may range from high prevalence to low prevalence depending upon the number of people affected, timing of prevalence and seriousness of the problem.
Severity of the Consequences of the Problems (How serious or significant are the consequences/outcome of this problem in this community?)
This refers to the nature and magnitude of the resultant problems i.e. the impact of the problems, if problems concerned are not resolved on time. It is the mortality, morbidity, disability from the disease, injury, accidents, violence and crime associated with the problem.
Salience: (How does the community perceives this problem?)
It refers to the community's perception and evaluation of the problems in terms of seriousness and urgency of attention needed.
Modifiability of the Problems (Whether the problem can be resolved?)
It refers to the possibility of resolving problems. It will depend upon the availability of resources relevant to resolve the problems.
Three points rating scale may be prepared to evaluate each problem against these criteria and give a score accordingly.72
Setting Goals and Objectives
Goal is an aim, intent, or end. Goals are broad statements that describe the intended or desired change in the client's behavior. Goal statements refer to the diagnostic label (or problem statement) of the nursing diagnosis. Once the priorities are established, relevant goals and objectives are setup.
It is very important to set up goals and objectives because goals and objectives not only give directions and determine relevant actions but also help in sustaining and evaluating the actions planned and implemented. They also help community understand about what is happening and what is expected of them. The goals and objectives must be acceptable to the community i.e. the client.
Characteristics of good objectives: The good objectives always follow SMART
Specific: Target specific population
Measurable: When the results are stated
Achievable: Within the capacity of the available resources
Relevant: Fits with the general police
Time bound: That is achieved within specified time frame.
Formulating Community Health Action Plans
An important step of community health nursing process is to develop effective community health strategies. A community action plan is a road map for implementing community change by identifying and specifying what will be done, who will do it, and how it will be done. In other words the community action plan describes what the community wants to accomplish, what activities are required during a specifies timeline and what resources (money, people, materials) are needed to be successful. It is critical that the activities selected seem feasible to implement. The point is not to become overwhelmed with the process, but rather to clearly define the health priorities, actions, and expected results. The key to developing successful plans is to begin with health priorities identified by the community, develop measurable objectives to address these priorities, use evidence-based interventions, and plan realistic evaluation methods. Formulation of community health action plans refers to identification of appropriate community health and nursing intervention and preparing an operational plan to be implemented to achieve the established goals and objectives. The interventions are identified on the basis of objectives. For any objective to be achieved there will be more than one possible course of action that appear suitable to the problem under consideration. All the possible alternative interventions must be listed and evaluated to select the most suitable one.
The criteria for formulating community action plan:
  • Agency policy.
  • The resources available.
  • The nature of problem.
  • The community's interest and feasibility.
  • Competencies of health personnel.
  • Practicability and efficiency etc.
  • It is a process for action not a blue print for future development
  • The solution of problem comes from the community itself.
  • Avoid activities like lecturing or teaching to people, concentrate more on workshops as a form of discussion with the community.
  • Avoid too many picture and text
  • Use simple language and avoid difficult term.
Steps for developing community action plan:
  1. Opening (Introduction and socialization): It provides a common understanding of the importance of having a good action plan.
  2. Social environmental mapping and financing: Collect latest information on community life (Social, economic, environmental condition). By developing a map the community will be able to get a better picture of problem and priorities.
  3. Identifying the problems, needs and resource potentials: This stage defines the problem that are actually faced by the community, financial resources available to accomplish the needs.
  4. Determining priority in the need: In this stage problem and needs are ranked by the community member according to their level of urgency, their importance for development of community life.
  5. Formulating the choice of strategy: The strategy is developed and the approach chosen that is the most feasible to be used in overcoming the problems and fulfilling the needs on the priority list.
  6. Formulating the implementation plan: This stage is used to formulate a schedule and the division of tasks in carrying out the action chosen.
  7. Formulating the monitoring and evaluation plan: Formulate a plan and system of monitoring and evaluating the execution of activities.
  8. Implementing, monitoring and evaluation: The final stage consists of carrying out the action and at the same time monitoring and evaluating.
Alternative Interventions
An intervention is a process or action intended to address an existing or potential problem. The alternative activities need to be listed for all objectives and enlisting those which are appropriate considering the criteria mentioned. This way it can help clubbing the common activities and strategies and can help in formulating a plan for a particular health problem/health situation, say e.g. in this case tackling of malnutrition problem. Likewise it can be done for other problems and together it can help formulating a comprehensive plan. Explain how the intervention addresses health disparities, individual, policy, or environmental change. The interventions can be classified as dependent, independent and collaborative interventions. Independent interventions are actions that the nurse is able to initiate independently. Dependent interventions will require an order from another health care provider such as a physician or any higher person. Collaborative interventions means the intervention is done by the effort of whole team which is specially applied to the community health nursing process.
The elements of comprehensive plan thus include general goals, specific objectives, planned actions, general strategy and schedule including when, where, how, by whom and in how much durations etc.
Criteria for judging best strategy/solution to a problem
  • Costs involved
  • Time required
  • People required
  • Driving forces and obstacles for taking action
  • Possible impact of taking/not taking action
  • Community preference of problem as priority
  • The likelihood of successful solution.
Planning with the Community
It is very important that what is being planned for the community is planned with them. This will not only add to their self-esteem but also create interest in them, develop sense of responsibility and autonomy. It is therefore useful to meet community after identification of community profile and community health problems/health needs.
If feasible, meet the whole community and share the findings and the ideas and then or else meet the village leaders/village health committee/planning groups to discuss and draw up some general plan. All the health workers involved in community identification and diagnosis need to participate and make joint presentation and lead the discussions.
The community would be interested to know the findings of the questions they were asked during the survey. But keep these information simple. Explain to them the main problems found in a manner which is understandable to them. The purpose is not only to give the information but also to sensitize and motivate the people so that they understand and feel the seriousness of their problems and realize the importance of finding solutions to the problems. Tell them the number of people having a particular problem and the consequences of the problem e.g. children suffering from malnutrition and their chances for contracting other illnesses like diarrhea, measles, pneumonia and resulting mortality. Help people to understand the preventive nature of the problem e.g. malnutrition can be prevented and controlled by proper and nutritious feeding.
Present the problems in order of priority as worked out but at the same time be flexible to change the priority as felt by the people or there may be some other problem expressed by them. After presenting the problems, discuss the actions that can be planned. If feasible in the same meeting or have a separate meeting after working out some plan that can be presented, discussed and finalized. All this will depend on their level of comprehension and readiness for such kind of approach.
Implementation refers to putting the plan into action to achieve the set goals and objectives of community health. In this phase, carrying out the activities delineated in the plan, either by nurse or other professionals. It is the action phase of the nursing process which refers to the translation of the planning into practice according to principles of nursing. Community interventions are the therapeutic actions designed to promote and protect the community, health, treat and remediate community health problems and support the community as it changes over time. The implementation is feasible through the collaborative efforts of the entire health team.
The general purpose/goal of community health action plan is to help people learn to help themselves in solving their health problems, in meeting their own health needs, using their resources so as to attain and 74maintain optimum level of health. This implies constant involvement of community people, families and groups to develop a sense of responsibility and autonomy. It also lays emphasis on educating people for whatever is done for them. The community health nurse along with her other nursing personnel is in a better position to achieve this general goal.
According to Ruth-Freeman there are three types of nursing interventions which a nurse can make use of while implementing community health actions which she as a nurse is supposed to do. These are:
  • Supplemental i.e. doing things for the families, groups and community at large which they are not able to do e.g. nursing care of the sick at home or in the centre or in any other setting. Also, preparing them to do so in her absence by training and supervision and guidance. The direct nursing care can be given by the PHN herself or by ANM under her supervision and guidance.
  • Facilitative i.e. removing barriers, obstacles etc. She helps them to mobilize and develop their resources. The nurse needs to know community resources-health and health allied, know their functions and establish functional relationship.
  • Developmental i.e. helping families, groups and people at large to develop and improve their capacities. She educates members to recognize their health problems, health needs, find solutions, mobilize and develop their resources and abilities to implement actions etc.
Most of the times all the three types of nursing interventions are implemented because one without the other is unable to bring desired outcomes. But, any one of these may predominate depending upon the situations and health problems/health needs.
The process of implementation requires review of the overall plan, understanding of the strategy and the schedule i.e., What ?, When?, How? and Who ? Clarify any doubt for smooth implementation.
It also requires mobilization of resources and establishing working relationship with the community and their active participation. Regular and periodical contacts and meetings should be arranged for the same. The plan is implemented as it is or modified and implemented depending upon the resources available, community's readiness to participate, the environmental conditions, urgency of the existing conditions and conditions which may emerge etc.
Above all, it is very essential to do the recording of all the interventions implemented and progress made, difficulties and constraints encountered. It is both descriptive and analytical. This alone can help in evaluation which is the next step.
Evaluation, the final step of the nursing process which involves determining whether the client goals have been met, have been partially met, or have not been met. Even though it is the final phase of the nursing process, evaluation is an ongoing part of daily nursing activities that determines the effectiveness of those activities in helping clients achieve expected outcomes. It begins with assessment phase when decisions are made while preparing community identification guide lines for collection of data. Evaluation is then done in the planning phase when problems are analyzed, priorities are established, goals and specific objectives are set and alternative actions are planned to achieve the goals and objectives. Evaluation is finally done when actions are implemented and results are observed and recorded.
Evaluation Process
Structure (Include the physical settings, instrumentalities and conditions through which nursing care is given)
Process (Includes all the steps of nursing process)
Outcome (changes in clients health status that results from nursing intervention)
  • Philosophy
  • Objective
  • Building
  • Organizational structure
  • Financial resources (Budget, equipment and staff)
  • Taking the family health data base
  • Performing physical examination
  • Making a nursing diagnosis
  • Determining nursing goal
  • Writing nursing care plan
  • Performing nursing intervention
  • Coordination of services
  • Measuring of success of nursing action
  • Modification of sign and symptom
  • Knowledge
  • Attitude
  • Satisfaction
  • Skill level of client
  • Compliance with treatment regimen
The evaluation is a two part process: The first part of the evaluation is the determination of what is of value or in simple terms the identification of the objective or goals towards which nursing process is aimed. The second part of evaluation is the judgement of whether 75these goals are being achieved or the event to which they are being achieved. So evaluation is a systematic process of determining the extent to which objectives are achieved.
Evaluation is an ongoing decision making process. Evaluation is done at each step of the process to get feedback so as to make accurate decisions as far as possible. Observations are also done of the difficulties encountered, time spent and actions which were not feasible and intended results not achieved. So far, it is concurrent or formative evaluation which is the evaluation of resources (structure evaluation) and the process (process evaluation). It helps in taking remedial measures and appropriate decisions throughout the community health process as far as possible.
Terminal evaluation is done at the end of determined period with set goals (standards) and objectives (criteria). Evidence of effectiveness are: reduction in morbidity rates, decrease in birth rates, increase in population coverage for various services, clinic attendance, change in knowledge, attitude and health practices and degree of self-dependence etc. This is the outcome of evaluation. It shows evaluation is both quantitative and qualitative. Outcomes will depend upon goals and objectives set up, base line information available, maintenance of accurate and complete record of services rendered, compiling and computing of results, observation of changes in health knowledge, health behavior, health practices and competencies etc. This also refers to terminal evaluation.
The terminal evaluation helps in determining the achievements and intended outcomes, difficulties and constraints encountered and help identify associated problems and new emergent problems etc. It promotes rethinking, data review and its update, review and revisions of goals and objectives, reformulation of action plan and activating of the plan considering various requirements etc. This evaluation is also known as summative evaluation.
Evaluation in community health nursing process is a long term process. In achievement of the some of the targets it may be take one year two year or more. As per the time determined during goal setting the achievements will be evaluated how much the goal is achieved. The community health nurse will do the evaluation of her contributions and responsibility throughout the community health nursing process. She will also participate as one of the members of team to evaluate the whole community health action plans. During terminal evaluation she will also follow some specific steps as
  • Determine what is to be evaluated
  • Establishment of standards and criteria
  • Planning the methodology
  • Gathering information
  • Analysis of results.
Evaluation is both individual member activity and team activity. It is done by individual team member of his/her share of contribution and responsibility e.g. community health nurse will do the evaluation of her contribution and responsibility e.g. community health action outcomes are due to the contributions of entire health team and it is difficult and may not be feasible to determine outcomes due to nursing intervention alone.
Table 1.2   Differences between community health nursing process, family health nursing process, and nursing process at hospital for individual patient
Nursing process for individual patient
Family health Nursing process
Community health Nursing process
Nursing process which is applied for individual patient
Nursing process which is applied for family
Nursing process which is applied for whole community
Catagories of informations required
Patient personal history, medical and surgical history, Patient’ present condition, investigation about diseases, etc.
Family characterstics, family history of diseases, family environment, family risk and threats and family abilities to solve the family health problems
Geographical area, geographical location/boundary of a community, physical set up, environmental sanitation, population characteristics, social system, communication pattern
Data collection methods
Individual interview, physical examination, lab investigation and other biophysiological measurements
Interview, observation,
review of family health records, Physical examination of family members
Interview, observation,
record review method, community forum method, conversation/discussion method76
Nursing diagnosis priority
Based on the seriousness of individual problems
Depends upon five different factors of family, type of health problems, extent of problems, modifiability of the problems, consequences of problems, preventive potential, salience
Depends upon five different factors of the community, type of health problems, extent of problems, modifiability of the problems consequence and available resource
Nursing diagnosis format
Diagnosis consists existing individual problem related factors, and signs and symptoms
Diagnosis consists any risk threat or foreseeable crises situation of the family, during development of family profile
Total mortality and morbidity conditions of the community, development of community profile
Characteristic of care plan
Based on only the individual patient problems
Based on over all family health problems
Based on whole community health problems
By following individual care plan
By following family health care plan
By following community health care action plan
People involvement
People will be informed and permission will be taken
More involvement of family members because the care is given in their own house
The community people will be only organizing community development program
Evaluation can be done then and there to assess the outcome of nursing procedure. It is a short term process
Evaluation may be a long term process sometimes.
Some of the goals can be achieved in short period of time
Evaluation is generally a long term process