Comprehensive Textbook of Community Health Nursing [First Edition] 9348385143, 9789348385147

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Shyamala D Manivannan PhD(N), MSc(N), RM, RN Former Professor and Director (Faculty of Nursing) Dr M G R Educational and Research Institute (Deemed University) Chennai, Tamil Nadu, India

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eISBN: 978-93-483-8514-7 Copyright © Authors and Publisher First e Book Edition: 2023

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Representatives Hyderabad Pune Nagpur Manipal Vijayawada Patna

Dedicated to

My beloved husband Mr A Manivannan, my family members & all nursing students...

About the Author Shyamala D Manivannan PhD(N), MSc(N), RM, RN Former Professor and Director (Faculty of Nursing) at Dr MGR Educational and Research Institute Deemed University, Chennai, Tamil Nadu, India. Formerly, Principal, MA Chidambaram College of Nursing, Chennai; Vice Dean, Academics: Kingdom of Saudi Arabia; Principal, Dr MGR Educational and Research Institute Deemed University, Chennai. She started her nursing career as a Military Nursing Officer from Command Hospital, Central Command, Lucknow in the year 1981. After that she pursued Postbasic BSc Nursing from College of Nursing [Christian Medical College & Hospital (CMCH), Vellore] and continued to work in the Department of Community Health Nursing as Tutor and Nurse Administrator for RUHSA. She pursued Masters in Community Health Nursing from CMCH, Vellore. She received her Doctorate in Community Health Nursing from Dr MGR Medical University, Chennai, Tamil Nadu in the year 2007. She served as a Resource Person in National and International Workshops and Conferences, inland and abroad. She has the credit of various National and International publications.

Reviewers Anita Yuvaraj Nawale PhD(N), MSc(N)

Jyotika Sharma MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Assistant Professor Bharati Vidyapeeth College of Nursing Pune, Maharashtra

Assistant Professor Shaheed Kartar Singh Sarabha College of Nursing Ludhiana, Punjab

Ankit Kumar Christian PhD(N), MSc(N), BSc(N)

Jeyaseelan M Devadason PhD(N)

(Community Health Nursing)

Nursing Tutor Manikaka Topawala Institute of Nursing CHARUSAT, Gujarat

Dean Annai JKK Sampoorani Ammal College of Nursing Komarapalayam, Tamil Nadu

A Malar Selvi PhD(N), MSc(N)

Kishore Singh Rathore MSc(N), BSc(N)

(Community Health Nursing)

(Community Health Nursing)

Associate Professor Holy Family College of Nursing Okhla, New Delhi

Associate Professor Bhagwan Mahavir Institute of Medical Sciences Pawapuri (BMIMS) Nalanda, Bihar

Devendra Kumar Verma PhD(N), MSc(N)

Kawaljeet Kaur MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Principal SAK Memorial Institute of Nursing Science Chhindwara, Madhya Pradesh

Demonstrator Shri Guru Ram Dass College of Nursing Vallah, Amritsar, Punjab

Ekta Raturi PhD (Scholar), MSc(N), BSc(N)

Karthika S MSc(N)

MBA (Healthcare Services Management)

(Community Health Nursing)

(Community Health Nursing)

Assistant Professor Sumandeep Nursing College Vadodara, Gujarat

Lecturer Department of Medical Education State College of Nursing Dehradun, Uttarakhand Indarjit Walia PhD (Community Medicine), MSc(N)

Lokesh Kumar Sharma MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Former Principal PGI NINE Chandigarh

Associate Professor Saraswati College of Nursing Dausa, Rajasthan

Reviewers’ names are arranged in alphabetical order.

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Mukesh Kumar Banjara MSc(N)

P M Arulmozhi Baskaran PhD(N), MSc(N) MA (Sociology), MBA (Hospital Administration)

(Community Health Nursing)

(Community Health Nursing)

Nursing Tutor Government College of Nursing Alwar, Rajasthan

Professor cum Head of the Department Narayana Hrudayalaya College of Nursing Bengaluru, Karnataka

Mukesh Soni MSc(N)

Pratul Prasann Nand MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Assistant Professor JIET College of Nursing Jodhpur, Rajasthan

Vice Principal Sanjivani Institute of Technology Uslapur, Chhattisgarh

Muzammil Ali MSc(N)

Ritika Rocque PhD(N), MSc(N)

(Community Health Nursing)

Nursing Tutor College of Nursing Dr Ram Manohar Lohia Institute of Medical Sciences Lucknow, Uttar Pradesh

viii

MBA, (Healthcare Management & Human Resource Management) (Community Health Nursing)

Nursing Tutor All India Institute of Medical Sciences Raipur, Chhattisgarh

Neethu Mariya Mathew MSc(N)

Sonia MSc(N), PGDHHM

(Community Health Nursing)

(Community Health Nursing)

Nursing Officer All India Institute of Medical Sciences New Delhi

Tutor College of Nursing Kasturba Hospital Dariyaganj, New Delhi

Nisha Kumari MSc(N)

Sameeksha Bhardwaj MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Associate cum Vice Principal Abhilashi College of Nursing Mandi, Himachal Pradesh

Lecturer Government Medical College Budaun, Uttar Pradesh

Parjinder Kaur MSc(N)

Savita Chaudhary MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Associate Professor University Institute of Nursing Chandigarh University Chandigarh

Assistant Professor Satyam College of Nursing Lanjot, Himachal Pradesh

Poonam Kumari MSc(N)

Sunil Malav MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Lecturer HIMCAPES’ College of Nursing Badhera, Una, Himachal Pradesh

Assistant Nursing Superintendent (ANS) All India Institute of Medical Sciences Patna, Bihar

Reviewers’ names are arranged in alphabetical order.

Reviewers Suman Khatkar PhD(N) Scholar, MSc(N)

Sushma Saini PhD(N), MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Assistant Professor Shaheed Baba Deep Singh College of Nursing Ratia, Haryana

Lecturer National Institute of Nursing Education PGIMER Chandigarh

Sanjay Kumar Gupta MSc(N)

Samta Soni PhD(N), MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Assistant Professor State Institute of Nursing and Paramedical Sciences Badal, Punjab

Lecturer Government College of Nursing Jaipur, Rajasthan

Suparna Sunil Patil PhD(N) MSc(N)

Varinder Kaur PhD(N), MSc(N)

(Community Health Nursing)

(Community Health Nursing)

Principal Women’s India Trust School of Nursing Thana, Maharashtra

Principal HIMCAPES’ College of Nursing Badhera, Una, Himachal Pradesh

Suresh Kumar Ray PhD(N), MSc(N)

Vikas Bhaskar MSc(N), MPH

(Community Health Nursing)

(Community Health Nursing)

Professor cum Vice Principal Head of Department Bharati Vidyapeeth College of Nursing Pune, Maharashtra

Assistant Professor Uttar Pradesh University of Medical Sciences Saifai, Etawah, Uttar Pradesh

Reviewers’ names are arranged in alphabetical order.

ix

Preface Nurses are the largest forces among all the health care-related professionals of the world. There are well-spoken reasons to say that “Nursing” had grown from community where people live together. The reason behind this is family, the foundational component of community considered for love, affection and inculcation of culture, moral and good behavior in an individual; and again the mother is the first nurse who is the most important element of family. I started my journey as a community health nurse in RUHSA (Rural Unit for Health and Social Affairs-CMCH-Vellore) 30 years ago with the educational foundation from military nursing school. To be specific here, each day of community exposure had its contribution in molding and polishing the author of today. When all other subjects of nursing discipline train nursing students under a magnificent roof, next to sophisticated patient’s bed in an air-conditioned cubicles using advanced technology, Community Health Nursing has its unique style of teaching students in natural setting in the home by walking in the sun, rain and amidst the flood and any other disasters. Community health nurses show keen interest in effective utilization of available resources. Analytical brain, skilful hands, effective communication and mobile feet are the major investments of the community health nurses to reach the needy, to learn the people and to live among them to provide promotive, preventive curative and rehabilitative services. Community-based nursing provides care to individuals and families across a continuum focusing on health promotion and rehabilitative primary health care through interdisciplinary collaboration for diverse populations (American Association of Colleges of Nursing, 2002; Quad Council of Public Health Nursing Organizations, 2008). India with 1.33 billion population is pressurized to strengthen the community health services to battle the diseases (communicable, noncommunicable) and social problems. Preparing community health nurses is one of the key components to bring desired changes in behavior of people that lead to control many factors that influence the diseases and other social hazards. This is obvious from the curriculum that the nursing students are perpetuated to learn community health nursing throughout the program. There are many approaches to move closure to community, like considering community as a partner, community as a client, etc. Before we could use any of these approaches we need to create necessary interest in today’s nursing graduates to work with the community. There is a known saying that solid, informative, eye catching textbooks grab learners’ attention and may have an impact on students’ learning. The author’s aim and ambition here is to provide a pleasant and friendly companion textbook with required content and current information that would help them walk the desk smoothly. In addition it should provide the learners an opportunity to assess self—using various levels of cognition and skills. For the past 2 years extensive efforts were put in to garner each and every aspect of the book in a meaningful way. Illustrations presented in appropriate places to provide the crisp of the content, meaningful flow charts for classifications of domains, important points highlighted in boxes will make the students feel as if a guide is sitting by their side. Each chapter ends with essential points to ponder and relevant questions to assess and practice in the given content. All these features of this textbook make me feel that I have done a justice to my aim of producing a user-friendly student companion for young community health nursing students and the instructors of community health nursing. This book has been developed as per the latest INC Curriculum for BSc Nursing Students. The text was organized and designed using a consistent approach in all the chapters. Many chapters include a big description or a short paragraph on historical perspective on the subject covered. Most chapters have some statistical figures since it is necessary to make the readers understand the burden of the disease or problem. Extensive efforts were made to provide current information wherever (magnitude of the problem, morbidity, mortality rates, demographic trends, etc.) it was essential. Live examples were provided in relevant places to enhance students’ understanding. Difficult concepts are simplified and presented. I hope this informative, illustrative, user-friendly, eye-catching first edition of “Comprehensive Textbook of Community Health Nursing” will function as a “guide by side” to the student nurses and good instructional source for the teachers of community health nursing. 

Shyamala D Manivannan

Acknowledgments “God You Stand first, and your child here…..” First, I submit my heartfelt thanks to God for giving me necessary wisdom, health and energy to accomplish this project. I have read, learnt, served, reflected, taught and walked through the path of many learning facilities and sought to learn repeatedly through series of discussions and debates. Continuous commitment to learning perpetuates a teacher to meet the needs of the students taught. I thank all my teachers, who played an important role in shaping me as today’s author. I am thankful to all my colleagues and friends for supporting me in my intellectual journey.

I am indebted to my students whose feedback and appreciation took the most important place in my journey of teaching.

I would like to thank Mr Satish Kumar Jain (Chairman) and Mr Varun Jain (Managing Director), M/s CBS Publishers and Distributors Pvt Ltd for providing me the platform in bringing out the book. I have no words to describe the role, efforts, inputs and initiatives undertaken by Mr Bhupesh Aarora [Sr Vice President—Publishing and Marketing (Health Sciences Division)] for helping and motivating me. I sincerely thank the entire CBS team for bringing out the book with utmost care and attractive presentation. I would like to thank Ms Nitasha Arora (Publishing Head and Content Strategist – Medical and Nursing), Ms Daljeet Kaur (Assistant Publishing Manager) and Dr Anju Dhir (Product Manager cum Commissioning Editor – Medical) for their editorial support. I would also extend my thanks to Mr Shivendu Bhushan Pandey (Sr Manager and Team Lead), Mr Ashutosh Pathak (Sr Proofreader cum Team Coordinator) and all the production team members for devoting laborious hours in designing and typesetting the book. Sincere efforts have been made to verify the correctness of the text. However, in spite of best efforts some inaccuracies, ambiguities and typographical mistakes are likely to be noticed by the readers. Therefore, feedback and suggestions from the teachers and students are invited for improving the future edition. Feedback received will be highly appreciated and duly acknowledged.

From Publisher’s Desk Dear Reader, Nursing Education has a rich history, often characterized by traditional teaching techniques that have evolved over time. Primarily, teaching took place within classroom settings. Lectures, textbooks, and clinical rotations were the core teaching tools; and students majorly relied on textbooks by local or foreign publishers for quality education. However, today, technology has completely transformed the field of nursing education, making it an integral part of the curriculum. It has evolved to include a range of technological tools that enhance the learning experience and better prepare students for clinical practice. As publishers, we’ve been contributing to the field of Medical Science, Nursing and Allied Sciences and earned the trust of many. By supporting Indian authors, coupled with nursing webinars and conferences, we have paved an easier path for aspiring nurses, empowering them to excel in national and state level exams. With this, we’re not only enhancing the quality of patient care but also enabling future nurses to adapt to new challenges and innovations in the rapidly evolving world of healthcare. Following the ideology of Bringing learning to people instead of people going for learning, so far, we’ve been doing our part by: •  •  •  • 

Developing quality content by qualified and well-versed authors Building a strong community of faculty and students Introducing a smart approach with Digital/Hybrid Books, and Offering simulation Nursing Procedures, etc.

Innovative teaching methodologies, such as modern-age Phygital Books, have sparked the interest of the Next-Gen students in pursuing advanced education. The enhancement of educational standards through Omnipresent Knowledge Sharing Platforms has further facilitated learning, bridging the gap between doctors and nurses. At Nursing Next Live, a sister concern of CBS Publishers & Distributors, we have long recognized the immense potential within the nursing field. Our journey in innovating nursing education has allowed us to make substantial and meaningful contributions. With the vision of strengthening learning at every stage, we have introduced several plans that cater to the specific needs of the students, including but not limited to Plan UG for undergraduates, Plan MSc for postgraduate aspirants, Plan FDP for upskilling faculties, SDL for integrated learning and Plan NP for bridging the gap between theoretical & practical learning. Additionally, we have successfully completed seven series of our Target High Book in a very short period, setting a milestone in the education industry. We have been able to achieve all this just with the sole vision of laying the foundation of diversified knowledge for all. With the rise of a new generation of educated, tech-savvy individuals, we anticipate even more remarkable advancements in the coming years. We take immense pride in our achievements and eagerly look forward to the future, brimming with new opportunities for innovation, growth and collaborations with experienced minds such as yourself who can contribute to our mission as Authors, Reviewers and/or Faculties. Together, let’s foster a generation of nurses who are confident, competent, and prepared to succeed in a technology-driven healthcare system.

Mr Bhupesh Aarora (Sr Vice President – Publishing & Marketing) [email protected]| +91 95553 53330

Special Features of the Book Learning Objectives given in the starting of the chapter, these enlist what the students will learn after reading the chapter.

Chapter Outline gives a glimpse of the content covered in the Chapter.

Important Key Terms used in the chapter are highlighted.

Numerous boxes summarizing important information have been included wherever necessary.

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Throughout the book Practical Clinical examples have been supplemented with the text.

Did You Know boxes have been added to provide additional important information.

Procedures of Community Health Nursing have been highlighted within the text to give the practical edge to the theoretical content.

Numerous Tables summarizing important information have been included wherever necessary.

xx

Special Features of the Book

Numerous Flowcharts and Figures are used to make learning easy for students.

Summary has been included at the end of every chapter. This will act as revision for the students to focus on the important concepts discussed in the chapter.

At the end of chapters, Assess Yourself section is given which contains a variety of subjective and multiple choice questions to help students assess their learning.

xxi

Syllabus Community Health Nursing–I Placement: V Semester Unit

Time (Hrs)

I

4 (T)

Learning Outcomes

• Define public

•

•

•

• II

8 (T)

Theory: 5 Credits (100 hours)

health, community health and community health nursing Explain the evolution of public health in India and scope of community health nursing Explain various concepts of health and disease, dimensions and determinants of health Explain the natural history of disease and levels of prevention Discuss the health problems of India

• Describe health

planning and its steps, and various health plans, and committees • Discuss health care delivery system in India at various levels • Describe SDGs, primary health care and comprehensive primary health care (CPHC) • Explain health care policies and regulations in India

Content Concepts of Community Health and Community Health Nursing

• Definition of public health, • •

• • •

community health and community health nursing Public health in India and its evolution and scope of community health nursing Review: Concepts of health and illness/disease: Definition, dimensions and determinants of health and disease Natural history of disease Levels of prevention: Primary, secondary and tertiary prevention—review Health problems (profile) of India

Health Care Planning and Organization of Health Care at Various Levels

• Health planning steps • Health planning in India: Various

• •

•

•

committees and commissions on health and family welfare and Five-Year plans Participation of community and stakeholders in health planning Health care delivery system in India: Infrastructure and health sectors, delivery of health services at subcenter (SC), PHC, CHC, district level, state level and national level Sustainable development goals (SDGs), Primary Health Care and Comprehensive Primary Health Care (CPHC): Elements, principles CPHC through SC/Health Wellness Center (HWC)

Teaching/Learning Activities

• Lecture • Discussion • Explain using chart, graphs

• Community needs

Assessment Methods

• • • •

Short answer Essay Objective type Survey report

assessment (Field survey on identification of demographic characteristics, health determinants and resources of a rural and an urban community) • Explain using examples

• Lecture • Discussion • Field visits to CHC, PHC, SC/Health Wellness Centers (HWC) • Directed reading

• Short answer • Essay • Evaluation of field visit reports and presentation

Contd…

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

• Role of MLHP/CHP • National Health Care Policies and

Regulations ƒ National Health Policy (1983, 2002, 2017) ƒ National Health Mission (NHM): National Rural Health Mission (NRHM), National Urban Health Mission (NUHM), NHM ƒ National Health Protection Mission (NHPM) ƒ Ayushman Bharat ƒ Universal Health Coverage

III

15 (T) • Identify the role of an individual in the conservation of natural resources • Describe ecosystem, its structure, types and functions • Explain the classification, value and threats to biodiversity • Enumerate the causes, effects and control measures of environmental pollution • Discuss about climate change, global warming, acid rain, and ozone layer depletion • Enumerate the role of an individual in creating awareness about the social issues related to environment

Environmental Science, Environmental Health, and Sanitation

• Natural resources: Renewable and

•

•

• •

•

•

•

• Lecture • Discussion • Debates on

environmental non-renewable resources, natural protection and resources and associated problems: preservation Forest resources, water resources, • Explain using charts, mineral resources, food resources, graphs, models, films, energy resources and land resources slides Role of individuals in conservation • Directed reading of natural resources, and equitable • Visits to water supply use of resources for sustainable and purification sites lifestyles Ecosystem: Concept, structure and functions of ecosystems, types and characteristics—Forest ecosystem, Grassland ecosystem, desert ecosystem, aquatic ecosystem, energy flow in ecosystem Biodiversity: Classification, value of biodiversity, threats to biodiversity, conservation of biodiversity Environmental pollution: Introduction, causes, effects and control measures of air pollution, water pollution, soil pollution, marine pollution, noise pollution, thermal pollution, nuclear hazards and their impact on health Climate change, global warming: Ex. heat wave, acid rain, ozone layer depletion, waste land reclamation and its impact on health Social issues and environment: Sustainable development, urban problems related to energy, water and environmental ethics Acts related to environmental protection and preservation

• Short answer • Essay • Field visit reports

Contd…

xxiv

Syllabus Unit

Time (Hrs)

Learning Outcomes

• List the Acts related to environmental protection and preservation • Describe the concept of environmental health and sanitation • Describe water conservation, rain water harvesting and water shed management • Explain waste management

Content Environmental Health and Sanitation

• Concept of environment health and sanitation

•

• • • •

• 7 (T)

• Describe the

various nutrition assessment methods at the community level • Plan and provide diet plans for all age groups including therapeutic diet • Provide nutrition counseling and education to all age groups and describe the national nutrition programs • Identify early the food borne diseases, and perform initial management and referral appropriately

harvesting plants

• Visit to sewage disposal

and treatment sites, and waste disposal sites

water, waterborne diseases, water purification processes, household purification of water Physical and chemical standards of drinking water quality and tests for assessing bacteriological quality of water Concepts of water conservation: Rain water harvesting and water shed management Concept of pollution prevention Air and noise pollution Role of nurse in prevention of pollution Solid waste management, human excreta disposal and management and sewage disposal and management Commonly used insecticides and pesticides

• • • • Review of nutrition • ƒ Concepts, types • ƒ Meal planning: Aims, steps and • Nutrition Assessment and Nutrition Education

diet plan for different age groups

ƒ Nutrition assessment of individ-

• uals, families and community by • using appropriate methods •

• Planning suitable diet for individuals

• • • •

and families according to local availability of foods, dietary habits and economic status General nutritional advice Nutrition education: Purpose, principles and methods and rehabilitation Review: Nutritional deficiency disorders National nutritional policy and programs in India

Assessment Methods

• Observe rain water

• Concept of safe water, sources of

•

IV

Teaching/Learning Activities

•

Lecture Discussion Demonstration Role play Market visit Nutritional assessment for different age groups Lecture Discussion Field visits to milk purification plants, slaughterhouse Refer Nutrition Module-BPCCHN Block 2-Unit I and Unit 5

• Performance

•

• • •

assessment of nutrition assessment for different age groups Evaluation on nutritional assessment reports Short answer Essay Field visit reports

Food Borne Diseases and Food Safety Food Borne Diseases:

• Definition, and burden, causes and classification

• Signs and symptoms • Transmission of food borne pathogens and toxins

• Early identification, initial

management and referral

Contd… xxv

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

Food Poisoning and Food Intoxication

• Epidemiological features/clinical

characteristics, types of food poisoning • Food intoxication—features, preventive and control measures • Public health response to food borne diseases V

VI

6 (T)

7 (T)

• Describe

Lecture Discussion Role play Demonstration: BCC skills • Supervised field practice • Refer: BCC/SBCC module (MoHFW and USAID)

• Short answer • Essay • Performance

Community Health Nursing Approaches, • Lecture Concepts, Roles and Responsibilities of • Discussion Community Health Nursing Personnel • Demonstration • Role plays • Approaches: • Supervised field practice ƒ Nursing process ƒ Epidemiological approach ƒ Problem solving approach ƒ Evidence-based approach ƒ Empowering people to care for themselves • Review: Primary health care and Comprehensive Primary Health Care (CPHC)

• Short answer • Essays • Assessment

Communication Management and behavior change Health Education communication • Behavior change communication skills skills • Counsel and provide ƒ Communication health education to ƒ Human behavior individuals, families ƒ Health belief model: concepts and community and definition, ways to for promotion influence behavior of healthy life ƒ Steps of behavior change style practices ƒ Techniques of behavior change: using appropriate Guiding principles in planning methods and media BCC activity ƒ Steps of BCC ƒ Social and behavior change communication strategies (SBCC): Techniques to collect social history from clients ƒ Barriers to effective communication, and methods to overcome them • Health promotion and health education: Methods/techniques, and audio-visual aids

• Describe

community health nursing approaches and concepts • Describe and identify the activities of community health nurse to promote and maintain family health through home visits

• • • •

evaluation of health education sessions to individuals and families

of supervised field practice

Home Visits:

• Concept, Principles, Process, and Techniques: Bag technique

• Qualities of Community Health Nurse • Roles and responsibilities of community health nursing personnel in family health services • Review: Principles and techniques of counseling

xxvi

Contd…

Syllabus Unit VII

Time (Hrs)

Learning Outcomes

10 (T) • Explain the specific activities of community health nurse in assisting individuals and groups to promote and maintain their health • Provide primary care at home/ health centers (HWC) using standing orders/ protocols as per public health standards/approved by MoH&FW and INC regulation • Develop skill in maintenance of records and reports

• Develop beginning

skills in handling social issues affecting the health and development of the family • Identify and assist the families to utilize the community resources appropriately

Content Assisting Individuals and Families to Promote and Maintain their Health A. Assessment of individuals and families (Review from child health nursing, Medical surgical nursing and OBG nursing) • Assessment of children, women, adolescents, elderly etc. • Children: Monitoring growth and development, milestones • Anthropometric measurements, BMI • Social development • Temperature and blood pressure monitoring • Menstrual cycle • Breast self-examination (BSE) and testicles self-examination (TSE) • Warning Signs of various diseases • Tests: Urine for sugar and albumin, blood sugar, hemoglobin

Teaching/Learning Activities

• • • • • • • • •

Lecture Discussion Demonstration Role plays Document and maintain: Individual records Family records Health center records Field visits

Assessment Methods

• Short answer • Essay • Assessment

of clinical performance in the field practice area • Assessment of procedural skills in lab procedures • Evaluation of records and reports • Evaluation of field visit reports

B. Provision of health services/primary health care:

• Routine check-up, immunization, counseling, and diagnosis

• Management of common diseases

at home and health center level ƒ Care based on standing orders/ protocols approved by MoH&FW ƒ Drugs dispensing and injections at health center C. Continue medical care and follow up in community for various diseases/disabilities D. Carry out therapeutic procedures as prescribed/required for client and family E. Maintenance of health records and reports • Maintenance of client records • Maintenance of health records at the facility level • Report writing and documentation of activities carried out during home visits, in the clinics/centers and field visits F. Sensitize and handle social issues affecting health and development of the family

• • • • • •

Women empowerment Women and child abuse Abuse of elders Female foeticide Commercial sex workers Substance abuse

Contd… xxvii

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

G. Utilize community resources for client and family

• • • • • • • • VIII

10 (T) • Describe the concepts, approaches and methods of epidemiology • Investigate an epidemic of communicable disease

Trauma services Old age homes Orphanages Homes for physically challenged individuals Homes for destitute Palliative care centers Hospice care centers Assisted living facility

Introduction to Epidemiology – Epidemiological Approaches and Processes

• Epidemiology: Concept and Definition

• Distribution and frequency of disease

• Aims and uses of epidemiology • Epidemiological models of causation of disease

• Concepts of disease transmission • Modes of transmission: Direct,

• • • • •

Lecture Discussion Demonstration Role play Field visits: Communicable disease hospital and entomology office • Investigation of an epidemic of communicable disease

• Short answer • Essay • Report

• • • • • • •

• Field visit

indirect and chain of infection

• Time trends or fluctuations in disease occurrence

• Epidemiological approaches:

Descriptive, analytical and experimental • Principles of control measures/ levels of prevention of disease • Investigation of an epidemic of communicable disease • Use of basic epidemiological tools to make community diagnosis for effective planning and intervention IX

15 (T) • Explain the epidemiology of specific communicable diseases • Describe the various methods of prevention, control and management of communicable diseases and the role of nurses in screening, diagnosing, primary management and referral to a health facility

Communicable Diseases and National Health Programs 1. Communicable diseases—Vector borne diseases (Every disease will be dealt under the following headlines)

• Epidemiology of the following vector born diseases

• Prevention and control measures • Screening, and diagnosing the

Lecture Discussion Demonstration Role play Suggested field visits Field practice Assessment of clients with communicable diseases

on visit to communicable disease hospital • Report on visit to entomology office • Report and presentation on investigating an epidemic of communicable disease

reports

• Assessment

of family case study • OSCE assessment • Short answer • Essay

following conditions, primary management, referral and follow up ƒ Malaria ƒ Filaria ƒ Kala-azar ƒ Japanese encephalitis ƒ Dengue ƒ Chickungunya

Contd… xxviii

Syllabus Unit

Time (Hrs)

Learning Outcomes

• Identify the

national health programs relevant to communicable diseases and explain the role of nurses in implementation of these programs

Content

Teaching/Learning Activities

Assessment Methods

2. Communicable diseases: Infectious diseases (Every disease will be dealt under the following headlines)

• Epidemiology of the following infectious diseases

• Prevention and control measures • Screening, diagnosing the following conditions, primary management, referral and follow up ƒ Leprosy ƒ Tuberculosis ƒ Vaccine preventable diseases— Diphtheria, whooping cough, tetanus, poliomyelitis and measles ƒ Enteric fever ƒ Viral hepatitis ƒ HIV/AIDS/RTI infections ƒ HIV/AIDS, and Sexually Transmitted Diseases/ Reproductive tract infections (STIs/RTIs) ƒ Diarrhea ƒ Respiratory tract infections ƒ COVID-19 ƒ Helminthic—Soil and food transmitted and parasitic infections—Scabies and pediculosis

3. Communicable diseases: Zoonotic diseases

• Epidemiology of Zoonotic diseases • Prevention and control measures • Screening and diagnosing the

following conditions, primary management, referral and follow up ƒ Rabies: Identify, suspect, primary management and referral to a health facility • Role of a nurses in control of communicable diseases National Health Programs 1. UIP: Universal Immunization Program (Diphtheria, Whooping cough, Tetanus, Poliomyelitis, Measles and Hepatitis B) 2. National Leprosy Eradication Program (NLEP) 3. Revised National Tuberculosis Control Program (RNTCP) 4. Integrated Disease Surveillance Program (IDSP): Enteric fever, Diarrhea, Respiratory infections and Scabies

Contd… xxix

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

5. National Aids Control Organization (NACO) 6. National Vector Borne Disease Control Program 7. National Air Quality Monitoring Program 8. Any other newly added program X

15 (T) Describe the national health program for the control of noncommunicable diseases and the role of nurses in screening, identification, primary management and referral to a health facility

Noncommunicable Diseases and National Health Program (NCD) • National response to NCDs (every disease will be dealt under the following headlines • Epidemiology of specific diseases • Prevention and control measures • Screening, diagnosing/identification and primary management, referral and follow up care NCD-1

• • • • • • •

Lecture Discussion Demonstration Role play Suggested field visits Field practice Assessment of clients with noncommunicable diseases • Participation in national health programs

• Field visit reports

• Assessment

of family case study • OSCE assessment • Short answer • Essay

• • • • •

Diabetes mellitus Hypertension Cardiovascular diseases Stroke and obesity Blindness: Categories of visual impairment and national program for control of blindness • Deafness: National program for prevention and control of deafness • Thyroid diseases • Injury and accidents: Risk factors for road traffic injuries and operational guidelines for trauma care facility on highways NCD-2 Cancers

• • • •

Cervical cancer Breast cancer Oral cancer Epidemiology of specific cancers, risk factors/causes, prevention, screening, diagnosis—signs, signs and symptoms, and early management and referral • Palliative care • Role of a nurse in noncommunicable disease control program National Health Programs

• National program for prevention

• • • • xxx

and control of cancer, diabetes, cardiovascular diseases and stroke (NPCDCS) National program for control of blindness National program for prevention and control of deafness National tobacco control program Standard treatment protocols used in national health programs

Contd…

Syllabus Unit

Time (Hrs)

XI

3 (T)

Learning Outcomes Enumerate the school health activities and the role functions of a school health nurse

Content School Health Services

• Objectives • Health problems of school children • Components of school health services

• Maintenance of school health

Teaching/Learning Activities

• • • • • •

Lecture Discussion Demonstration Role play Suggested field visits Field practice

records

• Initiation and planning of school health services

• Role of a school health nurse

Assessment Methods

• Short answer • Essay • Evaluation of health counseling to school children • Screen, diagnose, manage and refer school children • OSCE assessment

Community Health Nursing–II Placement: VII Semester Unit

Time (Hrs)

Learning Outcomes

I

10 (T)

Explain nurses‘ role in identification, primary management and referral of clients with common disorders/ conditions and emergencies including first aid

Theory: 5 Credits (100 hours) Content Management of Common Conditions and Emergencies Including First Aid Standing orders: Definition, uses Screening, diagnosing/identification, primary care and referral of gastrointestinal system • Abdominal pain • Nausea and vomiting • Diarrhea • Constipation • Jaundice • GI bleeding • Abdominal distension • Dysphagia and dyspepsia • Aphthous ulcers

Teaching/Learning Activities

• • • • • • •

Lecture Discussion Demonstration Role play Suggested field visits Field practice Assessment of clients with common conditions and provide referral

Assessment Methods

• Short answer • Essay • Field visit reports

• OSCE

assessment

Respiratory system Acute upper respiratory infections— rhinitis, sinusitis, pharyngitis, laryngitis, Tonsillitis

• Acute lower respiratory infections— bronchitis, pneumonia and bronchial asthma • Hemoptysis, acute chest pain Heart and blood

• Common heart diseases—heart attack/coronary artery disease, heart failure, arrhythmia • Blood anemia, blood cancers, bleeding disorders

Contd… xxxi

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

Eye and ENT conditions

• Eye—local infections, redness of

eye, conjunctivitis, stye, trachoma and refractive errors • ENT—Epistaxis, ASOM, sore throat, deafness Urinary system

• Urinary tract infections—cystitis,

pyelonephritis, prostatitis, UTIs in children

First aid in common emergency conditions—review

• High fever, low blood sugar,

minor injuries, fractures, fainting, bleeding, shock, stroke, bites, burns, choking, seizures, RTAs, poisoning, drowning and foreign bodies

II

20 (T)

• Provide

reproductive, maternal, newborn and childcare, including adolescent care in the urban and rural health care settings • Promote adolescent health and youth friendly services

Lecture • Short answer Discussion • Essay Demonstration • OSCE Role play assessment Suggested field visits and Present situation of reproductive, field practice maternal and child health in India • Assessment of antenatal, Antenatal care postnatal, newborn, infant, preschool • Objectives, antenatal visits and child, school child, and examination, nutrition during adolescent health pregnancy, counseling • Screen, manage and • Calcium and iron supplementation refer adolescents in pregnancy • Antenatal care at health center level • Counsel adolescents • Birth preparedness • High risk approach—screening/ early identification and primary management of complications— antepartum hemorrhage, preeclampsia, eclampsia, anemia, gestational diabetes mellitus, hypothyroidism, syphilis • Referral, follow up and maintenance of records and reports Reproductive, Maternal, Newborn, Child and Adolescent Health (Review from OBG Nursing and Application in Community Setting)

• • • • •

Intranatal care

• Normal labor—process, onset, stages of labor

• Monitoring and active management of different stages of labor

• Care of women after labor • Early identification, primary

management, referral and follow-up—preterm labor, fetal distress, prolonged and obstructed labor, vaginal and perennial tears, ruptured uterus • Care of newborn immediately after birth

xxxii

Contd…

Syllabus Unit

Time (Hrs)

Learning Outcomes

Content

• • • •

Teaching/Learning Activities

Assessment Methods

Maintenance of records and reports Use of Safe child birth check list SBA module—Review Organization of labor room

Postpartum care

• Objectives, postnatal visits, care of

mother and baby, breast feeding, diet during lactation, and health counseling • Early identification, primary management, referral and follow-up of complications, danger signs-postpartum hemorrhage, shock, puerperal sepsis, breast conditions, postpartum depression • Postpartum visit by health care provider Newborn and child care

• Review: Essential newborn care • Management of common neonatal problems

• Management of common child

health problems: pneumonia, diarrhea, sepsis, screening for congenital anomalies and referral • Review: IMNCI Module • Under-five clinics Adolescent health

• Common health problems and risk

factors in adolescent girls and boys

• Common gynecological conditions

—dysmenoorhea, premenstrual syndrome (PMS), vaginal discharge, mastitis, breast lump, pelvic pain, pelvic organ prolapse • Teenage pregnancy, awareness about legal age of marriage, nutritional status of adolescents National Menstrual Hygiene scheme • Youth friendly services: ƒ SRH service needs ƒ Role and attitude of nurses: Privacy, confidentiality, nonjudgmental attitude, client autonomy, respectful care and communication • Counseling for parents and teenagers (BCS—balanced counseling strategy) National programs

• RMNCH+A Approach—Aims, health systems strengthening, RMNCH+A strategies, Interventions across life stages, program management, monitoring and evaluation systems

Contd… xxxiii

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

• Universal immunization Program

(UIP) as per Government of India guidelines—Review • Rashtriya Bal Swasthya Karyakaram (RSBK)—Children • Rashtriya Kishor Swasthya Karyakram (RKSK)—adolescents Any other new programs III

4 (T)

Discuss the concepts and scope of demography

• • • • • •

Lecture Discussion Demonstration Role play Suggested field visits Field practice

• Short answer • Essay

• • • Population explosion and its impact • on social, economic development of • individual, society and country. • • Population control—women •

Lecture Discussion Demonstration Role play Suggested field visits Field practice

• Short answer • Essay • OSCE

Demography, Surveillance and Interpretation of Data

• Demography and vital statistics— • • • •

• • • IV

6 (T)

demographic cycle, world population trends, vital statistics Sex ratio and child sex ratio, trends of sex ratio in India, the causes and social implications Sources of vital statistics—Census, registration of vital events, sample registration system Morbidity and mortality indicators—Definition, calculation and interpretation Surveillance, Integrated disease surveillance project (IDSP), Organization of IDSP, flow of information and mother and child tracking system (MCTS) in India Collection, analysis, interpretation, use of data Review: Common sampling techniques—Random and nonrandom techniques Disaggregation of data

• Discuss population Population and its Control explosion and its impact on social and economic development of India • Describe the various methods of population control

•

• • • •

empowerment; social, economic and educational development Limiting family size—promotion of small family norm, temporary spacing methods (natural, biological, chemical, mechanical methods etc.), terminal methods (tubectomy, vasectomy) Emergency contraception Counseling in reproductive, sexual health including problems of adolescents Medical Termination of Pregnancy and MTP Act National population stabilization fund/JSK (Jansankhya Sthirata Kosh)

assessment

• Counseling on family planning

Contd… xxxiv

Syllabus Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

• Family Planning 2020 • National Family Welfare Program • Role of a nurse in Family Welfare Program

V

VI

5 (T)

6 (T)

Describe occupational health hazards, occupational diseases and the role of nurses in occupational health programs

Occupational Health

Identify health problems of older adults and provide primary care, counseling and supportive health services

Geriatric Health Care

• • • •

Occupational health hazards Occupational diseases ESI Act National/State Occupational Health Programs • Role of a nurse in occupational health services—Screening, diagnosing, management and referral of clients with occupational health problems

• Health problems of older adults • Management of common geriatric • • • •

VII

VIII

6 (T)

4 (T)

• • • • • •

Lecture Discussion Demonstration Role play Suggested field visits Field practice

• Lecture • Discussion • Demonstration

ailments: counseling, supportive treatment of older adults Organization of geriatric health services National program for health care of elderly (NPHCE) State level programs/Schemes for older adults Role of a community health nurse in geriatric health services—Screening, diagnosing, management and referral of older adults with health problems

• • • Screening, management, prevention • and referral for mental health • disorders • • Review:

Describe screening for mental health problems in the community, take preventive measures and provide appropriate referral services

Mental Health Disorders

Discuss about effective management of health information in community diagnosis and intervention

Health Management Information System (HMIS)

ƒ Depression, anxiety, acute

psychosis, schizophrenia Dementia Suicide Alcohol and substance abuse Drug deaddiction program National Mental Health Program National Mental Health Policy National Mental Health Act • Role of a community health nurse in screening, initiation of treatment and follow up of mentally ill clients ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Lecture Discussion Demonstration Role play Health counseling on promotion of mental health • Suggested field visits • Field practice

• • • • Introduction to health management • system: Data elements, recording • and reporting formats, data quality issues

Lecture Discussion Demonstration Role play Suggested field visits

• Essay • Short answer • Clinical performance evaluation

• Visit report on elderly home

• Essay • Short answer

• Essay • Short answer • Counseling report

• Group project report

• Essay • Short answer

Contd… xxxv

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

Learning Outcomes

Content

• Review:

ƒ Basic demography and vital

statistics

Teaching/Learning Activities

Assessment Methods

• Field practice • Group project on

community diagnosis – data management

ƒ Sources of vital statistics ƒ Common sampling techniques,

frequency distribution

ƒ Collection, analysis,

interpretation of data

• Analysis of data for community

needs assessment and preparation of health action plan

IX

12 (T)

Describe the system management of delivery of community health services in rural and urban areas

Management of Delivery of Community Health Services

• Planning, budgeting and material • •

•

• • •

X

xxxvi

15 (T)

• Describe the

leadership role in guiding, supervising, and monitoring the health services and the personnel at the PHCs, SCs and community level including financial management • Describe the roles and responsibilities of Mid-Level Health Care Providers (MHCPs) in Health Wellness Centers (HWCs)

management of CHC, PHC, SC/HWC Manpower planning as per IPHS standards Rural: Organization, staffing and material management of rural health services provided by Government at village, SC/HWC, PHC, CHC, hospitals—district, state and central Urban: Organization, staffing, and functions of urban health services provided by Government at slums, dispensaries, special clinics, municipal and corporate hospitals Defense services Institutional services Other systems of medicine and health: Indian system of medicine, AYUSH clinics, Alternative health care system referral systems, Indigenous health services

• Lecture • Discussion • Visits to various health

• • • Understanding work responsibilities/ • job description of DPHN, Health • Visitor, PHN, MPHW (Female), • Multipurpose health Worker (Male), • Leadership, Supervision and Monitoring

AWWs and ASHA

• Roles and responsibilities of Mid-

Level Health Care Providers (MLHPs)

• Village Health Sanitation and

Nutrition Committees (VHSNC): objectives, composition and roles and responsibilities • Health team management • Review: Leadership and supervision —concepts, principles and methods • Leadership in health: Leadership approaches in healthcare setting, taking control of health of community and organizing health camps, village clinics

care delivery systems

• Supervised field practice

Lecture Discussion Demonstration Role play Suggested field visits Field practice

• Essay • Short answer • Filed visit reports

• Report on

interaction with MPHWs, HVs, ASHA, AWWs • Participation in training programs • Essay • Short answer

Contd…

Syllabus Unit

Time (Hrs)

Learning Outcomes

Content

Teaching/Learning Activities

Assessment Methods

• Training, supportive supervision and monitoring—concepts, principles and process, e.g., performance of frontline health workers

Financial management and accounting and computing at health centers (SC)

• Activities for which funds are received

• Accounting and book keeping

requirements—accounting principles and policies, book of accounts to be maintained, basic accounting entries, accounting process, payments and expenditure, fixed asset, SOE reporting format, utilization certificate (UC) reporting • Preparing a budget • Audit Records and reports:

• Concepts of records and reports—

• • • •

• XI

6 (T)

Demonstrate initiative in preparing themselves and the community for disaster preparedness and management

importance, legal implications, purposes, use of records, principles of record writing, filing of records Types of records—Community related records, registers, guidelines for maintaining Report writing—Purposes, documentation of activities, types of reports Medical Records Department— Functions, filing and retention of medical records Electronic Medical Records (EMR)— Capabilities and components of EMR, electronic health record (EHR), levels of automation, attributes, benefits and disadvantages of HER Nurses’ responsibility in record keeping and reporting

Disaster Management

• • • •

Disaster types and magnitude Disaster preparedness Emergency preparedness Common problems during disasters and methods to overcome • Basic disaster supplies kit • Disaster response including emergency relief measures and Life saving techniques Use disaster management module

• • • • •

Lecture Discussion Demonstration Role play Suggested field visits, and field practice • Mock drills • Refer disaster module (NDMA) National Disaster/INC—Reaching out in emergencies

Contd…

xxxvii

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Unit

Time (Hrs)

XII

3 (T)

XIII

xxxviii

3 (T)

Learning Outcomes

Content

Describe the importance of biomedical waste management, its process and management

Biomedical Waste Management

Explain the roles and functions of various national and international health agencies

Health Agencies

• Waste collection, segregation,

transportation and management in the community • Waste management in health center/clinics • Biomedical waste management guidelines—2016, 2018 (Review)

• International: WHO, UNFPA, UNDP,

World Bank, FAO, UNICEF, European Commission, Red Cross, USAID, UNESCO, ILO, CAR, CIDA, JHPIEGO, any other • National: Indian Red Cross, Indian Council for Child Welfare, Family Planning Association of India, Tuberculosis Association of India, Central Social Welfare Board, All India Women‘s Conference, Blind Association of India, any other • Voluntary Health Association of India (VHA)

Teaching/Learning Activities

Assessment Methods

• Lecture cum discussion • Field visit to waste

• Field visit

• Lecture • Discussion • Field visits

• Essay • Short answer

management site

report

Contents About the Author .......................................................................................................................................................................................................... v Reviewers ...................................................................................................................................................................................................................... vii Preface ............................................................................................................................................................................................................................ xi Acknowledgments ..................................................................................................................................................................................................... xiii Special Features of the Book .................................................................................................................................................................................... xix Syllabus ...................................................................................................................................................................................................................... xxiii List of Abbreviations .................................................................................................................................................................................................. xli Chapter 1 Concepts of Health, Community Health and Community Health Nursing........................................................... 1–48 Chapter 2 Health Care Planning and Organization at Various Levels....................................................................................... 49–88 Chapter 3 Environmental Science, Environmental Health and Sanitation........................................................................... 89–162 Chapter 4 Nutritional Assessment and Nutritional Education............................................................................................... 163–212 Chapter 5 Communication Management and Health Education......................................................................................... 213–247 Chapter 6 Community Health Nursing Approaches, Concepts, Roles and Responsibilities of Community Health Nursing Personnel...................................................................................................................... 249–275 Chapter 7 Assisting Individuals and Families to Promote and Maintain their Health................................................... 277–325 Chapter 8 Introduction to Epidemiology—Epidemiological Approaches and Processes........................................... 327–364 Chapter 9 Communicable Diseases and National Health Programs.................................................................................... 365–462 Chapter 10 Noncommunicable Diseases and National Health Programs............................................................................. 463–496 Chapter 11 School Health Services..................................................................................................................................................... 497–505 Chapter 12 Management of Common Conditions and Emergencies Including First-Aid.............................................. 507–547 Chapter 13 Reproductive, Maternal, Newborn, Child and Adolescent Health................................................................... 549–629 Chapter 14 Demography, Surveillance and Interpretation of Data........................................................................................ 631–661 Chapter 15 Population and its Control.............................................................................................................................................. 663–692 Chapter 16 Occupational Health......................................................................................................................................................... 693–701

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Chapter 17 Geriatric Health Care......................................................................................................................................................... 703–715 Chapter 18 Mental Health Disorders.................................................................................................................................................. 717–731 Chapter 19 Health Management Information System................................................................................................................ 733–740 Chapter 20 Management of Delivery of Community Health Services.................................................................................. 741–765 Chapter 21 Leadership, Supervision and Monitoring.................................................................................................................. 767–800 Chapter 22 Disaster Management...................................................................................................................................................... 801–817 Chapter 23

Biomedical Waste Management................................................................................................................................... 819–827

Chapter 24 Health Agencies................................................................................................................................................................. 829–847 Annexures ................................................................................................................................................................................................ 849–882 Glossary ................................................................................................................................................................................................ 883–886 Index ................................................................................................................................................................................................ 887–905

xl

List of Abbreviations AABY: Aam Aadmi Bima Yojana AB: Ayushman Bharat AD: Alzheimer’s Disease AIDS: Acquired Immunodeficiency Syndrome AIWC: All India Women’s Conference AMG: Annual Maintenance Grant ANC: Antenatal Care ANM: Auxiliary Nurse Midwife APH: Antepartum hemorrhage ARSH: Adolescent Reproductive and Sexual Health ASDR: Age-specific Mortality Rate ASFR: Age-specific Fertility Rate ASHA: Accredited Social Health Activist ASMFR: Age-specific Marital Fertility Rates ATR: Action Taken Report AWC: Anganwadi Center AWW: Anganwadi Worker AYUSH: Ayurveda, Yoga and Naturopathy, Unani, Siddha And Homeopathy BAM: Block Accounts Manager BCC: Behavior Change Communication BCHC: Block Community Health Center BCM: Block Community Manager BHAP: Block Health Action Plan BMI: Body Mass Index BMO: Block Medical Officer BP: Blood Pressure BPHC: Block Primary Healthcare Center BPL: Below Poverty Line BPM: Block Program Manager BRS: Bank Reconciliation Statement BSE: Breast Self-examination BSS: Bharat Sevak Samaj CA: Chartered Accountant CARE: Cooperative for Assistance and Relief Everywhere CBR: Crude Birth Rate CCT: Controlled Cord Traction CDMO: Chief District Medical Officer

CDR: Crude Death Rate CGA: Comprehensive Geriatric Assessment CHC: Community Health Center CHO: Community Health Officer CMO: Chief Medical Officer COPD: Chronic Obstructive Pulmonary Disease COTPA: Cigarettes and Other Tobacco Products Act CPD: Cephalopelvic Disproportion CPHC: Comprehensive Primary Health Care CPR: Couple Protection Rate CRY: Child Rights and You CSR: Corporate Social Responsibility CSWB: Central Social Welfare Board DA: Data Assistant DALY: Disability Adjusted Life Years DAM: District Accounts Manager DANIDA: Danish international development agency DBCS: District blindness control society DCM: District Community Manager DDAP: Drug De-Addiction Program DGHS: Director General of Health Services DH: District Hospital DHAP: District Health Action Plan DHF: Dengue Hemorrhagic Fever DHS: District Health Society DIC: Disseminated Intravascular Coagulopathy DOTS: Directly Observed Therapy Short-Course DPM: District Program Manager DPMU: District Program Management Unit DPT: Diphtheria, pertussis, and tetanus vaccine DT: Diphtheria-Tetanus Toxoid dta: Diphtheria-tetanus adult type EBP: Evidence-Based Practice EDD: Expected Date of Delivery EML: Essential Medicines List EMR: Electronic Medical Records ESI: Employees’ State Insurance ESI Act: Employees’ State Insurance Act

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students FAO: Food and Agriculture Organization FHR: Fetal Heart Rate FHS: Fetal Heart Sound F-IMNCI: Facility-based Integrated Management of Neonatal and Childhood Illness FM: Financial Management FMG: Financial Management Group FMR: Financial Monitoring Report FPA India: Family Planning Association of India FRU: First Referral Unit FY: Financial Year GFR: General Fertility Rate GMFR: General Marital Fertility Rate GNM: General Nursing and Midwifery GoI: Government of India HAV: Hepatitis A Virus Hb: Hemoglobin HBV: Hepatitis B Virus HCV: Hepatitis C Virus Hib Vaccine: Haemophilus Influenzae Type B Vaccine HIV: Human Immunodeficiency Virus HMIS: Health Management Information System HPV: Human Papilloma Virus HWC: Health and Wellness Center ICCW: Indian Council for Child Welfare ICDS: Integrated Child Development Services ICMR: Indian Council of Medical Research ICPS: Integrated Child Protection Scheme ICTC: Integrated Counseling and Testing Center IDA: Iron Deficiency Anemia IDD: Iodine Deficiency Disorder IDHAP: Integrated District Health Action Plan IDSP: Integrated Disease Surveillance Program IDSP: Integrated Disease Surveillance Project IEC: Information, Education and Communication IFA: Iron–Folic Acid IGNOU: Indira Gandhi National Open University ILO: International Labor Organization IM: Intramuscular IMCI: Integrated Management of Childhood Illness IMNCI: Integrated Management of Neonatal and Childhood Illness IMR: Infant Mortality Rate IPHS: Indian Public Health Standards IPSrC: Integrated Program for Senior Citizens xlii

IPV: Inactivated Polio Vaccine ITBN: Insecticide Treated Bed Nets IUD: Intrauterine Death/Device IUGR: Intrauterine Growth Retardation JHPIEGO: Johns Hopkins Program for International Education in Gynecology and Obstetrics JSK: Jansankhya Sthirata Kosh JSSK: Janani Shishu Suraksha Karyakram JSY: Janani Suraksha Yojana KSY: Kishori Shakti Yojana LBW: Low Birth Weight LHV: Lady Health Visitor LLIN: Long Lasting Insecticide Nets LMP: Last Menstrual Period MAS: Mahila Arogya Samiti MCH: Mother and Child Health MCTS: Mother and Child Tracking System MCWC: Mother and Child Welfare Center MDGs: Millennium Development Goals MDM: Mid Day Meal MDT: Multi-Drug Therapy MIS: Management Information System MLA: Member of Legislative Assembly MLHP: Mid-Level Health Provider MMR: Maternal Mortality Rate MMUs: Mobile Medical Units MNREGA: Mahatma Gandhi National Rural Employment Guarantee Act MO: Medical Officer MoHFW: Ministry of Health and Family Welfare MOIC: Medical Officer In charge MP: Member of Parliament MPW: Multipurpose Worker MRD: Medical Records Department MRP: Manual Removal of Placenta MTP: Medical Termination Of Pregnancy MUAC: Mid Upper Arm Circumference MWCD: Ministry of Women and Child Development NACO: National AIDS Control Organization NACP: National AIDS Control Program NAMP: National Anti-Malaria Program NBCA: Newborn Care Area NBSU: Newborn Stabilization Unit NCCP: National Cancer Control Program NDCP: National Disease Control Program

List of Abbreviations NFCP: National Filaria Control Program NFHS: National Family Health Survey NGO: Non-governmental Organization NHM: National Health Mission NHP: National Health Policy NHSRC: National Health Systems Resource Center NIDDCP: National Iodine Deficiency Disorders Control Program NITI Aayog: National Institution for Transforming India Aayog NLCP: National Leprosy Control Program NLEP: National Leprosy Eradication Program NMCP: National Malaria Control Program NMEP: National Malaria Eradication Program NMHP: National Mental Health Program NMMUs: National Mobile Medical Units NNMBS: National Nutrition Monitoring Bureau Survey NPAG: Nutrition Program for Adolescent Girls NPCB: National Program for Control of Blindness NPCC: National Program Coordination Committee NPCDCS: National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke NPHCE: National Program for Health Care of the Elderly NRHM: National Rural Health Mission NSAID: Nonsteroidal Anti-inflammatory Drug NSSK: Navjaat Shishu Suraksha Karyakram NTCP: National Tuberculosis Control Program NVBDCP: National Vector Borne Disease Control Program OPV: Oral Polio Vaccine ORS: Oral Rehydration Solution PASB: Pan American Sanitary Bureau PHC: Primary Health Center PIH: Pregnancy-induced Hypertension PIP: Program Implementation Plan PMJAY: Pradhan Mantri Jan Arogya Yojana PMS: Premenstrual Syndrome PMSU: Program Management Supporting Unit PNC: Postnatal Care POP: Pelvic Organ Prolapse PPD: Purified Protein Derivative PPH: Postpartum Hemorrhage PROM: Premature or Prelabor Rupture of Membranes RCH: Reproductive and Child Health RGI: Registrar General of India RKS: Rogi Kalyan Samiti RMNCH+A: Reproductive, Maternal, Newborn, Child Health

plus Adolescents RNTCP: Revised National Tuberculosis Control Program RSBY: Rashtriya Swasthya Bima Yojana RTI: Reproductive Tract Infection SACS: State AIDS Control Society SAM: State Accounts Manager SAPSrC: State Action Plan for Senior Citizens SARS: Severe Acute Respiratory Syndrome SBA: Skilled Birth Attendant SC: Sub Center SDGs: Sustainable Development Goals SEARO: South-East Asian Regional Office SFM: State Finance Manager SHC: Sub Health Center SHGs: Self Help Groups SHS: State Health Society SHSRC: State Health Systems Resource Center SoE: Statement of Expenditure SPIP: State Project Implementation Plan SPMU: State Program Management Unit SRS: Sample Registration Survey STGs: Standard Treatment Guidelines STI: Sexually Transmitted Infection STP: Standard Treatment Protocol TAI: Tuberculosis Association of India TB: Tuberculosis TBA: Traditional Birth Attendant TFR: Total Fertility Rate TORCH infections: Toxoplasma gondii, rubella virus, cytomegalovirus and herpes virus infections TSE: Testicular Self-Examination TSH: Thyroid Stimulating Hormone TT: Tetanus Toxoid UC: Utilization Certificate UHC: Universal Health Coverage UHND: Urban Health and Nutrition Day ULB: Urban Local Body UNDP: United Nations Development Program UNESCO: United Nations Educational, Scientific and Cultural Organization UNFPA: United Nations Population Fund UNFPA: United Nations Fund for Population Activities UNICEF: United Nations Children’s Emergency Fund UNRRA: The United Nations Relief and Rehabilitation Administration xliii

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students UPHC: Urban Primary Health Center USAID: The United States Agency for International Development VHND: Village Health and Nutrition Day VHSC: Village Health and Sanitation Committee VHSNC: Village Health, Sanitation and Nutrition Committee

xliv

VVM: Vaccine Vial Monitor WB: World Bank WCD: Women and Child Development WHO: World Health Organization WIFS: Weekly Iron and Folic Acid Supplementation WRA: Women of Reproductive Age

C H A P T E R

Concepts of Health, Community Health and Community Health Nursing

1

  LEARNING OBJECTIVES This chapter is designed to enable the learner to: ˆ ˆ

ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ

Comprehend health in different perspectives. Interpret people’s experience of health through the findings of the cross-cultural studies. Define health. Explain changing concepts of health and disease. Describe the dimensions of health. Describe health continuum. Describe the determinants of health. Define public health, community health and population health. List down the elements of community. State the types of communities.

ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ ˆ

Describe the factors affecting the health of the community. Define public health nursing and community health nursing. List down the principles of community health nursing. Define community health nurses and their education in India. Describe the scope of community health nursing. Describe roles of community health nurse. Describe worksites for community health nurse. Describe the levels of health promotion. Explain natural history of the disease.

ˆ

Natural History of the Disease Risk Factors Levels of Prevention Modes of Intervention Public Health Evolution: World Evolution of Community Health Nursing: Global Perspective Challenges of 21st Century for Community Health Nursing

¬

ˆ ˆ ˆ ˆ ˆ

Explain the levels of prevention applied to disease progression. Describe natural history of the disease. Discuss the evolution of public health in India. Discuss the evolution of community health nursing in India. Describe national health problems in India. Discuss the challenges of community health nurses in 21st century.

  CHAPTER OUTLINE ¬ ¬

¬ ¬

Concepts of Health and Illness/ Disease Concepts of Public Health, Community Health and Community Health Nursing Community Health Nurses and Their Education in India Scope of Community Health Nursing

¬ ¬ ¬ ¬ ¬ ¬ ¬

¬ ¬

National Health Problems in India Moving into the Future Twenty-First Century and Challenges for Community Health Nursing

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

  KEY TERMS ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬

Health Public health Community health Population health Community Healthy community Geographic community Common-interest community Community of solution Community organizing Community health nursing

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Public health nursing Biomedical concept Ecological concept Psychological concept Holistic concept Right to health Dimensions of health Wellness, illness and health continuum Prerequisites for health Levels of prevention

CONCEPTS OF HEALTH AND ILLNESS/ DISEASE Health in Different Perspectives In our daily life, most of us have the practice of greeting one another usually using a phrase “How are you?” Yes, we really want to know how a person is doing. The answer to it may be “fine”, “nice”, “excellent”, “well”, “ok”, “not bad”, “not ok”…goes on. The answer is based on one’s own feeling and perception related to his physical/mental/social or any other state. What is health? Seems a bit silly question; surely we all know what health is? But, is that right? Do we really know what health is, health for ourselves and health for others? A large part of what we do is help people regain and maintain health. Therefore, it is important to explain what health is. What is health? There are no easy, straightforward answers to this. In addition, some people use entirely different words when they actually mean what others would call “health”. The word health is derived from hal, which means “hale, sound, whole”. Trying to define health relies on developing understanding about a wide range of perspectives, subjectivities and experiences that are, in turn, socially, historically and culturally located. Discussing your health is one of the most common topics of conversation when people meet and in the media and in our own conversations we talk of having a healthy bank account, having a healthy attitude, mind, body or appetite, buying healthy foods and having a healthy respect for someone. Health can mean many things in addition to the personal beliefs. It can also be an adjective to describe the provision of a service (health visitor, health inspector, multipurpose health worker) or something you can buy such as food (Health mix, Health drink), or a broad community (Community health) or world (World health). The mouth is connected to stomach through “food pipe” and “the heart has four chambers” are the facts 2

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Health promotion Health maintenance Primary prevention Secondary prevention Tertiary prevention Epidemiological triad Natural history of the disease Scope of community health nursing Health problems

that through anatomical investigation we can find conclusive proof for. “Health” is not as easy to prove, or agree upon and find evidence. Health is highly individualized perception. Health is not something that a person achieves suddenly at a specific time. It is an ongoing process. Many factors affect individual definitions of health. Definitions may vary according to an individual’s previous experience, expectations of self, age and sociocultural influences. Nurses should be aware of their own personal definitions of health and appreciate that the other people have their individual definitions as well.

People’s Experiences of Health Cross-cultural studies indicate that people’s experience of health can be organized (Lyn Talbot and Glenda Verrinder) as follows: • Feeling vital • Having good social relationships • Experiencing a sense of control over one’s life and one’s living conditions • Being able to do things one enjoys • Having a sense of purpose in life • Experiencing a connectedness to community.

Definition of Health Health in the abstract refers to a person’s physical, mental, and spiritual state; it can be positive (as being in good health) or negative (as being in poor health). On April 7, 1948, the World Health Organization (WHO) provided a definition of “health” that has become very famous. “Health is a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.” The 21 word definition has interestingly not been amended since 1948 and is found in the first pages of the Constitution of the

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing WHO as adopted by the International Health Conference, New York, June 19–22, 1946 which was signed on July 22, 1946 by the representatives of 61 states.

Changing Concepts of Health Biomedical Concept Perception of the concept of health differs from one individual to another, one professional community to another. Conventionally health is a concept paralleled to “absence of disease”. Consequently, a person who is free of diseases is healthy. This concept was popularly described as “biomedical concept”. Pathologically, an individual’s body described as a machine, disease referred to a fault in the machine and doctor is the corrector of the machine.

Holistic Concept

• Holistic concept agrees the ancient population’s customary • • • •

Criticism This “biomedical concept” did not pay much attention on the other determinants of health especially social, environmental, psychological and cultural. Hence, this was weak in answering the key health-related problems like accidents, malnutrition, antisocial activities, etc.

Ecological Concept

•

definition of health (Sound mind in a sound body in a sound family and in a sound environment). As the name implies this holistic concept puts together all the other concepts on health. Focuses on the impact of social, political and environmental challenges on health. This concept uses multidimensional approach in attaining the well-being of a person in his/her environment. The holistic approach designates that all parts/segments/ sectors of the society tend to influence health. All the departments that focus on promotion and protection of health play important roles. The various departments may include agriculture, animal husbandry, food, industry, education, housing, public works, communication, etc. Disease prevention is safe, cheaper and sustainable through ecological and environmental approach. Higher importance paid to environmental and ecological factors at the very beginning of the planning process itself.

Right to Health Universal Declaration of Human Rights established a

• Human ecology is a part of the science of ecology. declaration in 1948, “Everyone has the right to a standard of Human ecosystem includes all dimensions of manmade environment—physical, chemical, biological and psychological in addition to natural environment. • According to the ecologists, health is viewed as a dynamic equilibrium between man and environment, and disease is viewed as an imbalance between the two. Human ecological and cultural adaptations do determine not only the occurrence of disease, but also food security and population explosion. • The ecological concept revolves around two issues: (i) man and (ii) environment. Adaptation of man to natural environment can result in prolonged life expectancies and better quality of life even in the absence of modern health amenities. Man has created new health problems by altering the environment in terms of various activities like urbanization, industrialization, deforestation, construction of dams and canals.

Psychological Concept

• Developments in social sciences revealed the fact that •

health is not only absence of disease but also is a social, economic, psychological, cultural and political entity. These factors should be considered while measuring health.

living adequate for the health and well-being of himself and his family”. The preamble to the WHO constitution also affirms that it is one of the fundamental rights of every human being to enjoy “the highest attainable standard of health”. The concept “right to health” encompasses: • Right to medical care • Right to responsibility for health • Right to healthy environment • Right to food • Right to procreate or not • Right of the deceased persons (determination of death, autopsies, abortion, etc.) • Right to die

Wellness, Illness and Health Continuum People are either well or ill. Yet wellness is a relative concept, not an absolute, and illness is a state of being relatively unhealthy. There are many levels and degrees of wellness and illness. Community health practitioners place a strong emphasis on wellness, which includes the definition of health mentioned but incorporates the capacity to develop a person’s potential to lead a fulfilling and productive life, one that can be measured in terms of quality of life. Health is depicted in a continuum since it comprises various levels of health ranging from optimal health at one end

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Fig. 1.1: Wellness-illness continuum

and total disability or death at the other end (Fig. 1.1). Effective application of health continuum while caring the individual, families and communities is very much essential. For example, while encountering a family with dysfunctionality, a nurse might discuss about the relative degree of illness; whereas, while meeting a healthy family, the nurse focuses on listing out the wellness characteristics like good communication, decision making, conflict resolution, etc., and family’s ability to work together to achieve their goals using available resources effectively. Likewise, a community, as a collection of people, may be described in terms of degrees of wellness or illness. The health of an individual, family, group, or community moves back and forth along this continuum throughout life. The level (degree) of illness increases as one moves toward total disability or death; the level of wellness increases as one moves toward optimal health. This continuum shows the relative nature of health. At any given time, a person can be placed at some point along the continuum. A person’s relative health is usually in a state of flux, either improving or deteriorating. Figure 1.1 shows several examples of people in changing states of health.

Prerequisites for Health

In addition to the aspects (physical, mental and social) of health mentioned, there are few more aspects of dimensions of health described by many scholars. These dimensions of health cannot be seen as factors in isolation since they all continuously interact and complement each other for contributing to the health of an individual or community (Fig. 1.2).

Physical Dimension Physical dimension of health means the physical routines of a person. A person with good routines like saying no to tobacco, drugs, alcohol and other kinds of practices that may lead to ill health is placed on basic pillars of a good physical development. In addition to “saying no” to bad habits as mentioned, inculcation of good habits like recognizing the importance of good balanced diet, avoiding the inactive physical state are the foundation for building physical health. While traveling in the path of wellness man has to show interest in building his physical strength using various measures like exercise, good nutrition, character building and morality. In his journey, the man should have the knowledge and ability to recognize his health-related warning signs so that he can prevent himself by taking necessary precautions to prevent the disease. He must be capable to seek medical care for treating his illnesses. The man should also have a very good access to medical care. The benefits of good physical health are so many from feeling good to having a sense of esteem, actualization and a sense of well-being. Signs of Good Physical Health

• Good complexion • Clear skin

The fundamental conditions and resources for health are: • Peace • Shelter • Education • Food • Income • A stable ecosystem • Sustainable resources • Social justice and equity Improvement in health requires a secure foundation in these basic prerequisites.

Dimensions of Health There are many scholars who contributed volumes in explaining the various dimensions of health. We can take a base for the dimensions of health from the WHO’s definition on health, which was presented, in early paragraph of this chapter. 4

Fig. 1.2: Dimensions of health

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

• • • • • • • • • • • • • •

Bright eyes Lustrous hair Body well clothed Firm flesh Not too fat A sweet breath A good appetite Sound sleep Regular activity of bowels and bladder Smooth, easy, coordinated movement of the body All the organs of the body are of unexceptional size and function normally All the special senses are intact The resting pulse rate, blood pressure, and exercise tolerance are all within the range of normality for individuals’ age and sex In the young and growing individual there is a steady gain in weight.

Assess Various Aspects of Your Physical Health

• • • • • • • • •

Self-assessment on overall health. Assess for symptoms of risk and illness. Assess your shape and size and try to be fit. Encouraging good habits (Exercise and eating habits). Discourage bad habits (Alcohol, tobacco chewing, and smoking). Enquiry in to medical services and routine master health checkup. Assess your nutrition pattern and relate it to your performance. Assess the level of self-achievements and self-actualization. Finally assess the related issues enhancing or disrupting your physical health.

Mental Dimension A good state of mental health is the ability to respond to many varied experiences of life with flexibility and a sense of purpose. Mental health is defined as a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment. A few decades ago mind and body were considered as separate entities but now it is not so. Researchers have identified that psychological factors can induce all kinds of diseases not only the mental illness. To assess or identify we need to know the following characteristics of a mentally healthy person:

• A mentally healthy person is free from internal conflicts; • • • • • •

he is not at war with himself. He is well adjusted, i.e., He is able to get along well with others. He accepts criticism and is not easily upset. He searches for identity. He has a strong sense of self-esteem. He knows himself; his needs, problems and goals (selfactualization). He has good self-control balances—rationality and emotionality. He faces problems and tries to solve them intelligently, i.e., coping with stress and anxiety.

Social Dimension Man is a social animal. People who go for work from morning to evening return back to the families in the evening. When they meet each other the sharing of whole day’s experience occur. Social well-being is defined as the “Quantity and quality of the individual’s interpersonal ties and the extent of involvement in the community.” The social dimension explains and motivates on how to contribute to nurture one’s own environment and community. It actually highlights the relationship and inter dependability of others and nature. Individual’s journey in a wellness path helps in realizing his importance in society and the impact he has on the various environments. During wellness journey, one may look for ways to preserve the beauty and balance of nature. Enhancing personal relationships and important friendships would help in building better living and community. Every individual has responsibility in improving the world by motivating healthier living through effective communication with people around him. How to assess your social dimension of health? • Assess your interpersonal skills and your ability to gel with the family and community. • Evaluate your contribution to the common welfare. • Assess conflict levels and learn to develop harmony in living with others.

Intellectual Dimension The intellectual dimension distinguishes one’s creative innovative and motivating mental activities. A well person always looks for food opportunities to expand his knowledge as well trying to share it with others. No matter where the place is: Person with intellectual abilities uses his abilities in all places like classroom, family, smaller communities and community at large. Wellness path is a big ever-ending journey and each one born on the earth need to be alert on abdicating 5

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students wrong diversions from wellness road. Person with intellectual abilities takes extra precautions to safeguard his journey in the wellness path. Classroom learning, independent learning through various media and experiencing with experienced/ experts are some of the means for earning intellectual skills. All these would help a person exploring issues related to problem solving, creativity, and decision-making. Assessing Intellectual Dimensions of Health

• Try always challenging our minds with intellectual and •

creative tasks and never try to remain self-satisfied and uncreative. Recognize possible difficulties in your path and take appropriate courses of action based on available information. Do not wait and worry with major struggles later.

Spiritual Dimension The spiritual dimension identifies and explores the meaning and purposes of our life. While hunting for meaning of human existence man deeply appreciates the natural forces and God’s creations on this universe. This gives a peace and paradoxical balance between his feelings and hard stretches of his life path. All the religions try to tune man’s behavior by showing him the spiritual path. Man may have varied feelings in his spiritual journey from doubt, despair, fear, disappointment and dislocation to pleasure, joy and happiness. The spirituality functions as component of value system of a person. Spirituality is one of the essential components of holistic nursing care. Assessing Spiritual Dimension of Health

• Consider and internalize the meaning of life and necessity •

in accepting the beliefs of others. Each day we must behave consistently using our values and beliefs; this may help us to be free from worrying about our deceitfulness to ourselves.

Emotional Dimension The emotional dimension recognizes awareness and acceptance of one’s feelings. Emotional wellness includes the degree to which one feels positive and enthusiastic about one’s self and life. It includes the capacity to manage one’s feelings and related behaviors including the realistic assessment of one’s limitations, development of autonomy, and ability to cope effectively with stress. The well person maintains satisfying relationships with others. Personal choices and decisions made using the synthesis of feelings, thoughts, philosophies, and behavior. Able to form interdependent relationships with others based upon a foundation of mutual commitment, trust, and respect. 6

To Assess or Evaluate Emotional Dimension of Health

• It is better to be aware of and accept our feelings than to •

deny them. It is better to be optimistic in our approach to life than pessimistic.

Vocational Dimension The vocational dimension recognizes personal satisfaction and enrichment in one’s life through work. Vocational or occupational development is related to one’s attitude about one’s work. When work is fully adapted to human goals, capacities and limitations, work often plays a role in promoting both physical and mental health. Contributing one’s own unique gifts, skills, and talents to his or her work is both personally meaningful and rewarding. Values conveyed through involvement in activities that are gratifying a person. The choice of profession, job satisfaction, career ambitions, and personal performance are important components of this dimension. To Assess or Evaluate Vocational Dimension of Health

• Choosing a career which is consistent with our personal •

values, interests, and beliefs. Developing functional, transferable skills through structured involvement opportunities.

Environmental Dimension Ryff and Singer (2006) describe environmental mastery as a dimension of wellness and state that, to make the most of interpersonal flourishing. In the definition of environmental wellness, Ranger and coauthors (2000) include the balance between home and work life, as well as the individual’s relationship with nature and community resources (i.e., involvement in defining wellness and its determinants a recycling or community clean-up effort). Some other dimensions below are also suggested for consideration to define the health aspects of a person: • Philosophical dimension • Cultural dimension • Socioeconomic dimension First, most authors incorporated the idea that wellness is not just absence of illness, as first outlined by the WHO wellness definition. Second, wellness is described in terms of various factors that interact in a complex, integrated, and synergistic fashion, and the dynamic interaction of the dimensions causes the sum of the dimensions to be greater than the whole. Each dimension is integral to the whole and no one dimension operates independently.

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

Determinants of Health You may be wondering why some people are healthy and others are not; why some are active and others are not, so; why some are having higher intelligent quotient (IQ) and others with less IQ. These comparative questions can be kept growing until we understand that there are many factors contributing to the health status of a person. We witness volumes of writing on determinants of health (Fig. 1.3).

Biological and Genetic Makeup Health is largely determined by the basic biology and the gene of our body. Genetic inheritance plays an important role in determining our life span, health status and the risk of developing certain illnesses. Inherited genetic frame of an individual predisposes the individual responses that are affecting the health status. Though there are many other factors that determine the overall health of a person, genetic endowment takes a lead and specific role in predisposing particular disease or health problems in certain individuals. The best example is sickle cell disease. Sickle cell disease is a common example of a genetically inherited disease. When both parents carry the gene for sickle cell, their child inherits the same and develops sickle cell disease.

Income and Status Income of a family determines the health status of the family. Family with higher income lives in a good house with all

the needed amenities. They can keep away many diseases occurring in relation to poor living conditions. Higher income families always spend a major amount on food that strengthens the family members and help in developing the resistance against diseases. Being poor may expose people to poor physical environments that put them at risk for health problems. The people in the societies with the principle of “equitable distribution of wealth” are the healthiest and they prosper in all aspects.

Social Support Networks Family is the first social institution that any child comes across. The family binds the members together and extends support to its members at any situation. Family gives each member an individual role, sense of belonging, togetherness, confidence and enhances the physical, social, mental and spiritual development of its members. A man enters in society with the lessons learnt in the family and develops his social relationship with the others. The support he receives from family, friends, and communities is linked to his better health. The sense of belonging, love and affection, caring support, self-respect and the predominant role he or she plays in a group/society enhances the well-being at greater satisfactory levels and acts as buffers against health problems.

Education Education provides a status quo in the society. Society respects educated people and man learns many things through education. It is one of the means for employment and income. Education is one of the factors that define the “social status” of a person. Social position of a child during its childhood positively or negatively affects the opportunities for education. Further, his occupation, income, his partner, his housing condition—all these are determined by his educational status. All these factors are indirectly contributing to the health of the individual.

Employment

Fig. 1.3: Determinants of health

Factors like unemployment and underemployment negatively influence the health status of a person. Among employed: Employees work under great pressure develop stress-related illnesses. The employees need to satisfy many people to prove their abilities as well to get increments and promotions; in addition, they need to amidst of the politics in the working area and prove them on daily basis. The people with more control over their work with no stress or fewer stresses are healthier than the others who work in more stressful jobs. Studies also proved that the employees with fewer stresses live longer than the other group who work with more stress. 7

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Social Environments The strength of the community lies on its social networks within the community. Social network activities are found between institutions, organizations and among people. People share resources to strengthen the good relationships with one another. The norms and values of the society influence the health and well-being of the individuals and aggregates in various ways. Other social measure that avoid potential risks to health are recognizing the diversity, establishing good working relationships, providing safe environment, ensuring social stability and good working relationships. Societal networks function efficiently to reduce the risks related to health.

Physical Environments Most diseases are born in the inferior physical environment where there is no safe water to drink, clean air to breath, standard house to live and no conducive environment to work. Contaminated water, air, poor living conditions and working environment increases the risk of diseases. Safe houses, good connecting roads, healthful housing, grains and vegetables grown in good soil, pollution-free air and water are the factors influencing our physical environment there by our health.

Personal Health Practices Personal health practices refer to the individual’s ability to promote his or her health, prevent disease, become selfsufficient and self-reliant, develop coping skills to manage day-to-day pressure and stress, develop skills in analyzing the problems and finding solutions and make suitable choices that enhance health. It is widely recognized that the personal choices are influenced by socioeconomic environment.

Healthy Child Development Research evidences tell us the importance of early childhood development. Early childhood development contributes to the school readiness and health in later life. All the other health determinants which we have discussed have positive or negative influences on the health of the child accordingly. The child’s development is affected by many factors like genetic makeup, the income of the family, birth order, age and occupation of the parents, education of the parents, living conditions of the house, access to food and medical facilities, geographic area where the child lives and all the other facilities.

Health Services There are different sectors providing health care to people but the goal is the same. India renders primary health care services to people since 1978. Secondary and tertiary care falls into the subsequent levels. Health services provide preventive, 8

promotive, curative, and rehabilitative services. It becomes the responsibility of the nation to assure good health care services. Availability of health care services alone cannot meet the requirements of people; it must be accessible and affordable too for the individuals.

Gender Gender means a range of roles or functions ascribed to the two sexes on a differential basis by the society. Health system uses the gendered norms for referring to man or woman. Prime importance is given to male with many facilities. The gender-based discrimination is found among families. This discrimination makes the difference in their health.

Culture Culture plays an important role in raising or impeding the health of a person. Some of the cultural beliefs and practices are good to health; others drastically affect the health of a person. For example, in some culture, “rooming-in” occurs only on the 11th or 14th postnatal day and till then mother is not allowed to take bath. Many mothers do not feed the colostrum (initial breast milk) to babies since the culture believes that it would cause sickness to baby.

CONCEPTS OF PUBLIC HEALTH, COMMUNITY HEALTH AND COMMUNITY HEALTH NURSING Definitions: Public Health, Community Health, Population health, Community The health of the individuals and country are influenced by the public health practices of the country. India’s health care system comprises governmental sectors, private sectors, voluntary health agencies and health programs. Public health is given the prime importance; the population based community health practice brings multiple communities under one umbrella. The aim of public health practice is the health of the entire country. Public health care is rendered at primary, secondary and tertiary levels. The major focus of the community health nursing is to plan and provide care to individual, group, family and community.

Public Health Historically, Winslow (1923) defined public health as the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. The Institute of Medicine (IOM) defines public health as “organized community efforts aimed at the prevention of disease and promotion of health”.

Community Health Community health is the identification of needs and the protection and improvement of collective health within a geographically defined area. There are many definitions available on community health. Community health refers to the health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health.

Population Health The term population health, which is similar to community health, has emerged in recent years. The primary difference between these two terms is the degree of organization or identity of the people. Population health refers to the health status of people who are not organized and have no identity as a group or locality and the actions and conditions to promote, protect, and preserve their health.

The definition of a community should take into account “opportunity for interpersonal and networking interactions within the unit”. —Hancock et al., 1997

Elements of Community

• • • • •

Healthy Community A healthy community, first described by Cottrell (1976) as a competent community, is one in which the various organizations, groups, and aggregates of people making up the community do at least four things: 1. They collaborate effectively in identifying the problems and needs of the community. 2. They achieve a working consensus on goals and priorities. 3. They agree on ways and means to implement the agreed goals. 4. They collaborate effectively in the required actions.

Types of Communities

• Geographic community: ƒ

Community “Community” refers to a multidimensional system, which encompasses interactions across both horizontal and vertical levels and is characterized by people and organizations, actions, context, and consciousness perceptions and cultural constructs. Community is variable and permeable, shaped and reshaped continuously by changing actions and relationships. —Walter, 1997 The term community refers to a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging. “Community” implies people acting together in some way as a group, and the whole meaning more than the sum of its parts. A community is not just a collection of individuals; those individuals are part of something bigger, which has meaning for them and for others. The function of any community includes its members’ collective sense of belonging and their shared identity, values, norms, communication, and common interests and concerns.  —Bruce and McKane, 2000; Clark, 2002 Communities are “systems composed of individual members and sectors that have a variety of distinct characteristics and interrelationships”. They can be defined by the characteristics of its people; geographic boundaries; shared values, interests, or history; or power dynamics. —CDC, 1998

A sense of membership. Common symbol systems; common values. Reciprocal influence. Common needs and a commitment to meeting them; and A shared history. (Israel et al., 1994)

•

•

A community often is defined by its geographic boundaries and thus is called a geographic community. A city, town, or neighborhood is a geographic community (e.g., North Indian, South Indian). Common-interest community: ƒ A community can also be identified by a common interest or goal. A collection of people, even if they are widely scattered geographically, can have an interest or goal that binds the members together (e.g., the members of Student Nurses’ Association). Community of solution: ƒ A type of community encountered frequently in community health practice is a group of people who come together to solve a problem that affects all of them (Villagers seeking transport communication to their village).

Features of Community A community has three features: (1) location, (2) population and (3) social system. 1. Location: Every physical community carries out its daily existence in a specific geographical location. The health of the community is affected by this location, including the placement of the service, the geographical features.

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students 2. Population: Consists of specialized aggregates, but all diverse people who live within the boundary of the community. 3. Social system: The various parts of communities’ social system that interact and include the health system, family system, economic system, and educational system.

Factors that Affect the Health of a Community Many factors affect the health of a community (Fig. 1.4). They are classified as: • Physical factors • Industrialization • Social and cultural factors • Community organization • Individual behaviors Physical Factors Physical factors include the influences of geography, the environment, community size, and industrial development. • Geography: A community’s health problems can be directly influenced by its altitude, latitude, and climate. In tropical countries where warm, humid temperatures and rain prevail throughout the year, parasitic and infectious diseases are a leading community health problem. • Environment: Environment has good and bad influences on our health. Many experts believe that if we continue to allow uncontrolled population growth and continue to deplete nonrenewable natural resources, succeeding generations will inhabit communities that are less desirable than ours. • Community size: The larger the community, the greater its range of health problems and the greater its number of health resources. Larger communities should have more health professionals and better health facilities than smaller communities should.

Fig. 1.4: Factors affecting the health of a community

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The size of the community can have an impact on the health status of the community. This could be positive or negative. Efficient planning, organizing and utilization of resources will always lead to an effective management. The resources can be wasted, ruined, or damaged if decisions are not made in a timely fashion or if the wrong decisions are executed. Trained community always saves money and avoids waste. Proper governmental administration and practices help to reduce any kind of waste. Industrialization Industrialization of a country may give rise to positive and negative effects. For example, industrialized country can have improved communication network that enhances the relationship for trading and other communication between the countries and at the same time it becomes the major reason for polluted environment and health hazards related to occupation. Social and Cultural Factors Social factors are the ones that influence the relationship between the people and groups within the community. Social factors emerge because of interaction between people. Man being a social animal cannot stay in isolation. Due to increased urbanization and industrialization, man leads a machine life specifically in urban areas; he does not find time to interact even with his own family members and mostly lives under stress. Concerning this, the rural community leads life much leisurely. On the other side, urban communities have access to huge number and choices of health care facilities which is not possible in rural communities. • Culture: It is the most important factor that decides the health of the community. Each culture will have different cooking and eating practices. Diet is the basic determinant of one’s health. Culture is the one that determines childrearing practices, coping with stress and pain, valuing health and showing positive and negative attitude toward health care. So, it is very important for a community health nurse to understand the culture of the community where she serves. • Beliefs, traditions, and prejudices: People tend to practice wrong things because they believe that it is been practiced from generation to generation. They have a kind of predetermined belief about someone or some object without having adequate rational knowledge. For example in the community, mothers do not wean their babies on time because they believe that weaning before 1 year of age will cause diarrhea. This wrong belief will disturb the growth and the children will be malnourished inviting many infections.

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

• Economy: Economic status of the country can affect the nursing and public health practice applied to promote and protect

• •

•

•

health status of the community because the provision of health services is totally depending upon the resources available. Politics: The decisions of ruling government in a state level or at a central level can either promote or demote the health of the community. Religion: A number of religions have taken a position on health care. For example, some religious communities limit the type of medical treatment their members may receive. Some do not permit immunizations; others do not permit their members to be treated by physicians. Still others prohibit certain foods. Social norms: They determine the acceptable or unacceptable behavior of the people in a given society. This can cause positive or negative effects. For example in Saudi Arabia, alcoholism is an unacceptable behavior. In some countries public smoking is prohibited this has reduced the number of passive smokers. Socioeconomic status (SES): SES contributes to the health of the people; poor people live in houses without basic sanitation facilities, this invites many diseases. The rich people live in good houses with all amenities. Although, the rich people can keep away some diseases relating to hygiene, they are more prone to diseases like obesity, diabetes and hypertension due to their inactive state, overeating and socialized lifestyle.

Community Organization Community organizing is the efficient means of organizing the resources of a community. If community resources are put together it becomes a unified force that avoids any duplication and unnecessary cost and thereby increases its productivity. This would also help in avoiding the solutions that are not meeting the needs of the local community and culture. Individual Behaviors The behavior and practices of each individual of the community contribute to the health status of the community. For example if the mothers are volunteering for bringing their children to health subcenter for polio drops instillation, more children will be immunized against poliomyelitis, this will strengthen the herd immunity of the community.

Definitions: Community Health Nursing and Public Health Nursing

the health of population. It combines all the basic elements of professional, clinical nursing with public health and community practice. Community health nursing is community based and, most importantly, it is population focused. Operating within the environment of rapid change and increasingly complex challenges, this field of nursing holds the potential for positively shaping the quality of community health services and improving the health of the general public. Community health nursing, as a field of nursing, combines nursing science with public health science to formulate a community-based and populationfocused practice. —Williams, 2000 Community health nurses mobilize the efforts of the community through engaging the community, collaborating with the community and making partnership with the community. These efforts help in organizing the community to work collectively for common good of the community health. The focus of the population-based practice is to identify the problems of the population under care. Population-based data guide in identifying the problems of the community. The identified problems are approached on priority base. Common characteristics of community health nursing include: • Planning and executing services to the community • Emphasize on promotion of health and maintenance of health • Rendering care in the community at all three levels.

Public Health Nursing According to ANA (1999), public health nursing is a population-focused community nursing practice with the goal of prevention of disease and disability by creating the conditions where people can be healthy. Public health nursing is the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences (American Public Health Association, Public Health Nursing Section, 1996).

Community Health Nursing Community health nursing is a synthesis of nursing practice and public health practice, applied to promoting and preserving the health of populations. Health promotion, health maintenance, health education and management, coordination, and continuity of care are used in a holistic approach to the management of the health care of individuals, families, and groups in a community (American Nurses’ Association, 1986).

Community Health Nursing

Characteristics of Community Health Nursing

Community health nurses are on the front lines of health care and prevention. Community health nursing is the synthesis of

• It is a field of nursing. • It combines public health with nursing. 11

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

• • • • • •

It is population focused. It emphasizes prevention, health promotion, and wellness. It promotes client responsibility and self-care. It uses aggregate measurement and analysis. It uses principles of organizational theory. It involves interprofessional collaboration.

Principles of Community Health Nursing In community health nursing practice, nurses build their expertise in a specialty area and demonstrate skills using following principles: • Promote, protect and preserve health, prevent disease and injury. • Promote, protect and preserve the environment that contributes to health. • Advocate for healthy public policy • Lead the integration of comprehensive and multiple health promotion approaches that build the capacity of clients. • Respect the diversity of clients and caregivers, focus on the linkages between health and illness experiences and enable clients to achieve health. • Provide evidence informed care in a variety of settings such as the client’s home, school, office, clinics, on the street, communal living settings or workplace. • Cooperate, coordinate and collaborate with a variety of partners, disciplines, and sectors. • Recognize that healthy communities and systems that support health contribute to health for all. Engage a range of resources to support health by coordinating care, and planning services, and programs. • Work with a high degree of autonomy to initiate strategies that will address the determinants of health and positively impact people and their community.

Essential Elements of Community Health Nursing (ANA, 1999; Williams, 1977, 2000) • History and philosophy of public health, including •

• •

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emphasis on the greatest good for the greatest number. Concept of aggregates—assessing needs, planning and providing services, and evaluating services’ impact on population groups—including aggregate-level decisionmaking. Priority of preventive, protective, and health-promoting strategies over curative strategies. Means for measurement and analysis of community health problems, including epidemiologic concepts and biostatistics.

• Influence of environmental factors on aggregate health. • Principles underlying management and organization for • •

community health, because the goal of public health is accomplished through organized community efforts. Public policy analysis and development. Health advocacy and the political process.

COMMUNITY HEALTH NURSES AND THEIR EDUCATION IN INDIA • Indian Nursing Council took great interest in providing

•

•

higher-level importance for community health nursing in curriculum. Community health nursing is found as a core subject in all the basic courses like multipurpose health workers (MPHWs), diploma in general nursing and midwifery (DGNM), basic BSc nursing and post basic BSc nursing India, holding the second most populous country of the world needs more number of community health nurses to tackle the challenges in the community. In India, the “primary level care” in the community is mostly shouldered by the MPWs whose educational preparation is minimum to meet the challenges of community. There are different educational levels with which community health nurses function in the field of community: Diploma in General Nursing and Midwifery (DGNM) and Bachelor of Science (BSc) in Nursing nurses work in primary health centers and community health centers and community clinics. BSc nursing degree holders can work as tutors in nursing schools and colleges and as “public health nursing tutors” in community training centers. Master degree holders in community health nursing specialty are eligible to function from “tutor” to “professor cum principal level” based on their experience and norms set by “Indian Nursing Council”. Nurses with “MSc in community health nursing specialization” are eligible to pursue PhD and later postnursing doctoral education. As per Indian Nursing Council, PhD is the desirable qualification to function as principal or vice principal in nursing colleges.

SCOPE OF COMMUNITY HEALTH NURSING In the “health care system” of any given country, public health care delivery accounts for the major share. Qualified health care professionals of different fields work together as a team to provide comprehensive care to the public. The core knowledge “public health” makes foundation for public and community health nursing.

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing The WHO recommends that “basic nursing education for community health practice should prepare nurses to identify, assess, plan, implement, and evaluate the population at risk (WHO, 1985)”. The major areas of work for nurses are at the bedside, in the community, in hospitals and in homes. Nurses are the largest group of health care professionals who are always placed on the front lines of work. They are the primary point of contact for individuals/families and they function at the first level of decision-making. Community health nursing emphasizes on promotion of the health and provision of care to the individuals, families, and communities. Institute of Medicine’s report 2010 says, “By virtue of its numbers and adaptive capacity, the nursing profession has the potential to effect wide-reaching changes in the health care system.” Community health nurses practice in many settings in hospitals, primary health centers, community health centers, schools, homes, health clinics, long-term care facilities, various clinics like—mother care clinics, well baby clinics, lactation clinics, mobile clinics, immunization clinics, counseling centers, hospice centers, etc. They possess varying levels of education and skills. This community nursing education starts from licensed practical nurses, who take up the major share in contributing direct patient care in homes and primary health centers, to nurse scientist who works in researching and finding effective ways of promoting health, preventing the disease and protecting and maintaining the health. The WHO states that the community health care system of many of the developing nations includes five layers, which are represented as: Individual care, family care, care and support by neighbors and known groups, support from health care providers and healers and support by local governments and community welfare organizations. The scope of practice of community health nurses includes having collaboration as well being sensitive to the changes occurring with each layer of the system. The roles and responsibilities of the community health nurse vary as per the policies, practices, health care demands, norms of the statutory bodies and service settings in which she functions. Community health nurses work in close proximity to individuals, families, community, and other health team members. They serve as real key players to make contracts and partnerships to provide quality care in the community. The community health nurses usually win the confidence of their clients and are considered trustworthy. This helps them in collecting appropriate client data, which facilitates in identifying strengths, weaknesses, and further needs of the individuals and families. Community health nurses take up many roles in day-to-day practice. However, there is always one primary role.

Fig. 1.5: Roles of community health nurses

Roles of Community Health Nurses (Fig. 1.5) • • • • • • •

Nurse clinician Nurse educator Nurse advocate Nurse manager Nurse collaborator Nurse leader Nurse researcher.

DID YOU KNOW? In any setting, the role of community health nurse focuses on the prevention of illness, injury, or disability; the promotion of health; and maintenance of health.

Nurse Clinician The most common and well-known role of the nurse is of a clinician or a care provider. However, in the context of community health nursing, the role of a clinician comes with various practical challenges. The clinician role in community health appropriates the health services to individuals and families, to groups and populations. A nurse’s role as a clinician in the hospital focuses only on individuals and their families. The clinician role of a nurse in community is differentiated from the clinician role in a hospital with a specific emphasis on holism, health promotion and skill expansion (Fig. 1.6).

Nurse Educator The most important and popular role of the community health nurse is that of an educator or nurse-health teacher. Nurses act as educators to individuals or groups and community. Health teaching is a well-known component of community health 13

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students teachers, health educators, social workers, physical therapists, nutritionists, occupational therapists, psychologists, epidemiologists, biostatisticians and legislators.

Nurse Researcher Literature provides the base for evidence-based community health nursing practice. Active questions relating to current knowledge and practice and finding an answer through research will contribute to the existing knowledge of community health nursing. Fig. 1.6: Roles of community health nurse as a clinician

nursing practice and a basic weapon in preventing behaviororiented communicable diseases and noncommunicable diseases (NCDs). Community health nurses in the capacity of health educators facilitate client’s learning and create awareness on health matters. Client receives information both formally and informally. Considering the concept of selfcare, clients are oriented to use appropriate health resources and seek out health information for themselves. The process of health teaching focuses on disease prevention and health promotion throughout.

Nurse Advocate Community health nurses are the most easily available and approachable guides for people’s advocacy. They explain about the health care system, advice on diseases, provide referrals, and guide them for follow-up. In community, people need someone to guide them through the complex system and assure the satisfaction of their needs. The nurse advocate role sets certain criteria like being assertive, willing to take risks, communicating and negotiating, and identifying resources and obtaining results.

Nurse Leader Community health nursing is purely a matter of knowing people; their needs and problems, and working in collaboration to find solutions for the problems. Community health nurse needs to be an able leader and administrator to tackle people from various religion castes, culture and backgrounds. According to WHO, new nurse graduates should be trained as generalists with strengths in community health nursing interventions to meet the challenges of community health care rather than specialists in community health care.

Worksites of Community Health Nurse Home Care Community health nurses provide care in the houses of people since time immemorial. The services may include preventive, promotive, curative and rehabilitative. Present days, community health nursing concentrates more on family centered care. Basically the very structure, functions, and processes of the family predisposes the individual family member’s health or illness leading to overall health status of the family (Fig. 1.7).

Nurse Manager As a manager, the nurse exercises administrative direction toward the accomplishment of specified goals by assessing clients’ needs; planning and organizing to meet those needs; directing and leading to achieve results; and controlling and evaluating the progress to ensure that goals are met.

Nurse Collaborator Community health nurses take up the role of collaborator, in which they work together with others toward a common goal or purpose. Community health nurses work in government or private firms in collaboration with other nurses, physicians, 14

Fig. 1.7: Care at home by community health nurse

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing Family refers to two or more individuals, who depend on one another for emotional, physical, and economical support. The members of the family are self-defined.  —Hanson, 2005 Family health is a dynamic changing state of well-being, which includes the biological, psychological, spiritual, sociological, and cultural factors of individual members and the whole family system. —Hanson, 2005 Family meets the basic needs of the family members. Some of them may include identity, affection, food, shelter, clothing and protection. Community health nurses have focused on family care role even during yester years. It is easy to understand the “ripple effect” when you observe and work amidst the family. Ripple effect refers to “the changes in individual member of the family are reflected as changes in the family.” Community health nurse provides care at home to newborn, infants, preschoolers, school aged, antenatal, postnatal mothers, and persons with acute and chronic illnesses. Apart, health promotion, health protection and health maintenance and rehabilitation are the most prominent roles of the community health nurses at home.

School Health Nurse School is the most popular worksite of community health nurse. Health promotion, periodical health checkup, immunization, nutrition, screening for diseases and treatment of minor ailments and referrals are the functions of the school health nurse. In previous decades, community health nurses performed periodical checkup, health promotion and disease prevention activities in government-schools of India. Primary health centers are responsible to conduct screening and periodical checkups in their assigned areas and community health nurses take significant role in it. In addition, in recent years, many private owned schools appoint community health nurses in the designation of health officer to take care of health activities in the school. In recent years, some corporate hospitals in India also have started to concentrate on school health by appointing BSc and MSc nursing graduates as nursing health officers.

In Industries Western countries offer Masters degree in occupational health nursing. Nevertheless, in most developing countries community health nurses play the role. They work in factories and industries to perform health promotion, disease prevention, health protection, and maintenance activities among the workers. Occupational health nursing also extends the care to members of the family. Reviewing the folders of the family members would help in knowing the family’s strength and stressors of the individual and plan his care accordingly.

Occupational health nurses actively participate in: • Promotion of nutrition • Personal hygiene and health maintenance • Prevention of communicable diseases and environmental sanitation • Promotion of mental health • Promotion of small family norm • Health education • Counseling and training programs.

NATURAL HISTORY OF THE DISEASE It is very important for the nurses to know and gain adequate knowledge about natural history. The natural history of disease is a key concept in epidemiology. It explains the way in which a disease evolves over time from prepathogenesis phase to its termination, as recovery, disability or death. Each disease has its own unique natural history, which is not necessarily the same in all individuals; so, any general formulation of the natural history of disease is necessarily arbitrary. The natural history of disease is best understood by cohort studies. Natural history of disease is described in two phases: (1) Prepathogenesis (i.e., the process in the environment) and (2) Pathogenesis (i.e., the process in man).

Prepathogenesis Phase In this stage, the disease has not developed yet but the ground has been laid by the presence of factors that influence its occurrence. Except the entry of disease producing agent into the host rest all the other factors that facilitate the initiation of the disease are in place. This is a phase in which the man is exposed to the risk of disease. Mere presence of the agent, host and environment is not sufficient to begin the disease. The interplay of all the three factors needs to occur with each other to develop the disease. The combination of the agent, host and environment decide not only the onset of disease which may range from a single case to epidemics but also the distribution of disease in the community. Traditionally the “Epidemiologic triad” model (Fig. 1.8) was used to explain the infectious disease causation. This triad elaborates on how the interaction occurs between external agent, a susceptible host, and an environment. There need to be interaction of these three factors to initiate the disease process in man/host.

Pathogenesis Phase This phase starts when the disease producing organism or the causative agent enters the man. As a result of interaction of

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Agent Factors

Fig. 1.8: Epidemiological triad model

the three factors, i.e., agent, host and environment, the agent enters the host and multiplies in it and the signs and symptoms are shown out. The further events in the pathogenesis phase are clear-cut in infectious diseases, i.e., the disease agent multiplies and induces tissue and physiological changes, the disease progresses through a period of incubation and later through early and late pathogenesis. The host can end up in recovery or complications leading to death or disability. The pathogenesis phase may be modified by intervention measures such as immunization and chemotherapy. The specific points we need to remember are: Host’s reaction to infection with a disease agent is not predictable, means, the infection may be clinical or subclinical; typical or atypical or the host may become a carrier with or without having developed clinical disease as in the case of hepatitis B. In chronic diseases (e.g., coronary heart disease, hypertension, cancer), the early pathogenesis phase is less manifested. This phase in chronic diseases is “presymptomatic phase”. During the presymptomatic stage signs and symptoms not manifested. The pathological changes are essentially below the level of the “clinical horizon”. The clinical stage begins only when recognizable signs or symptoms appear. By the time the signs and symptoms appear the disease phase is already well advanced to late pathogenesis phase. If the disease that cannot be treated at this level (secondary prevention) will become complicated and the person will be moving toward the next level where tertiary level of prevention is required. Tertiary level of prevention is required to rehabilitate and limit further disability.

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Agent is an infectious agent causing the disease. Agent can be a virus, bacterium, parasite, or any other microorganism. In general, a causative agent is necessary to cause disease. On the other hand, presence of causative agent alone is not enough to cause disease. There are many factors influence the exposure to an organism leading to disease that includes the pathogenicity and dose of infectious agent. Disease agents are classified as: • Biological agents: This includes the living agents of disease like viruses, fungi, bacteria, rickettsiae, protozoa and metazoan. The basic properties of biological agents include infectivity, pathogenicity and virulence. • Nutrients: Any excess or deficiency of intake of proteins, fats, carbohydrates, vitamins, minerals and water may result in nutritional disorders and can even predispose other chronic diseases. Protein-energy malnutrition (PEM), anemia, goiter, obesity and vitamin deficiencies are some of the current nutritional problems found in many countries. • Physical agents: Physical agents include heat, cold, humidity, pressure, radiation, electricity and noise that may result in sicknesses. • Chemical agents: Chemical agents are of two types: 1. Endogenous chemical agents: On many occasions, chemicals that are present in the body or released as the outcome of various activities of our body can cause harmful effects if the quantity is changed. The best examples are: urea (uremia), serum bilirubin (jaundice), ketones (ketosis), uric acid (gout). 2. Endogenous chemical agents: Agents arising out of human host like allergens, dust, fumes, gases and insecticides. • Mechanical factors: Mechanical forces may cause injuries like sprains, dislocation, fracture, crush, contusion and death. • Social agents—absence or insufficiency or excess of a factor necessary to health: Some of the most predominant social agents that predispose the diseases are poverty, smoking, drug abuse, alcoholism and unacceptable and abnormal sexual behavior, etc. • Absence or insufficiency or excess of a factor necessary to health: These may include: (1) chemical factors, e.g., hormone (insulin, estrogen, enzymes); (2) nutrient

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing factors (listed above under no. 2); (3) lack of structure, e.g., thymus; (4) lack of part of structure, e.g., cardiac defects; (5) Chromosomal factors, e.g., Mongolian, Turner’s syndrome; and (6) immunological factors, e.g., agammaglobulinemia.

and created many new things in his physical environment. Regrettably, those things brought many health problems to the human community. The most popular examples may include air pollution, water pollution, noise pollution, urbanization and radiation, etc.

Host Factors (Intrinsic)

2. Biological Environment

Host denotes a man who can get the disease. Various intrinsic factors of the host are addressed as risk factors that can have an influence on individual’s exposure, susceptibility, or response to a causative agent. A man’s behaviors like sexual practices, maintenance of hygiene as well as sexual preferences, age and occupation contribute to the exposure of man to a particular condition or disease. Further man’s susceptibility and response to an agent are influenced by factors such as genetic build, nutritional status, immunity, psychological makeup and presence of disease or medications. We can also classify these host factors into: • Demographic features: Age, sex, ethnicity • Biological features: Genetic makeup, biochemical levels of blood, blood groups, physiological functions of different organ systems (e.g., blood pressure). • Socioeconomic features: Socioeconomic status, education, occupation, marital status, stress and housing, etc. • Lifestyle: Personality traits, living habits, use of alcohol, drugs and smoking

Biological environment may include all living things like bacteria, rodents, insects, animals and plants, etc. There need to be a harmonious relationship to achieve a state of peaceful cohabitation. If any kind of disturbance occur to this harmony may lead to health problems.

Environment (Extrinsic) Though the vulnerability of the host extends invitation to the causative agent, the environment favors the interplay between the host and the agent. It is not the agent alone, causing the disease. There are several other factors related to host and environment, which determine whether disease will occur in the exposed host. There are two types of environment: (1) Intrinsic (internal) and (2) extrinsic (external). Intrinsic means the internal environment of the man. The macroenvironment (external) is defined as, “all that which is external to individual human host, living and nonliving, and with which he is in constant interaction”. The external environment includes all factors, external to either the susceptible host or the infected source, that may assist or impede the exposure to, or transmission of, the infectious agent from the infected source to the susceptible host. External or macroenvironment is divided into three: 1. Physical Environment Physical environment refers to all nonliving things and physical factors such as air, water, noise, light, climate, heat, etc. Powerful and brilliant nature of man had altered

3. Psychosocial Environment Psychosocial environment is defined as “those factors affecting personal health, health care and community well-being that stem from the psychosocial makeup of individuals and the structure and functions of the social groups.” The component list of psychosocial environment is very lengthy and includes cultural values, customs, beliefs, habits, attitudes, morals, religion, education and health services, social and political organization. Man is a social animal. He has to adjust with many people to maintain his social circle. On day-to-day practice, he has to interact with many people like from his family to his external world. His social environment may affect him positively or negatively. Psychosocial factors may put us in to stressful situation leading to many problems such as anxiety, depression and frustration, etc. A harmony between man and his environment is essential to reduce man’s susceptibility to disease. Since man exists concurrently in so many environmental contexts we must study him in his “total environment”.

RISK FACTORS When we deal with communicable disease, there is known causative agent for each specific disease. There are many diseases for which causative agents are still unidentified, e.g., coronary heart disease, cancer, peptic ulcer, mental illness, etc. In such cases, the etiology is generally discussed in terms of “risk factors”. The term “risk factor” is defined as: (1) an attribute or exposure that is significantly associated with the development of a disease or (2) a determinant that can be modified by intervention, thereby reducing the possibility of occurrence of disease or other specified outcomes. The presence of a risk factor does not imply that the disease will occur, and in its absence, the disease will not occur. Table 1.1 shows popularly known risk factors related to some diseases. 17

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Table 1.1: Some risk factors and associated diseases Heart disease

Smoking, high blood pressure, elevated serum cholesterol, diabetes, obesity, lack of exercise, type A personality

Cancer

Smoking, alcohol, solar radiation, ionizing radiation, work-site hazards, environmental pollution, medications, infectious agents, dietary factors

Stroke

High blood pressure, elevated cholesterol, smoking

Motor vehicle accidents

Alcohol, non-use of seat belts, speed, automobile design, roadway design

Diabetes

Obesity, diet

Cirrhosis of liver

Alcohol

LEVELS OF PREVENTION The four levels of prevention, corresponding to different phases in the development of disease are explained here (Figs 1.9 and 1.10):

1. Primordial Prevention Primordial prevention refers to the prevention of appearance or development of risk factors in countries or population groups in which they have never appeared before. Primordial prevention, efforts are intended for discouraging children from adopting hazardous lifestyles. 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 (for example, smoking, eating patterns, physical exercise). The main intervention in primordial prevention is through individual and mass education.

Fig. 1.9: Four levels of prevention

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Fig. 1.10: Levels of prevention with examples

2. Primary Prevention Primary preventive measures help the client to avoid the expenses, discomforts and pressure to the quality of life that a disease may cause. It signifies intervention in the prepathogenesis phase of a disease or health problem. Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures (Flowchart 1.1). • A primary prevention goal relies upon holistic approach that signifies intervention in the prepathogenesis phase. In primary prevention, “necessary preventive measures are taken prior to the onset of disease, which removes the likelihood of a disease occurrence”. Flowchart 1.1: Primary prevention interventions

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

• Intervention at primary level promotes general health and

well-being and specific protective measures. • It promotes individual’s attitude toward life and health and the necessary step she takes for himself, his family and his community. • Primary prevention includes health promotion and specific protection. The concept of primary prevention is now being applied to the prevention of chronic diseases such as coronary heart disease, hypertension and cancer based on elimination or modification of “risk-factors” of disease. WHO recommended two approaches for prevention chronic NCDs: i. Population (mass) strategy: It is directed at the whole population irrespective of individual risk levels. ii. High-risk strategy: The high-risk strategy aims to bring preventive care to individuals at special risk.

3. Secondary Prevention Secondary prevention focuses on early identification of health problems and prompts intervention to alleviate health problems. Its goal is to identify individuals in early stage of disease process and limit future disability. • Secondary prevention involves efforts to detect and treat existing health problems at the earliest possible stage when disease or impairment already exists. Examples: ƒ Cervical cancer screening through pap smears helps in early detection of cervical cancers. ƒ Hypertension and cholesterol, screening programs in many communities help to identify high-risk individuals and encourage early treatment to prevent heart attacks or stroke.

4. Tertiary Prevention • Tertiary prevention focuses on restoration and

rehabilitation with the goal of returning the individual to an optimum level of functioning. • Tertiary prevention attempts to reduce the extent and severity of a health problem to its lowest possible level, so as to minimize disability and restore or preserve function. Examples: ƒ Treatment and rehabilitation of persons after a stroke to reduce impairment. ƒ Postmastectomy exercise programs to restore functioning ƒ Early treatment and management of diabetes to reduce problems or slow their progress.

MODES OF INTERVENTION “Intervention” can be defined as any attempt to intervene or interrupt the usual sequence in the development of disease in man. There are five modes of intervention corresponding to the natural history of any disease. These levels are related to agent, host and environment, shown in Figure 1.8. The five modes of intervention are as follows:

Prevention Level: Primordial Prevention 1. Health Promotion Health promotion is the process that facilitates people to have greater control over their health. Health promotion is considered to be a behavioral social science that comes from the biological, environmental, psychological, physical, and medical sciences to promote health and prevent disease, disability, and premature death through educational and voluntary behavior change activities. Health promotion is the development of individual, group, institutional, community and systemic strategies to improve health, knowledge, attitudes, skills and behavior. The responsibility of the health sector does not lie only on health sector. The responsibility is shared among individuals, family, community, schools, health professionals, health service institutions and governments. All these sectors must work together to provide a health care system that enhances health. The purpose of health promotion is to positively influence the health behavior of individuals and communities as well as the living and working conditions that influence their health. Health promotional approaches are adopted mainly to strengthen the host. Popular interventions are as follows: • Health education • Environmental modifications • Nutritional interventions • Lifestyle and behavioral changes. Health Education Health education is any combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes. The WHO health promotion glossary describes health education as not limited to the dissemination of healthrelated information but also “fostering the motivation, skills and confidence (self-efficacy) necessary to take action to improve health”, as well as “the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students individual risk factors and risk behaviors, and use of the health care system”. Many diseases can be prevented with little or no medical intervention through mere provision of adequate information on those. Environmental Modifications There is a mutual relationship subsists between human health and the environment that is known from many evidences. Health promotion strategies should not only be the education and communication. It should go beyond to achieve substantial behavioral changes among the population in target. Environmental modifications are thought to be an important addition to health promotion. Second-hand smoke at home, public places and workplaces cause the development of some cancers. Other factors contribute to ill health are like poorly ventilated fireplaces and stoves, water quality, food sources and food quality, etc. Environmental Protection Agency (EPA) reports on the relationship between long-term use of pesticides and birth defects, nerve damage and other long-term developmental problems in children. Man cannot be separated from his environment. All possible measures should be taken to promote healthy environment. All potential man-made disasters and pollution activities should be avoided or controlled to keep our environment safe for living. Many chronic diseases can be controlled through integration of lifestyle modification, injury prevention measures and strategies to promote a healthy environment. The health and lifestyle of an individual influences the extent to which food contributes to good social, mental and physical well-being. The activities required to modify environment: • Provision of safe water • Installation of sanitary latrines • Control of insects and rodents • Improvement of housing • Safe disposal of waste, etc.

and other actions implemented by schools, individuals or groups to make healthy nutrition a way of daily life. Nutrition interventions are designed to promote health and reduce the risk of disease. Adequately nourished people enjoy optimal growth, health and well-being. In most countries underfive nutrition is given attention through feeding programs. India has launched many nutritional programs sponsored by central or state governments in order to promote the health of children, antenatal and postnatal women as well old age people. Some of the nutritional interventions include improvement of vulnerable groups, child feeding programs, food fortification and nutrition education. Lifestyle and Behavioral Changes New research conducted in Iran shows that lifestyle changes in diet and levels of physical activity improve the health of entire communities. Most of the problems of the people are related to the living conditions, such as poverty, marginalization, poor housing and unemployment, which put them at a risk of developing illness or disease. The “lifestyle” problems are smoking, drinking alcohol, using drugs, engaging in unsafe sex, or being overweight or obese. The biggest contributors to most preventable diseases are the economic status, tobacco, alcohol, physical inactivity and poor diet. These four lifestyle behaviors need to be targeted to improve the health of the nation. Good verbal and behavioral communication between patient and nurse is fundamental to behavior change attempts and outcomes (Robinson et al., 2008). Nurses can use the following framework behavioral change interaction:

The 5 A’s Framework by Canadian Taskforce Canadian task force recommended a framework using 5 A’s approach preventive health care, feasible for behavior change interactions (Fig. 1.11). The five A’s approach includes: (1) Assess, (2) Advise, (3) Agree, (4) Assist and (5) Arrange

Nutritional Interventions Malnutrition impairs the growth and development and causes death of many (millions) children. Good nutrition is needed to strengthen the learning potential of children. Primary prevention is the most effective and affordable method to prevent chronic disease, and that dietary intervention positively impacts health outcomes across the life span. In general, healthy nutrition contributes to the physiological, mental and social well-being of individuals. Nutrition interventions are policies, services, learning experiences

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Fig. 1.11: Behavior change interaction

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing 1. Assess: The first stage includes assessment on patients’ awareness of any unhealthy behaviors and their motivation and readiness to change. 2. Advice: Following the assessment advice and information should be provided on the risks and benefits associated with a health behavior and support services available to help the patient. 3. Agree: Once patients have been fully informed, nurses should initiate the collaborative work with them to agree a set of attainable, measurable goals. 4. Assist: Assistance should be provided in the form of skills development, barrier identification, problem-solving and social support. 5. Arrange: It is important to arrange follow-up on activities carried to provide further opportunity for reassessment and observe progress and adjust action plans accordingly. Throughout all stages, encouraging interviewing skills can be used to engage patients via open-ended questions that enhance their autonomy. The community health nurses act as the key players in promoting health and preventing disease. The above model will be very helpful in assessing the change in patient’s behavior. Research suggests that long-term behavior change is unlikely to be sustained without the involvement of health professionals (Prochaska et al., 1992). Observing patients’ lifestyle and communicating with them over behavior change, nurses are endorsing a healthy lifestyle, enhancing patient health and well-being, and taking primary and secondary preventive measures.

Prevention Level: Primary Prevention 2. Specific Protection Specific prevention activities focuses on enhancing resistance to some factors like viruses and bacteria or modifying the environment to decrease potentially harmful interactions such as exposure to toxic agents in the environment. Some examples of specific protection are: • Immunization against specific diseases • Use of specific nutrients • Chemoprophylaxis • Protection against occupation hazards • Protection against accidents, protection against carcinogens • Avoidance of allergens • The control of hazards in the environment like air pollution, noise pollution, water pollution, etc.

Immunization Immunization is an essential factor in all stages of life. Immature immune system of infants and young children makes them susceptible to vaccine preventable diseases since they cannot fight infection; children require timely immunization. Older children, adults and pregnant women also need immunization to renovate weakening immunity and to build new immunity against diseases that are more common in adults (Tables 1.2 and 1.3). • Primary prevention includes health promotion and specific protection. Health promotion and specific protection are components of primary prevention. Flowchart 1.1 shows health promotion and specific protection with examples of activities under each • Immunization directly protects individuals who receive vaccines. Immunization also prevents the spread of infection in the community and protects people by strengthening the herd immunity: Infants who are too young to be vaccinated, people who cannot be vaccinated for medical reasons (e.g., certain immunosuppressed people who cannot receive live vaccines), people who may not adequately respond to immunization (e.g., the elderly). Community health nurses should educate people in a culturally sensitive way, preferably in their own language by establishing a very good rapport: • Vaccination and its importance • Vaccines preventable diseases • Immunization schedules • Importance of immunization at recommended ages • Need for carrying the immunization record while visiting the health care units/hospitals • Before and after care of immunization to the mother and relatives is essential. Active immunization The inoculation of immunogenic material to induce an immune response leading to immunological memory in the recipient is active immunization. Active immunity takes longer to develop than passive but it lasts longer, may be life-long. • Killed organisms: The collected the viruses that cause rabies, influenza and polio undergo heat or chemical treatment to kill the organisms. These products serve as effective vaccinating agents against the specific disease(s). The bacteria responsible for cholera, whooping cough (pertussis) and typhoid fever also undergo the same procedure to get the vaccinating agents.

21

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Table 1.2: National immunization schedule—infant (NRHM) Vaccine

When to give

Dose

Route

Site

BCG

At birth or as early as possible till 1 year of age

0.1 mL (0.05 mL until 1 month age)

Intradermal

Left arm

OPV-0 (Zero polio)

At birth or as early as possible within the first 15 days

2 drops

Oral

Oral

Hepatitis B-0

At birth or as early as possible within 24 hours

0.5 mL

Intramuscular

Anterolateral side of mid-thigh

OPV 1, 2 and 3

At 6 weeks, 10 weeks and 14 weeks

2 drops

Oral

Oral

DPT 1, 2 and 3

At 6 weeks, 10 weeks and 14 weeks

0.5 mL

Intramuscular

Anterolateral side of mid-thigh

Hepatitis B 1, 2 and 3

At 6 weeks, 10 weeks and 14 weeks

0.5 mL

Intramuscular

Anterolateral side of mid-thigh

Measles—1

9 completed months–12 months (give up to 5 years if not received at 9–12 months age)

0.5 mL

Subcutaneous

Right upper arm

Vitamin A— 1st dose

At 9 months along with measles-1

0.1 mL

Oral

Oral

DPT booster

16–24 months

0.5 mL

Intramuscular

Anterolateral side of mid-thigh

OPV booster

16–24 months

2 drops

Oral

Measles-2

16–24 months

0.5 mL

Subcutaneous

Right upper arm

Vitamin A—2nd dose

With DPT/OPV booster

2.0 mL

Oral

Oral

Vitamin A—3rd dose

One dose every 6 months up to the age of 5 years

2.0 mL

Oral

Oral

DPT booster

5–6 years

0.5 mL

Intramuscular

Anterolateral side of mid-thigh

TT

10 years and 16 years

0.5 mL

Intramuscular

Upper arm

Table 1.3: National immunization schedule—for pregnant women Vaccine

When to give

Dose

Route

Site

TT-1

Early in pregnancy

0.5 mL

Intramuscular

Upper arm

TT-2

4 weeks after TT-1*

0.5 mL

Intramuscular

Upper arm

TT booster

1 dose if TT is given in last 3 years*

0.5 mL

Intramuscular

Upper arm

*Give TT-2 or TT booster preferably before 36 weeks of pregnancy.

• Attenuated organisms: Live viruses, but in a weakened • Human antibodies: These are normal human referred to “attenuated” organisms. Such weakened forms serve as effective vaccination for measles, mumps and polio (e.g., Sabin vaccine), and influenza (as nasal mist).

Passive immunization Passive immunization is a choice when there is no time to wait for the development of active immunity or when no effective active vaccine exists. Injection of antibody to a pathogen can provide very rapid, short-lived resistance to infection and is referred to passive immunization. 22

immunoglobulin, IgG, prepared from many individual donors. This holds significant levels of antibody to measles and hepatitis viruses. High levels of protective antibody for tetanus gotten from donors immunized with tetanus. Anti-zoster antibodies are collected from the serum of patients during recovery from an infection (zoster virus causes chicken pox and Shingles). These antibodies are administered to people who are at risk of acquiring the disease

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

• Antisera or antitoxins: Passive immunization achieved 4. Psychological hazards: Various stressors of workplace by the administration of antisera or antitoxins prepared from nonhuman sources such as horses. Antisera are used in diseases like tetanus, diphtheria, botulism, gas gangrene and snake bite, etc.

Use of Specific Nutrients In general the specific nutrients of our food may promote or disturb our health status. Less consumption of “vitamin A” is associated with cancer. High consumption of fat intake causes colorectal cancer. Larger sodium intake causes hypertension. Stomach cancer have been related to deficiency of vitamin C. Coronary artery diseases are less common among people eating high carbohydrate diets. Regular intake of high-calorie foods like fast foods, baked food items can easily induce obesity in children. Soft drinks, candy and desserts also promote weight gain. Chemoprophylaxis The practice of administering an antimicrobial agent for preventing an infection or for suppressing contacted infection before the clinical manifestations. There are two types of chemoprophylaxis. (1) When given to an uninfected person to prevent the occurrence of infection, it is primary chemoprophylaxis. (2) If given to an infected person to prevent the development of the disease, it is secondary chemoprophylaxis. Protection Against Occupation Hazards An occupational hazard is something objectionable which one may suffer or experience as a result of doing a work or leisure pursuit. The four types of occupational hazards and related diseases are as follows: 1. Chemical hazards: Some common diseases found among workers due to chemical hazards are respiratory diseases, skin allergy, skin diseases, cardiac disease, cancer and neurological disorders. These diseases may be temporary or chronic in nature. These diseases often reduce the employees’ life expectancy. 2. Biological hazards: Diseases caused by bacteria, fungi, viruses, insects, dietary deficiencies, excessive drinking, allergies, brain fever, imbalances, tetanus, stresses and strains are some of the examples of biological hazards. 3. Environmental hazards: Environmental hazards may include noise pollution, vibration and shocks, illumination, radiation, heat, ventilation, air and water pollution. These hazards cause redness of eyes, genetic disorders, cancer, sterility, hearing loss, nerve injury, etc., to workers.

like work demands, organizational leadership, lack of group unity, intra- and intergroup conflicts, life and career changes predispose psychological problems. These factors lead to emotional disturbances which, in turn, lead to fatigue and exhaustion. All these have negative impact on health. ƒ Work is essential for life; however, the harmful agents in the work environment can be prevented, through adequate control measures that will help to protect workers’ health and damage to the environment. ƒ Occupational hygiene protects and promotes workers’ health, by providing safe and sustainable development. ƒ Preventive action should be part of strategic plan and must start much earlier. ƒ The work environment should be under continuous surveillance.

Protection from Accidents Safety needs of the children at home are very much essential. Keeping medicine, breakable items, chemicals, sharp instruments out of reach of the children and eliminating water collection sites around the home are some examples of protecting children from home accidents. Wearing helmet, while driving two wheelers, wearing seat belt in a car, strict adherence to road safety rules are some of the measures to prevent road accidents. Environmental Control This includes prevention of water pollution, air pollution, noise pollution, safe disposal of waste, etc. Protective measures like proper housing and ventilation and seasonal clothing also contribute to health protection.

Prevention Level: Secondary Prevention The Secondary level of prevention is suitable where the actual problem has already occurred. This focuses on the early diagnosis and treatment of the disease. This is mainly to at least prevent, delay, or stop further complications, to limit disabilities. Secondary prevention is the action taken to halt the progress of a disease at its early stage and prevent further complications.

3. Early Diagnosis and Treatment

• It helps in detecting a disease in its earliest stages, before

symptoms appear, and intervening to slow or stop its progression: “catch it early”. The assumption is that earlier intervention will be more effective, and that the disease can be slowed or reversed. 23

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

• Secondary preventive measures are delivered in hospitals,

homes and other secondary facilities. It comprises of diagnostic screening programs, public education to promote self-examinations to be able to recognize early signs and symptoms of certain diseases. • Screening tests or specific procedures are used to detect serious disease as early as possible so that the progress can be detained. For example, Pap test to screen for cancer of the cervix. Referrals follow the early diagnosis and treatment. If the disease cannot be treated at the secondary level the patient will be referred to tertiary level care for further management. Examples include: • Regular examinations and screening tests to detect disease in its earliest stages (e.g., mammograms to detect breast cancer); • Daily, low-dose aspirins and/or diet and exercise programs to prevent further heart attacks or strokes; • Suitably modified work so injured or ill workers can return safely to their jobs.

Prevention Level: Tertiary Prevention 4. Disability Limitation The Tertiary level of prevention begins early in the period of the client’s recovery from illness. It occurs when a disease or disability is present or is permanent and irreversible. Tertiary prevention defined as all measures available to reduce or limit impairments and disabilities, minimize suffering caused by existing departure from good health. Interventions are disability limitation and rehabilitation. The tertiary level, which focuses more on the rehabilitation, includes strict compliance of giving medications, moving and positioning to prevent complications, passive/active exercises, and continuing health supervision during rehabilitation. Tertiary prevention includes: • Disability limitation • Rehabilitation Disability Limitation A disability is any continuing condition that restricts everyday activities. The Disability Services Act (1993) defines disability as something which is attributable to an intellectual, psychiatric, cognitive, neurological, sensory or physical impairment or a combination of those impairments; which is permanent or likely to be permanent; which may or may not be of a chronic or episodic nature resulting in: a substantially reduced capacity of the person for communication, social interaction, learning or mobility; and a need for continuing support services. 24

• Impairment is “any loss or abnormality of psychological,

physiological or anatomical structure or function”. • Disability is defined as any restriction or lack of ability to perform an activity in the manner or within the range considered normal for the human being. • Handicap is termed as “a disadvantage for a given individual, resulting from an impairment or disability that limits or prevents the fulfillment of a role in the community that is normal (depending on age, sex, and social and cultural factors) for that individual.” The concept of disability prevention relates to all the levels of prevention: • Reducing the occurrence of impairment, e.g., immunization against poliomyelitis (primary prevention). • Disability limitation by appropriate treatment (secondary prevention). • Preventing the transition of disability in to handicap (tertiary prevention). Examples include: • Cardiac or stroke rehabilitation programs, chronic disease management programs (e.g., for diabetes, arthritis, depression, etc.). • Support groups that allow members to share strategies for living well. • Vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible. Rehabilitation Rehabilitation is the combined and coordinated use of medical, social, educational and vocational measures for training and retraining the individual to the highest possible level of functional ability. The purpose of rehabilitation is to bring about productive people out of nonproductive people. Rehabilitation includes: • Medical rehabilitation: Physical medicine and rehabilitation (PM&R), also known as physiatry or rehabilitation medicine, is a branch of medicine. This focuses to enhance and restore functional ability and quality of life to those with physical impairments or disabilities • Vocational rehabilitation: It means the restoration of the capacity to earn a livelihood. Vocational rehabilitation is a process which enables persons with functional, psychological, developmental, cognitive and emotional impairments or health conditions to overcome barriers to accessing, maintaining or returning to employment or other useful occupation

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

• Social rehabilitation: It refers to restoration of family

•

and social relationships—a set of activities aimed at rehabilitation and improving the functional capability of people and their inclusion in the society. Psychological rehabilitation: It means the restoration of personal dignity and confidence. It is the process of restoration of community functioning and well-being of an individual diagnosed in mental health or mental or emotional disorder and who may be considered to have a psychiatric disability.

PUBLIC HEALTH EVOLUTION: WORLD Modern public health system started to take a shape some 150 years ago. The major factors that contributed to the community development are knowledge on causes and control of diseases and cooperation extended from the public to accept the process of disease prevention and control. Scientific knowledge provided a platform to public health authorities to initiate various activities like educating mass on various aspects of health to enhance individual responsibility on personal health. Public sanitation, immunization and health regulations were given large attention to perpetuate the human life. Advancing technology, high expectations of people and increasing burden of elderly population resulted in escalating costs on health care in industrial countries. Further, people of developing countries live amidst of poverty with unmet needs.

Ancient Societies Archaeological research activities at sites of some of the earliest civilizations indicated the evidences for community health activities. Archaeological findings from the Indus Valley of Northern India, dating from about 2000 BC, reveal the evidence of bathrooms and drains in homes and sewers below street level. It was evident from ruins of ancient Egypt (2700–2000 BC) that drainage facilities were in place in houses and streets. The Mycenaean who lived in 1600 BC had the facilities like toilets, flushing systems, and sewers. They had the practice of burying famous people in large, circular tombs with possessions to go along with them in the next world. Egyptians were aware of more than 700 drugs in 1500 BC itself. It is hard to trace most community practices of early communities due to the missing records or evidences. They were strict in insisting people not to defecate near the drinking water sources. Herbal use was prominent to cure the diseases. Shared roles within a family and the community helped the mothers in labor and child rearing practices. They followed specific customs and practices related to burial of the dead.

Fig. 1.12: Hippocrates

Hippocrates (460 BC) (Fig. 1.12) highlighted the importance of environment and human behaviors in health.

Classical Cultures (500 BC to AD 500) It is widely accepted fact that basic sciences like anatomy, physiology and psychology were of importance to identify the cause of the diseases as well to promote health. Medical schools started and the popular philosophy noted was “Methodists” that equals medical thinking. Asclepius was the founder of Methodist medical school that stressed on health maintenance and understanding the patient and his health. The Greeks showed interest in community sanitation. They had the practice of meeting the water requirements of the city by storing water in huge cisterns placed high above the sea level. Hippocrates believed practicing medicine in a scientific way based on the natural sciences. Hippocrates is the founder of ancient Greek medicine. Hippocrates wanted physicians to study anatomy, especially that of the spine and its relationship to the nervous system that controlled all functions of the body. He advised to keep wound dry after cleaning with wine or water for quick healing. The ancient Greeks believed that body and mind should be in harmony to maintain good health. Physical activity was considered as a vital component of the training in schools to promote physical and mental health. Galen (Fig. 1.13) was one of the great physicians after Hippocrates. Romans outperformed Greeks in promoting the evolution of nursing. Roman armies developed war-nursing units in which nurses took care of injured soldiers. Initially these nurses were selected from family members, servants or slaves. However, Roman era gave importance to nursing 25

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students many monasteries and convents to take care of sick provided a strong foundation for the development of nursing activities. Practice of nurses joining military orders during the time of Crusades started between 1091 and 1291. Initially, Christian services started through churches to care only sick, poor and fatherless. Crusaders came up with hospitals with a gained knowledge from Arabs. During this era, many nuns came forward to care patients. Health education gained importance to enhance personal hygiene. Christianity took interest in inculcating the concept of responsibility for self and others which taught people to show positive attitude in caring sick people. Some books written on health promotion created awareness among people. A changed philosophy on community health and personal health emerged with Christian era.

Renaissance (1500 AD to 1700 AD) Fig. 1.13: Galen

discipline and nursing grew as a separate discipline. Initially the hospitals were set in corridors and dormitories, which were later converted into hospitals.

Middle Ages (500–1500 AD) Before the Eighteenth Century

26

Communicable diseases that ended up in epidemics were identified as a threat to humanity. Public health system of the nations tried to protect the people from diseases like smallpox, cholera, etc. Strict practices on isolation of ill and quarantine of travellers were adopted to protect people from dreadful communicable diseases. European cities enforced isolation, quarantine practices related to communicable diseases and advised to report the deaths from plague. People gradually accepted to take up inoculations administered from smallpox scab to prevent smallpox. Decline of Roman dynasty pulled down the developments in community health organization. Though there were some developments in the field of health care man showed interest in believing superstitions, his brain went empty. People started to construct big houses to get the feel of “safe home”. Big buildings and huge wall around the house invited overcrowding, poor sanitation and poor hygiene. There was no provision for clean water, waste disposal and sanitation. People threw the garbage on the street and no health behavior seen in people. People did not show interest in their health and environment. People seldom bathed since they believed it was immoral to look at their bodies. Though people lacked knowledge on health, hospitals emerged to take care of needy like sick, old and neglected individuals. Emergent of

People gradually changed their attitude toward health. People with superstitious beliefs slowly took a transition to make intellectual inquiries. There was a growing interest advancing science and technology that facilitated the developments in medicine and public health field. In 1601, the Church of England introduced, “Elizabethan poor law” and made it compulsory. This made people care for poor, blind, orphans and lame. Wealthy people took care of the sick at home by paying nurses. Poor did not have means to do so. Under the directions of “Poor law”, sick poor were taken care in hospitals or alms houses. Many people arrived hospital with advanced sickness/ diseases. So, most often they died in the hospital itself. Graunt was the first person who analyzed the bills of mortality, which documented the weekly counts of births and deaths in London. Graunt published the results of his findings in the year 1662 in “Natural and Political Observations...Made upon the Bills of Mortality”.

Eighteenth Century Many cities like New York, Boston came forward to enforce quarantine and isolation measures. Initially the neighbors in local communities cared people with physical and mental illnesses. Later this became official in England by adoption of “1601-poor law”. Due to the increase in number of sick people, the demand for care also went high where poor law practices could not help it. As a result in 1752 the first American voluntary hospital was established in Philadelphia for people who were physically ill. The first public mental hospital was established in Williamsburg, Virginia in 1773 (Turner, 1977). During 18th century James Lind, a surgeon from British navy strengthened the foundations of epidemiology through his contribution on scurvy. Based on Mendel’s findings British navy made lemon juice as a compulsory one in sailors’ diets. This strategy had helped to

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing eradicate scurvy from the British navy. In late 18th century (1760) industrial revolution began in England. Government took no efforts to improve health care system until 18th century.

Nineteenth Century Due to increased urbanization people of London suffered many diseases like smallpox, cholera, typhoid, and tuberculosis to reach unimaginable numbers. Survey of 16th ward of New York identified more than 1,200 cases of smallpox and more than 2,000 cases of typhus (Winslow, 1923). In Massachusetts, in 1850, deaths from tuberculosis were 300 per 100,000 populations, and infant mortality was about 200 per 1,000 live births (Hanlon and Pickett, 1984). Toward mid-19th century there was tremendous advancement in public health. During this period filth was identified as the reason for disease and its transmission. This provided a basic platform for change in people’s perception and thought about health. Illness, considered as the reflection of poor moral, spiritual, living and environmental conditions. Hygiene, faithfulness and isolation were recognized measures to prevent the disease. This period was referred to “the great sanitary awakening” (Winslow, 1923). Sanitation and public health became the focus to protect public health from diseases and maintain sound health. The huge cholera epidemic of 1832 grabbed the attention of Sir Edwin Chadwick (Fig. 1.14), a London lawyer to show a great interest in the “sanitary reform movement”. As a basic step Chadwick assessed the health status of people with a view to improve people’s living conditions. The “Poor law commission” of London conducted studies of the life and health of the working class in 1838 and that of the entire country in 1842 under the head of Chadwick. This study

Fig. 1.14: Sir Edwin Chadwick

documented the poor working conditions of industrial towns and rural areas of the United Kingdom that have compelled their deaths. Chadwick assumed that the diseases occurred by bad air from the decomposed waste; Chadwick proposed to build a drainage network to remove sewage and waste. He also recommended that to local national board of health. His suggestions adopted in the Public Health Act of 1848 and his work influenced later developments in public health in England and the United States. After Chadwick’s report, many cities showed interest in conducting surveys. Lemuel Shattuck, a Massachusetts bookseller and statistician published a survey Report of the Massachusetts Sanitary Commission in 1850. Shattuck’s report highlighted the importance of adopting various measures to improve health conditions. Shattuck’s recommendations are as follows: Establishment of state health departments, sanitary surveys, cleanliness, morality, personal responsibility, surveys of local health conditions, supervision of water supplies and waste disposal, census and vital health statistics were some measures included in the report to control the diseases. He also expected services to public under the names: well childcare, school age children’s health, immunization, mental health, health education for all and health planning. Shattuck’s report was very much revolutionary toward public health mission and scope. Unfortunately, his report was accepted and recognized only after his death. After much contradiction, Shattuck’s report was considered as one of the most farsighted and influential documents in the history of the American public health system. Edward Jenner of Berkeley found that persons who developed cowpox never got smallpox, a deadly disease. He had saved many lives with his discovery of “smallpox vaccination”. With his wonderful discovery in 1980 the smallpox disease was declared as eradicated. William Farr (1839) stressed the importance of vital statistics for studying health problems. This century started to have many successful events in controlling communicable diseases. John Snow, English physician, a specialist in obstetric anesthesiology, was interested to find the cause and spread of cholera epidemics that occurred periodically in London. In 1854, Snow started his inquiries during the third cholera epidemics. While most physicians attributed the disease to miasma (bad air) Snow, held the deep-seated view that cholera was caused by contact with germ contaminated matter, particularly bad water. Snow’s collected details revealed that the cholera spreads through contaminated water. After resolving the cholera epidemics in London, John Snow (Fig. 1.15) was given the title of “Father of modern epidemiology”. 27

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Twentieth Century During 20th century, people started looking beyond the traditional concept of protecting people from polluted environment and communicable diseases. More attention was paid to preventive behavior and lifestyle-oriented diseases and its prevention and reduction. In this period, people started to understand the relationship between bacteria and communicable diseases. After the initial few decades of 20th century, there was a great planning among the health experts to provide significant importance on provision of safe water and sanitation, nutrition, control of communicable diseases and specific immunizations.

DID YOU KNOW? Fig. 1.15: John Snow

In 1877, Louis Pasteur (Fig. 1.16), a French chemist, proved that anthrax is caused by bacteria. In 1884, with his untiring efforts he could develop an artificial immunization against anthrax. The germ theory of disease took a lead role in providing scientific foundation for public health. Laboratory research revealed exact causes and specific methods for preventing every single disease. The fact that disease had single, specific cause was brought to light. Science also revealed that both the environment and people could be the agents of disease. In 1891, WT Sedgwick, biologist for Massachusetts, identified the presence of fecal bacteria in water as the cause of typhoid fever and voluntarily developed the first sewage treatment techniques. His work focused on improving environmental sanitation.

One of the biggest challenges of 20th century was HIV/AIDS. According to UNAIDS, there were 30 million HIV-related deaths globally during this period.

In the early 20th century, home visits offered by public health nurses in New York and Baltimore. School health clinics were established in Boston (1894), New York (1903) and in Rhode Island (1906) to support and promote the health of school going children. In 1906, Food and Drug Act passed to control the manufacture, labeling, and sale of food. An expert like Winslow exclaimed at the improved work of sanitary engineering and bacteriology in preventing people from diseases. Contemporary diseases like obesity, hypertension, and accidents grabbed the attention of health professionals and health system. One of the biggest challenges that emerged during late 20th century was HIV/AIDS. According to UNAIDS, there were 30 million HIV related deaths globally during this period. In 1923, CEA Winslow defined public health as the science not only preventing contagious disease, but also “prolonging life, and promoting physical health and efficiency”. Federal Board of Maternity and Infant Hygiene was established by Sheppard-Towner Act (1922) to provide funds to the Children’s Bureau and states to establish maternal and child health programs. This act was the first to assist personal health services through federal funding.

Twenty-First Century

Fig. 1.16: Louis Pasteur

28

We are in the second decade of 21st century. There are many developments occurring in the field of community health and community health nursing. Community partnership research is a greatly encouraged methodology to place people’s health in their hands and sensitizing their personal accountability on health.

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

EVOLUTION OF COMMUNITY HEALTH NURSING: GLOBAL PERSPECTIVE In ancient days, family members provided nursing care to each other. The first nurse was the first mother. Elders of the families who had lived in experiences on handling health-related issues provided consultation to their own family members and guided them. In ancient period, nursing care rendered in home setting. This is evident from the New Testament that there was a practice of visiting sick people at home to speed up their recovery. Nursing care in 20th century more associated with hospital settings.

Development of Public Health Nursing: Significant Events Worldwide In the middle Ages, family members only took care of the sick and ill. Few hospitals run by monks and nuns could be affordable only by the wealthy. Overcrowding, lack of sanitation and increasing population caused persistent epidemics. Black Plague of 14th century killed about onefourth of the population of Europe. From the 1500s through the 1700s, the renaissance in Europe stimulated the rise of scientific thought and social consciousness. The Sisters (or Daughters) of Charity or “Grey Sisters” was founded in 1617 in France, with the aim of providing care to the sick poor. The mission was successful and taken from the rural districts to Paris. In 1633, a training program established for young women to serve needy people. By 19th century, this nursing community had established itself throughout the world for providing care to the poor sick. The motherhouse “Sisters of Charity” is located in Paris. With many reforms by 1825, England had established around 154 hospitals; but it was not possible to bring down the fatality rates. Many deaths occurred among newborns and people with open wound. People were afraid to go to hospitals and addressed hospitals as, “death houses”. The main reason indicated was the caregivers in the hospitals were only “ward maids” means housekeepers. In Holland, women appointed by churches to care for the poor called deaconess-groups. In 1836, Theodor Fliedner, a German Lutheran pastor, started 3 years training school for Deaconesses, following which parish districts founded to provide care to residents. Florence Nightingale, daughter of Wealthy English family, committed to prevent illness and death. In 1851, she attended Theodor Fliedner’s program for deaconesses—for nurse training—in Kaiserswerth, Germany. Florence took a

lead role with a team of nurses and assisted soldiers during the Crimean War (1854–1856). This is a recorded historical event saved lives through prevention of infections and improving. During Victorian era, poor houses accommodated chronically ill poor people, who were often elderly and did not have family or any other support. Some “pauper nurses” assigned were poor, illiterate, intoxicated and were cruel to residents. In 1859, William Rathbone, a Quaker merchant and philanthropist of England hired Mary Robinson, a nurse (who later named as the first district nurse) to take care of people in one of the poorest parish districts in Liverpool. Soon the mission of district nursing started disseminated from Liverpool to other places. Rathbone took assistance from Florence Nightingale one who attended Theodor Fliedner’s nurse training program for deaconesses in Kaiserswerth, Germany. Nightingale with her team of nurses assisted soldiers during the Crimean War (1854–1856) and promptly recorded her successes with necessary statistical diagrams. In 1860, following the war, Nightingale started the first school of nursing, and Rathbone hired several graduates as district nurses. Two years later, with Nightingale’s assistance, he established a nursing school in Liverpool. William Rathbone (Fig. 1.17) showed great concern and interest in nursing which “... occupied more than half his life... he was the founder of district nursing... (and) he recognized the importance of effective training for all nurses. He was also largely responsible for improved workhouse conditions...” (Gwen Hardy. William Rathbone and the Early History of District Nursing, 1981, p. 5). During mid-20th century (1930–1970), there was great expansion in the roles of the government in encouraging personal health. National League for Nursing (NLN) has predicted 10 trends in health care that will affect nursing in forthcoming decades: 1. Population dynamics 2. Proliferating technology 3. Globalization of the world’s economy and society

Fig. 1.17: William Rathbone

29

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students 4. Educated consumers, alternative therapies and genomics, and palliative care 5. Focus on population-based care 6. Rise in health care costs and challenges of managed care 7. Impact of health policy and regulation 8. Growing necessity for interdisciplinary education and collaborative practice 9. Nursing shortages, opportunities for lifelong learning, and workforce development 10. Significant advances in nursing science and research.

At the beginning of 19th century people were well aware about the then existing health care system and were in need of an organized system. In 1809, the Sisters of Charity (also called Daughters of Charity) founded by Elizabeth Ann Seton (Fig. 1.18) came up with many hospitals, orphanages, and educational institutions to help people. In 1813, the Ladies’ Benevolent Society of Charleston, South Carolina, started to provide organized home care services to the sick. In 1836, Dorothea Dix met William Rathbone in Liverpool, England. During that time, the “lunacy reform movement of England” published detailed investigations on madhouses resulted in legislative changes. After returning from England in 1840, Dix also visited jails and insane asylums in Massachusetts. After a compelling report from Dix funds allocated to establish the first hospitals for the mentally ill. Clara Barton widely recognized for her social interest during the Civil War; she distributed supplies, cared for the injured soldiers and casualties with a team of nurses. She served as a major cause for establishing American Red Cross Society to provide aid for natural disasters. In the 1880s, 20 years after the establishment of district nursing in England, a similar movement began in the United States to combat the challenges caused by unsanitary conditions and infectious diseases.

Lillian Wald was a nurse passed out from New York Hospital School of Nursing. In 1893, Wald and her classmate Mary Brewster founded the Henry Street Settlement and they considered the affordability of patients while fixing fee. In addition to care they also delivered classes on health and hygiene. Wald addressed her services as “public health nursing”. Soon many other settlement houses developed in American cities. Lillian Wald known as the founder of public health nursing. Gradually the Henry Street Settlement developed a team of 20 nurses and offered array of innovative and effective social, recreational, and educational services. Later, the Henry Street Settlement changed its name as the Visiting Nurse Association of New York City. In 1912, Wald assisted to find the National Organization for Public Health Nursing. The first professional standards for the practice of public health nursing were set by this organization. These standards served as a precursor to ANA’s Public Health Nursing: Scope and Standards of Practice, which guides the practice of public health nursing today. Wald insisted to appoint first professor of nursing in institutions of higher learning that laid the foundation for higher nursing education. During 20th century, there was a tremendous growth in the field of public health nursing. Federal governments recognized public health nursing as one of the most vital area. Initially the focus of public health nurses were to render care at the bedside, but later changed their idea thinking that it may not yield good results in unsanitary and poor houses which had no food. Public health nurses functioned as role models to others to care for the sick, instructing them on how to prevent illness, and promoting maternal and child health. Mary Breckinridge (Fig. 1.19) the founder of “Frontier nursing” traveled on horseback, and assessed the health situations and needs of the mountain people. In 1939, she helped to establish the Frontier Graduate School of Midwifery, one of the first midwifery programs in the country. The number of public health nurses employed by

Fig. 1.18: Elizabeth Ann Seton

Fig. 1.19: Mary Breckinridge

Initiatives in United States

30

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing industry almost doubled during this time. The discipline of public health nursing expanded in rural areas after World War I and II where many countries were involved.

CHALLENGES OF 21ST CENTURY FOR COMMUNITY HEALTH NURSING Many unexpected changes may occur in this 21st century all over the world in the field of health/nursing/community health nursing. There are chances for serious transformation that may dominate the environment along with the changes in other areas like culture, beliefs, practice, technology and economy.

Evidence-Based Practice In this fast growing customer-oriented quality driven world, the major weapon to be used in practice is “Evidence-based practice”. Evidence-based public health is a public health venture in which there is cautious use of evidence derived from variety of sciences and social sciences research. Most often community health nurses use the evidences from the field of epidemiologic research to assess their clients and for planning and implementing care in the community. Evidence based practice helps in updating of knowledge and skill to function as a real-time clinician.

Growing Cultural Interaction This is one of the issues in the front line which seeks the nurses to be culturally competent as well recognize the assessment needs pertaining to increasing interaction among different cultures.

Evolution of Community Health Nursing in India: Preindependence It is evident from the history that the ancient people of India focused on birth, health, illness, and deaths and no religion or culture was ignorant of these factual events. Though the early society did not own much technology base they still adapted efficient practices like choosing the burial place and waste disposal areas away from the living areas. They also developed sewage systems, and draining marshes to control communicable disease. The family and community attended the sick people on most occasions. The main caregivers of ancient time were usually women. These early caregivers practiced heat and cold applications to relieve pain, immobilized fractures for better healing, dressed the wounds with herbs cultivated by them, delivered babies and took great work to attend dead bodies. Knowing the genesis of the profession would help us with the background knowledge for better understanding the characteristics of nursing profession

and activities of today. Following the Government of India Act in 1858, the British Government took up the administration of India. British rule in India lasted from 1757 to 1947 for the period of about 190 years. Community nursing has been continuously growing and changing in response to government policy and ever changing needs of the communities. Prior to independence colonial British officials and missionaries took bigger efforts to design and construct the framework for nursing. During British rule India received funds and help from both Britain and USA. This had a great influence in giving directions to the development of nursing profession in India. British officials inculcated the image of a professional nurse that may include but not limited to high professionalism, noble dedication, and decorum. Caring for the sick people confined to bed was the realm of the family. People perceived woman as selfless caregiver for her family members. And again, nursing care of the family members was the extended duty of her household work. The Sushruta Samhita, (600–350 BCE) described four types of midwives and among which one was “good at giving birth to a child (prajananakusalah)”. The text also recommends that the midwife should be a female who assisted with childbirth. The indigenous, rural midwife, “dai” the female who rendered the care giving services in India. Dais, were from low-caste, primarily worked in villages, conducted deliveries and engaged in midwifery services. In order to reach the aim of having a professional modern Indian nurse, caste was a great challenge to British colonial officials. British officials wanted to admire idealized cleanliness and rationality whereas the dai was an ignorant, superstitious lady who never gave importance for cleanliness or hygiene in her care practices. Efforts to develop modern midwifery in India started in 19th century and concentrated on training Indian dais. The Government of Madras sanctioned a training school for midwives in the year 1854 which offered a diploma in midwifery. Missionaries started to train “dais” in the field midwifery in late 1860s. St. Stephen’s Hospital, Delhi, in 1867 started to provide training to Indian women in a systematic nursing training course. Colonial British and American officials strongly believed that education would help Indian nurses to understand the profession and to surpass the perception of branding nursing as a as a low-caste profession. During 19th century hospitals in England was equaled to death houses and the nurses were drunk and disordered as we discussed earlier. For Nightingale, it became important to make nursing an acceptable profession for women and she also felt that this was possible only by boosting the morale through necessary respect. Her very entry to nursing profession, improved the image and respect of nurses in England since Nightingale was from a wealthy family. Nightingale’s model 31

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

32

Fig. 1.20: Florence Nightingale

Fig. 1.21: Lady Dufferin

of nursing recognized women nurses and the practice of paying for their services introduced. This enhanced the professional image of nurses all over the world. Nursing model of Nightingale was adopted by other countries United States and Australia. British colonial officials adopted and replicated the same ideas to develop the nursing profession in India. These modern nursing thoughts developed from Florence Nightingale (Fig. 1.20) played a significant role in professionalizing and inculcating nursing culture in India. According to a historian, British officials in India did not show much interest to the health of Indian women prior to 1885. Though Florence Nightingale never visited India, her ideas stood front in influencing the creation of the Royal Sanitary Commission in 1859 on the Health of the British Army stationed in India. Consequent to the report of Royal Sanitary Commission in 1863, the Indian Nursing Service (INS) was created in 1888 to provide proper nursing care for British soldiers. The INS was renamed as the Queen Alexandra’s Military Nursing Service for India (QAIMNS) in 1903. Nurses of QAIMNS served during World War I. The Vicereine, Lady Dufferin (Fig. 1.21), in 1883 established “Dufferin Fund” at Queen Victoria’s request to supply medical aid to Indian women. This fund also extended financial support to provide tuition to doctors and nurses and midwives. The Vicereine, Lady Minto, launched the Indian Nursing Association in 1906. The Minto Nurses’ were mainly trained to provide nursing care primarily to European families. The Trained Nurses’ Association of India (TNAI) formed in 1908 at the conference held for Association of Nursing Superintendents in Bombay (now Mumbai). There was an ever-growing focus on maternal and child health in India. From 1920, it was believed that the community health nurses role is significant to bring changes in health and politics. In 1918, Lady Chelmsford (Fig. 1.22) provided great support in starting training courses for health visitors and

maternity supervisors. A “Health school” was opened in Delhi with the grants from government, which was later named as “Lady Reading School”. In the Indian history of development, upper class British women had significant importance because they always stood forefront for developing Indian women’s education and training. In addition, upper class Indian women entered the political field during the 1920–30 following their participation in the nationalist movement. Witnessing collectivism and unity among Indian and British women, both British and Indian nurses developed unity about “global sisterhood”. In 1920–30 British and American officials showed strong interest in establishing professional organizations. As influenced the provincial governments legislated nurse registration acts in late 1920s and Tamil Nadu Nurses and Midwives Act for registering nurses introduced in 1926. In 1922 Griffin launched a new wing for health visitors under TNAI in the name of “Health Visitors’ League”. This was renamed as “association for ANMS” from 1970 onward.

Fig. 1.22: Lady Chelmsford

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing By 1931 health schools started in Punjab and Calcutta for training health visitors. The Red Cross Society also started health schools in Nagpur, Chennai and Calcutta. But involvement of nurses in India those days was not paradoxically balanced between hospitals and community, the focus was primarily in the hospitals. Major proportion of nurses worked in hospitals rather than in community health programs. However, nursing leaders of India considered community health as an important branch of nursing. In 1938, Florence Nightingale memorial scholarship to pursue further training in England announced. This obligated nurses to write on public health titles like maternal and child health, nutrition, school health, etc. With the support from the Rockefeller Foundation, seven health centers were established from 1931 to 1939 in the cities of Delhi, Madras, Bangalore, Lucknow, Trivandrum, Pune and Calcutta. In 1942, there was severe “shortage of trained nurses”. Following which the Auxiliary Nursing Service (ANS) was established. Auxiliary nurses were given 6 months training in civil hospitals and appointed as assistant nurses to serve the colonial army. Diana Hartley, a British nurse, the editor of “Nursing Journal of India” between 1935 and 1944 in her writings stated that the Indian nurses sick and lived in poor conditions. In 1944 TNAI strongly suggested and recommended to include “Public health nursing” nursing in nurse’s basic training. Four years bachelor program for nursing was first established in India in 1946 at the Colleges of Nursing in Delhi and Christian Medical College and Hospital (CMCH) Vellore. The Rajkumari Amrit Kaur College of Nursing, New Delhi, under Ministry of Health and Family Welfare established in 1946 with the aim of developing model programs in nursing education. College of Nursing in New Delhi, CMC Hospital Vellore and the Government General Hospital Madras started to offer Post-certificate courses in nursing administration, supervision and teaching even prior to 1947. All the above educational foundations helped in developing qualified and skillful nursing graduates who could use scientific rationale while practicing in hospital as well in community.

Development of Community Health Nursing: Postindependence In 1935, Hartley wrote that nurses’ quarters were more sordid than pigsties. In 1947, survey conducted by CMAI revealed that the nurses were in poor living conditions with low salaries; only 40% of the nurses had the salary of above `30/month. In the beginning couple of decades of 19th century “caste and purdah system” of India denied entry into nursing profession.

In 1946, Bhore committee gave the recommendations on nurse to population ratio. One of the recommendations of Bhore committee was to staff PHC with two doctors, one nurse, four public health nurses, four midwives, four trained dais, two sanitary inspectors, two health assistants, one pharmacist and fifteen other class IV employees. In 1947, nurse leaders from the Nurses’ Auxiliary of the CMAI openly conveyed about the fact that nursing is not publicly accepted as a profession but looked upon as a lower menial service; stressed the urgent need to get students from “higher cultural and social backgrounds” to make them know and understand about nursing (CMAI, 1947). In 1947, greater concentration on community development and expansion of hospital service have created huge demand for nurses, auxiliary nurse midwives (ANMs), health visitors, midwives, nursing tutors and nursing administrators. On December 31, 1947, an ordinance passed to start “Indian Nursing Council” and constituted in the year 1949. In 1956, Ms TK Adranvala became the Nursing Advisor to Government of India. The development of community health nursing in India was highly influenced by World War and British rule. Apart from these the Christian missionaries made enormous contribution toward the development of community health nursing. International agencies like World Health Organization, United Nations Children’s Fund (UNICEF), Red Cross, and United States Agency for International Development (USAID) were also the significant contributors of community health nursing development in India. Exercise: Learners may take up some of the significant roles (leaders/pioneers/Vicereine) from the historical development of community health nursing and make a role play. In 1952, international tutors (4 in number) were appointed in Calcutta to train nurses in general nursing, nursing arts, midwifery and pediatric nursing. A certificate course in Public Health Nursing (CPHN) that included comprehensive health nursing services was introduced in 1953. Twenty-four students joined in certificate course of public health nursing in All India Institute of Hygiene and Public Health (Calcutta) in 1953 which was a big number compared to 3 of the previous year. Ms TK Adranvala in one of her articles of the Nursing Journal of India (NJI) mentioned about the initiation of a midwifery tutor course in Delhi in the year 1956. In 1959 the first Master’s degree course for 2 years of duration was developed in India at the University of Delhi. Further, some specialization courses started in different specialties like public health nursing, Psychiatric Nursing, and Pediatric Nursing, etc. In 1959, Rockefeller provided 2 nursing fellowships and the Colombo plan sent 29 Indian nurses to abroad to pursue higher education. 33

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students In 1959–1961, World Health Organization offered nine fellowships to Indian nurses. During postindependence, many popular Indian nursing leaders were sent abroad one or the other form of higher education in nursing to enrich nursing education in India. In addition, time spent on nursing educational certificates or degrees abroad, gave respect and benefit to Indian nurses. Overseas education of Indian nurses provided current updates and novel ideas in the area of public health education. In 1960, international seminar on “nursing research” was hosted by the joint efforts of TNAI and INC. In 1962, USAID sponsored 45 Indian nurses to pursue public health education from USA. In 1962, Mudaliar committee reported that primary health centers were understaffed and most of the workload was shouldered by ANMs or public health nurses and the PHCs should be strengthened. Chadha Committee, 1963 recommended 1 basic health worker per 10,000 populations to carry out NMEP National Malaria Eradication Program (NMEP) vigilance activity as well to function as MPWs. Mukherjee Committee, 1965 recommended separate staff for the family planning program and delink the staff from NMEP. In 1971, trained nurses of India sponsored conference at Chandigarh stressed the need on taking up nursing education to university system. From 1990s TNAI highlighted the need for phasing out of general nursing program. Kartar Singh Committee, 1973, had recommended converting auxiliary nurse midwives into MPW (F) and the basic health workers to MPW (M); in addition, the designation of “health visitor” was changed into “health supervisor”. In 1975, Adranvala stated that nurses have responsibility to speak on behalf of ANMs and Health visitors. Shrivastav Committee, 1975, served as a cause for establishment of “Rural Health Service” in the year 1977. A foremost important health strategy by this committee was bringing in the concept of cadre of village-based health auxiliaries called the Community Health workers. The program was started in 777 Primary health centers where MPWs were already in place. The community health workers got training for 3 months in simple promotive and curative skills and supervised by MPWs. In the year 1987, succession of nursing leaders started “College of Nursing Community Health Services” (CONCH) at Vellore, Tamil Nadu. This program functions under Community Health Nursing Department—College of Nursing CMCH, Vellore. This was mainly to serve the rural and semi urban population through regular home visits, nurse run clinics with standing orders and referral system. 34

In 1991, the Baby-Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF to promote and support breastfeeding. In 2005, INC decided to advice on upgrading all nursing schools to college. In 2007, INC initiated National Florence Nightingale Award to recognize the services of nurses. In 2008, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) project was taken up by INC in coordination with National AIDS Control Organization (NACO) in order to strengthen 55 nursing institutes and to train 90,000 nurses of India on HIV/AIDS and ARV. From 2009 onward INC and NACO started to train nurses under this project. In 2010, World Health Organization published “A framework for community health nursing education”. In 2012, Directorate General of health services Ministry of Health and Family Welfare revised the Indian Public Health Standards (IPHS) Guidelines for community health centers, PHCs and health sub centers. In 2016, INC has drafted “primary health care practitioner” course in order to develop nurses with advanced skills to function efficiently in community. In 2020, Government of India repealed the existing Indian Nursing Council Act and replaced it with the National Nursing and Midwifery Commission Bill, 2020. Since the time of independence, the nursing education has grown rapidly with a significant rise in the infrastructure and manpower.

Significant Milestones of Public Health Development in British India The significant milestones of public health development in British India have been given in Table 1.4. Table 1.4: Significant milestones of public health development in British India Year

Events

1757

The British had established the civil and military services sooner they captured the power to rule India.

1825

Quarantine Act: A public health policy emerged in 14th century following “Black Death”. Under this quarantine system traveler and merchandise who came from known infected places or regions were isolated to protect people.

1829

Royal Commission appointed in India. It served to find out the reasons for the poor health status of British Army. This commission had recommended to establish “Commission of Public Health” mainly to protect water sources, and provide drainage facilities with a view to prevent epidemics and maintain the health of the civilians thereby protect their army. Contd…

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing Year

Events

Year

Events

1864

Establishment of sanitary commissions at Bombay, Madras and Bengal. The Civil Surgeons/District Medical Officers became ex-officio District Health Officers.

1930

The All India Institute of Hygiene and Public Health, Calcutta was established. The Rockefeller Foundation provided the aid to start this.

1869

A Public Health Commissioner and a Statistical Officer appointed by government of India.

1930

The Child Marriage Restraint Act (Sarda Act) introduced: Minimum age of marriage for girls and boys fixed as 14 and 18 respectively.

1873

A Birth and Death Registration Act came in to force to register and maintain the birth and death data all over India.

1931

A Maternity and Child Welfare Bureau was established. This was set to function under the Indian Red Cross Society

1880

The Vaccination Act introduced. This act had the power to prohibit inoculation and to make the vaccination of children compulsory.

1935

1881

The Indian Factories Act introduced. This Act was designed to protect children from child labor and to develop necessary measures to promote health and safety of the workers.

The Government of India Act, 1935 revitalized the 1919 Act: Provinces gained greater autonomy. Health activities were grouped under the names of federal, concurrent and provincial lists and controlled by Central, Central-cum-Provincial and Provincial Governments respectively.

1937

Establishment of the central advisory board for health: Public Health Commissioner appointed as Secretary and representatives from the provinces appointed as members. This is mainly to coordinate the public health activities of the country.

1939

The Madras Public Health Act was passed. Under this the first Rural Health Training Center at Singur (near Calcutta) established with the aid from the Rockefeller Foundation.

1885

The Local Self-Government Act launched.

1888

The Government of India assigned local bodies responsible for sanitation. Though they were assigned for sanitation no public health staff was brought into look after sanitation.

1896

The Plague Commission was appointed.

1897

The Epidemic Diseases Act was passed. The epidemic disease act focused on protecting people from dangerous epidemic diseases.

1939

The Plague Commission report submitted. Plague commission suggested to reorganize, expand public health departments with facilities for research and production of vaccines.

Tuberculosis Association of India was established. This association aims at the prevention, control, treatment, relief and research activities of tuberculosis.

1940

The Drugs Act was passed, the main purpose was to bring all the drugs under control.

1943

The Health Survey and Development Committee (Bhore Committee) appointed. This focus was to survey the existing position concerning health conditions and health organization in the country and to provide recommendations for further development in future.

1946

Bhore (Fig. 1.23) committee submitted its report after making a thorough observation on existing public health, medical relief, professional education, research and international health. The committee also set short and long-term programs to attain realistic health services that match concept of modern health practice.

1904

1909

The Central Malaria Bureau founded at Kasauli. Initially concentrated only on malarial activities. Later, shifted to Delhi, on July 30, 1963 and named as “The National Institute of Communicable Diseases” to cover all other communicable diseases under its umbrella.

1911

The Indian Research Fund Association formulated to promote research and now this functions in the name of ICMR.

1918

The Lady Reading Health School, Delhi, established to train health visitors to work in the community.

1918

The Nutrition Research Laboratory established at Coonoor in 1918 at Pasteur Institute of South India. The Institute was shifted to Hyderabad in 1959 and renamed as National Institute of Nutrition (NIN) in 1978.

1919

The Montague-Chelmsford Constitutional Reforms initiated: Provinces took care of public health, sanitation and vital statistics under the direction of an elected minister. Decentralization of health administration began in India.

1920–21 Municipality and Local Board Act passed. This helped for further advancement of public health in most provinces with legal provisions. Contd…

Fig. 1.23: Sir Joseph William Bhore Note: Calcutta is now Kolkata, Bombay is now Mumbai, Bangalore is now Bengaluru, Madras is now Chennai.

35

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Developmental Milestones of Public Health in Independent India

Year

Events

1953

• The central council of health accepted to set one

The developmental milestones of public health in independent India have been given in Table 1.5. •

Table 1.5: Developmental milestones of public health in independent India Year

Events

•

1947

Ministers for health appointed. The new post of Director to the Union Government on both medical and public health matters introduced.

•

1948

1949

1950

• India became a member state in World Health Organization (WHO). WHO addresses the most important public health concerns of populations around the world and responds to the needs of member states. • The Employees State Insurance Act passed. This applies to all employees in factories or establishments and they shall be insured as per the regulations of this Act. • The report of the Environmental Hygiene Committee was published. The central government appointed this committee to assess the prevailing problems related to environmental hygiene and make necessary recommendations for the welfare of the nation and people.

1954

of India on November 26, 1949. The Constituent of assembly of India met in total 11 sessions. The first session was held in December 1946 and the eleventh session took place between 14 and 26 November, 1949. • Post of Registrar General of India introduced • World Health Organization’s “South East Asia Regional Office established in New Delhi. • The Indian Research Fund Association reconstituted into Indian Council of Medical Research to strengthen the medical research.

• The Planning Commission was set up. • India became a Republic in the Commonwealth. • Drafting of the First Five-Year Plan began for the

1951

• The BCG vaccination program implemented in

1952

• The Community Development Program was

the country to prevent tuberculosis by vaccinating babies.

launched on October 2, 1952. The main focus was all-round development of the rural areas with a provision of medical relief and preventive health services. • The Central Council of Health was constituted: Central health council coordinated health policies between the central and state governments. Contd…

• Central government launched Contributory Health • • • •

1955

• The Constituent Assembly adopted the Constitution

period between 1951 and 1956.

36

•

primary health center in each block: It was planned to set up primary health centers in a phased manner with community participation. The National Malaria Control Program (NMCP) started. It was one of the major components of the First Five-Year Plan to control malaria. The national extension service program started in many states as a permanent organization to bring about rural development. Family planning program introduced throughout the nation. This was considered as a measure to control population and to bring up nation’s health and economic status. Model Public Health Act India appointed a committee to draft a Model Public Health Act for the country. Service Scheme at Delhi. Government provided free medical service or reimbursement to employees. India set up the Central Social Welfare Board. National leprosy control program started. VDRL antigen production started in Calcutta. Parliament passed “The Prevention of Food Adulteration Act”.

• National Filaria Control Program was initiated under First Five-Year Plan.

• Filaria training center was established in Ernakulam. • The Hindu Marriage Act sets the age for marriage: 18 years for boys and 15 years for girls were set as acceptable age for marriage.

1956

• India launched its Second Five-Year Plan (1956–61). • •

• •

₹4,800 crore is allocated in general; ₹225 crore, earmarked for health programs. The Model Public Health Act, published. Union Health Ministry established “The Central Health Education Bureau”. This was started with the primarily for educating the people about health plans and programs. But, currently, it also concentrates on training, supplying of health education (IEC) materials and research. Union health ministry appointed a Director to direct Family Planning services to strengthen the family planning services. The Government of India and the Sir Dorabji Tata Trust sponsored jointly “The Demographic Training and Research Center” in Bombay. It was known as the International Institute for Population Studies (IIPS) till 1985. This was primarily established to train persons from India and other countries in demography and family planning and develop research. Now recognized as premier institute for training and research in population studies for developing countries in the Asia and Pacific region. Now functioning as Deemed University. Contd…

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing Year

Events

Year

• The Tuberculosis Chemotherapy Center established

• A “National Nutrition Advisory Committee”

in Madras. This was set up by the joint venture of ICMR, Madras government, WHO and British Medical Research council. • The Indian Government initiated the “Trachoma Control Pilot Project” with the assistance from the WHO and UNICEF to prevent com­municable eye diseases through primary health care approach, training and research. • Union health ministry started the R-C-A projects. • Ford Foundation provided the aid for RCA projects. 1957

• Influenza pandemic swept the country and subcontinent within 12 weeks.

• Influenza attacked India with an initial entry to Madras. • The Demographic Research Centers were

constituted to provide advice regarding the nutritional policies that the government should adopt. • Pilot projects for the eradication of smallpox were initiated. This helped in strengthening the eradication measures. • Ministry of Home Affairs was assigned the work of maintenance of vital statistics Accordingly Registrar General of India, Ministry of Home Affairs, took over the responsibility of vital statistics from the Directorate General of Health Services. 1961

• The Third Five-Year Plan (1961–66) was launched

1962

• The Central Family Planning Institute was

established in Calcutta, Delhi and Trivandrum to strengthen the research in demography.

1958

1959

1960

• The National Malaria Control Program (NMCP)

converted into National Malaria Eradication Program. Remarkable accomplishment of NMCP motivated to change it to “National Malarial Eradication Program (NMEP)” in 1958. • The Leprosy Advisory Committee of India was set up to provide advice and guide the leprosy control activities. • The National Development Council approved the recommendations of Balwantrai Mehta Committee on Panchayati Raj. A three-tier structure of local self-governing bodies from the village to the district has been recommended for dispersal of power and responsibilities in the future. • The National TB Survey was conducted to obtain the baseline data on tuberculosis for further planning and management.

• The “School Health Committee” constituted by the

Union Health Ministry of India. This was constituted to assess the existing standards of health and nutrition on school children and suggest ways and means to improve them. Contd…

and ₹7,500 crore assigned. Out of which ₹342 crore (4.3%) were provided for health programs. • The “Report of the Mudaliar Committee” published. • The Central Bureau of Health Intelligence was established. established in Delhi.

• This helped to combine Family Planning Training • • • 1963

• • • • •

1964

Center, family Planning Communications and action Research Center. The National Smallpox Eradication Program was launched. The School Health Program was initiated. The National Goiter Control Program was launched. The District Tuberculosis Program started.

• • The Applied Nutrition Program was launched by •

• Government of India appointed Mudaliar

Committee to review the improvement in the field of health. Mainly to review the improvement took place in health services following the submission of the Bhore Committee’s report, and make recommendations for further action. • A Central Expert Committee appointed under the ICMR specifically to study the problems of cholera and smallpox. The committee had strongly recommended on measures to adopt to eradicate cholera and smallpox. • Introduction of “Panchayati Raj System” to state in India. Rajasthan was the first State to introduce Panchayati Raj. • The National Tuberculosis Institute at Bangalore was established.

Events

the Government of India with aid from UNICEF, FAO and WHO. The Defense Institute of Physiology and Allied Sciences was set up. The National Institute of Communicable Diseases (formerly Malaria Institute of India) was set up. The National Trachoma Control Program was launched. Contributory Health Service Scheme was renamed as “Central Government Health Scheme”. Extended Family Planning Program was launched. There was a shift from the clinic approach to “Extension approach” in family planning services. The Chadha committee sets a norm as one basic health worker to 10,000 population to provide efficient services at basic level in the community. A Drinking Water Board was set up.

• • The National Institute of Health Administration and Education was instituted.

• This had the collaboration with the Ford Foundation.

• A Committee was set up by the Union Government under the chairmanship of Shantilal Shah, to study the question for legalizing abortions.

Contd…

37

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Year

Events

Year

Events

1965

• Director, ICMR, recommended Lippes Loop as a

1970

• The Drugs (Price Control) Order, promulgated. • All India Hospital (Postpartum) Family Planning

1966

safe and effective method for a mass program. • Reinforced Extended Family Planning was launched. • “Direct” BCG vaccination with prior tuberculin test, on a house to house basis, was introduced.

•

• •

1968

April 1970.

• Chittaranjan Mobile Hospitals (mobile training-cum-

• India

•

1967

Program was started.

• The Population Council of India was formed in

constituted a committee of Health Secretaries headed by Mukherjee, Secretary, Ministry of Health, Government of India to give special attention into the minimum additional staff required for the primary health centers to take up the maintenance work of malaria and smallpox. The Minister of Health was also appointed Minister for Family Planning. A separate department of Family Planning in the Union Ministry of Health advised to coordinate family planning program at the Center and States by paying extra attention. The Population Council initiated the “International Postpartum Family Planning Program” in 25 hospitals in 15 countries. Two of these hospitals were located in India—Delhi and Trivandrum.

• The Madhok Committee was constituted. To

review the working of the National Malaria Eradication Program and recommend measures for improvement. • A Small Family Norm Committee was set up to recommend suitable incentives to the people who accept the small family norm and practicing family planning. • The Central Council of Health recommended the levy of a health cess on patients attending hospitals. A minimum charge of 10 paise per patient and a minimum charge of 25 paise per day of hospital stay.

service unit) were installed on the birth centenary (November 5, 1970) of Late CR Dass. The scheme stressed the importance of attachment of a mobile hospital to a suitable medical college in each State. • The name of the Demographic Training and Research Center, Bombay was changed into International Institute for Population Studies. 1971

to compel medical personnel below 30 years of age to take up work in the countryside came into force. • The National Nutrition Monitoring Bureau under the Indian Council of Medical Research, with headquarters at the National Institute of Nutrition, Hyderabad was set up. Regional units established in the States. 1972

• The National “Minimum Needs Program” has been

1974

• The Fifth Five-Year Plan was launched on April 1,

1975

• India became smallpox free on 5 July, 1975 • The Government of India accepted the Revised

report.

• “A Bill of “Registration of Births and Deaths” passed by the Rajya Sabha.

Education Committee to review all aspects of medical education in relation to the needs and resources of India.

1969

• The Fourth Five-Year Plan (1969–74) • The Nutrition Research Laboratories renamed as National Institute of Nutrition.

• The Central Births and Deaths Registration Act (1969) was submitted.

• The Medical education Committee submitted its report.

• According to this committee, the total period for

38

MBBS course was set to 4½ years with 1 year of internship during which students to be posted in a rural center for a period of at least 3 months. • The medical training should prepare basic doctors who are aware of problems of the community and take up an efficient role in preventive and curative health services. Contd…

workers came into force.

• National Service Bill that authorized the Government

• The “Small Family Committee” submitted its

• The Government of India appointed the Medical

• The Family Pension Scheme (FPS) for industrial

incorporated in the Fifth Five-Year Plan. A sum of ₹2,803 crore allotted for this program, to cover elementary education, rural health, nutrition, rural roads and water supply, housing, slum improvement and rural electrification. • The Government has envisaged a scheme for setting up 30-bedded rural hospitals and one such hospital for every 4 primary health centers. • The Kartar Singh Committee recommended that a new cadre of health workers named “Multipurpose Health Workers” to deliver health, family planning and nutrition services to the rural communities; in addition, this cadre will replace the basic health workers, family planning health assistants, and auxiliary nurse midwives in a course of time. 1974 with a total outlay of ₹53,411 crore of which ₹37,250 crore for public sector and ₹16,161 crore for the private sector. A sum of ₹796 crore were allotted to health and ₹516 crore to family planning. • Reports on the National Malaria Eradication Program (NMEP) submitted. Evaluation and expert committees suggested “revised strategy” for malaria control. • The United Nations designated “the year 1974” as World Population Year. • Parliament enacted the Water (prevention and control of pollution) Act, 1974.

strategy for NMEP.

• The country has embarked on a scheme of

“Integrated Child Development” from October 2, 1975. Contd…

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing Year

Events

Year

1976

was set up. • The ESI Act was amended. • The Cigarettes Regulation (of Production, Supply and Distribution) Act, 1975 was passed by parliament. • The Group on Medical Education and Support Manpower (Shrivastav Committee) submitted its report.

1982

•

• Indian Factories Act of 1948 amended. • The Prevention of Food Adulteration April 1,

1983

•

•

• • • 1977

• • • •

1979

(Amendment) Act came into force on 1976. The Equal Remuneration Act, 1975 was promulgated providing for equal wages for men and women for the same work of a similar nature. The Union Health Ministry announced a “new population policy”. The Central Council of Health proposed a 3-tier plan for medical care in villages. The Indian Center of Japan Leprosy Mission for Asia at Agra was handed over to the Indian authorities. National Program for Prevention of Blindness was formulated.

•

• • 1984

• Eradication of smallpox declared in April by the •

1978

Events

• Report on “Health for All” was published by working

• A high powered National Children’s Welfare Board

International commission. National Institute of Health and Family Planning formed. Rural Health Scheme was launched. Training of community health workers was taken up. Revised Modified Plan of malaria eradication was put into operation. WHO adopted the goal of Health for All by the Year 2000 AD. Reorientation of medical education (ROME) scheme was launched.

• Bill on Air Pollution introduced in the Lok Sabha.

Parliament approved the Child Marriage Restraint (Amendment) Bill, 1978 fixing the minimum age at marriage 21 years for boys and 18 years for girls. Expanded program on Immunization (EPI) was launched. • The Charter for Health Development in South East Asia was finalized and endorsed. • Declaration of Alma-Ata and introduction of primary health care approach.

•

• • 1985

•

1986

•

1987

• • • •

1989

• •

1990

•

1991

•

1992

• •

• World Health Assembly endorsed the Declaration of Alma-Ata on primary health care.

• The offices of family welfare and NMEP were merged and named as Regional Office for Health and Family Welfare.

1980

1981

• On May 8, 1980, World Health Assembly declared officially on eradication of smallpox from the entire world. Sixth Five-Year Plan (1980–85) was launched.

• The 1981 census was taken. • WHO and Member Countries adopted the Global strategy for Health for All.

Contd…

committee formed by Planning Commission of India—is committed to the goal of providing safe drinking water and adequate sanitation for all by 1990, in view of Sanitation Decade 1981–90. The Air (Prevention and Control of Pollution) Act of 1981 was enacted. The New 20-Point Program was announced. India announced its National Health Policy. India launched a National Plan of Action against avoidable Disablement, known as “IMPACT India”. National Leprosy Control Program renamed as National Leprosy Eradication Program. Medical Education Review Committee submitted its report. National Health Policy was approved by the Parliament. Guinea-worm eradication Program was launched. Bhopal gas tragedy, the worst ever industrial accident happened due to leakage of gas on the night of December 2–3 took a toll of at least 2,500 people and no fewer than 50,000 affected. The ESI (Amendment) Bill, approved The Workmen’s Compensation (Amendment) Act came to force in July 1, 1984. Seventh Five-Year Plan (1985–90) was launched. Universal Immunization Program was launched. Women and Child Development was set up as a separate department under the newly established “Ministry of Human resource Development”. The Environment (Protection) Act, 1986 promulgated 20-point plan restructured. New 20-point program was launched by Indian Standards institution (ISI) and was renamed as “Bureau of Indian Standards”. “Safe motherhood” campaign—launched by World Bank throughout the world. National Diabetes Control Program and National AIDS Control Program initiated. The Factories (Amendment) Act 1987 operated— with inclusion of aims to protect employees exposed to hazardous processes. Blood Safety Program was launched. The ESI (Amendment) Act 1989 operated. This had the modifications in dependent, employee, family, factory and seasonal factory definitions and provisions in original Act. Acute Respiratory Infection (ARI) control program launched as in 14 districts as a pilot measure to reduce the mortality rates among under five children. India conducted the decadal census to count and update the population of the country. The Eighth Five-Year Plan (1992–97) launched. Child Survival and Safe Motherhood Program (CSSM) started on 20th August considering mother and child as one unit. Contd…

39

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Year

Events

1993

• Revised tuberculosis program was introduced

1995

1996

• Guidelines set for malaria action plan. • Pulse polio immunization for all children on

1997 1998– 99

2000

2001

2002

2006

and Childhood Illnesses (IMNCI) was launched in 16 states.

2007 2007

• Maintenance and Welfare of Parents and Senior

2009

• Ninth Five-Year Plan implemented (1997–2002). • Reproductive and child health program launched. • National family health survey conducted for

2011

• Influenza A (H1N1) pandemic occurred. • India conducted the second census of the century. • India launched “National Program for the Health

2011

• Janani Shishu Suraksha Karyakram (JSSK)

2012

• All India Institute of Medical Sciences (AIIMS)

2013

• National health mission launched. • RMNCH+A approach launched in 2013 with prime

90,000 women of reproductive age (15–49 years) group. • National malaria eradication program was renamed as National anti-malaria program.

• • • • • •

National population policy-2000 was launched. India was declared as “guinea worm free country”. India signed UN millennium declaration. National population commission constituted. First census of 21st century carried out. India launched women empowerment policy on 20th March 2001.

• India introduced National health policy 2002. • Tenth Five-Year Plan implemented (2002–2007). • National AIDS prevention and control policy

2003

• Control of cigarettes and other to tobacco

2004

• Vande Mataram Scheme launched. • Midday Meal Scheme launched. • Low osmolarity oral rehydration salt replaced the

2007

2011

2014

products act amended.

Citizens bill passed.

Care of Elderly (NPHCE)” scheme to ease the access to primary health care for elderly people.

introduced. JSSK launched on 1st of June, 2011 to assure free services to all pregnant women and sick neonates accessing public health institutions.

launched new hospitals additionally in seven places (Bhopal, Bhubaneswar, Jodhpur, Patna, Raipur and Rishikesh). • Twelfth Five-Year Plan launched for the period 2012–2017.

• Ministry of health and family welfare launched

• •

• • •

• Reproductive and child health phase II launched. • Janani Suraksha Yojana launched: India provided

onetime cash assistance to pregnant women for undergoing institutional/home births through skilled assistance. • National rural health mission launched. Contd…

centers and subcenters formulated.

attention on Reproductive, Maternal, Newborn, Child and Adolescent Health.

formula existed for oral rehydration during that period. • Feeding guidelines for infant and children introduced.

40

children introduced by WHO.

• National family health survey 3 conducted. • Integrated Management of Neonatal

were chosen as Pulse Polio Immunization days; Second phase: 7th Dec 1996 and 18th Jan 1997. • Family planning program started to use target-free approach from April 1, 1996 onward. • Prenatal diagnostic technique act was implemented from 1996. • Eradication program for Yaws launched.

announced. • Severe Acute Respiratory Syndrome (SARS) appeared

2005

• India achieved leprosy elimination target. • Plan of action for children formulated. • New pediatric growth chart based on breastfed

• Eleventh Five-Year Plan launched (2007–2012). • Indian public health standards for primary health

• First phase: 9th Dec (1995) and 20th Jan (1996)

1997

health centers formulated.

child development services).

preannounced days began to eradicate polio:

Events

• Indian public health standards for community

with “Directly Observed Treatment, Short-course (DOTS)”. • National nutrition policy introduced.

• Plague disease re-emerged after 28 years. • ICDS changed into IMCD (Integrated mother and

1994

Year

2015

“Mission Indradhanush” to immunize all children against seven major vaccine preventable diseases, namely diphtheria, pertussis, tetanus, poliomyelitis, tuberculosis, measles and hepatitis b by the year 2020. India launched TB-Mission 2020 to eliminate tuberculosis from the country by the year 2020. Ministry of Health and Family Welfare launched “Rashtriya Kishor Swasthya Karyakram (RKSK)” on January 7, 2014 to reach and serve adolescents with a special interest on marginalized and undeserved groups. The India Newborn Action Plan (INAP). India was declared as “Polio free country”. Swachh Bharat Abhiyan initiated by the Prime Minister Modi to provide total sanitation to every household by the year 2019.

• NITI Aayog replaced Yojana Aayog on January 1, 2015.

Contd…

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

Malaria

Year

Events

2016

• Sustainable goals officially launched on January 1,

2017 2018

• Aadhaar made must for death certificate • National health policy 2017 introduced • National health protection scheme under

2019

• RNTCP renamed as National Tuberculosis

2016. • Anganwadi workers were accepted as government employees • Malaria eradication plan launched • Shifted from tOPV to bOPV in April 2016

Ayushman Bharat launched

Elimination program (NTEP)

• In order to provide quality primary health care in

2019, a new Mid-level Health Care Provider role was introduced in India, also known as Community Health Officer/Community Health Provider.

2020

• New commission (NMC) National Medical

commission replaced MCI on 25/9/2020. COVID-19 pandemic took toll of many lives. • Government of India repealed the existing Indian Nursing Council Act and replaced it with the National Nursing and Midwifery Commission BiIl, 2020.

Note: Calcutta is now Kolkata, Bombay is now Mumbai, Bangalore and is now Bengaluru and Madras is now Chennai.

NATIONAL HEALTH PROBLEMS IN INDIA India has huge burden of health problems. In India, health problems are discussed under six major headings as commonly seen in the country (Flowchart 1.2). They are as follows:

Communicable Diseases From ancient days, communicable disease served as the major cause of morbidity and mortality profile of the country. The introduction of vaccines against communicable diseases brought down the mortality rates largely. But still, the diseases cause public health burden.

Total malaria cases declined by 42%, from 1.92 million in 2004 to 1.1 million in 2014. India the only high endemic country which has reported a decline of 17.6% in 2019 over 2018. India has sustained Annual Parasitic Incidence (API) of less than one since 2012. India has made considerable progress in reducing its malaria burden. Percentage of decline in the year 2019 as compared to 2018 is as follows: Odisha—40.35%, Meghalaya—59.10%, Jharkhand—34.96%, Madhya Pradesh—36.50% and Chhattisgarh—23.20%. India contributed to the largest absolute reductions: from about 20 million cases in 2000 to about 5.6 million in 2019. India accounted for 88% of malaria cases and 86% of malaria deaths in this South East Asian Region in 2019. WHO has initiated high burden to high impact (HBHI) strategy in 11 high malaria endemic countries and India is one among them. The malaria trends show drastic decline in last two decades (WMR 2020).

Filaria Around 1.1 billion people are at risk of getting lymphatic filariasis (LF) in 73 countries of the world. Among this 600 million Indian, who live in 250 districts of India, account for more than 40% of the global burden of LF. An estimated 50% of India’s LF endemic population resides in northeastern India in areas of poverty. Historically, Odisha identified as highly endemic and remains the same.

Acute Respiratory Infections Southeast Asia stands first in number for ARI incidence accounting for >80% of all incidences. In India, pneumonia found to be accountable for 13–16% of all deaths occurring in the pediatric hospitals. Available statistics shows that on an average, every child has five episodes of ARI/year and 3.5% of the global burden of disease is due to ARI. Around 20% of deaths in children of 10%. UNICEF, Indian Coalition for Control of Iodine Deficiency Disorders (ICCIDD), and World Health Organization recommend iodine daily intake.

Other Problems Now, problems like lathyrism and fluorosis have been found to be endemic in some parts of India. Another important and widely prevalent problem, which seeks attention, is food adulteration.

Environmental Sanitation Problems According to World Bank estimates, 21% of communicable diseases in India are due to unsafe water. Three “S’s” that are fundamental to global health include Safe water, Sanitation, and Safe water management. During 19th century, the “sanitary awakening” that took place in England had major share in changing and strengthening the environmental sanitation of many countries. But, India, which was under British rule then, lacks environmental sanitation even today. About 60% of this “toilet-less” population lives in India. This 60% equals 626 million people. Lack of safe water, old and improper methods of practice of excreta disposal, poverty and unemployment, increasing urbanization and industrialization and population increase are the major contributors of sanitation problems in India. It was recommended in the UN conference held in 1977 at Argentina that there should be provision of safe water supply and sanitation for all. Provision of safe water annually could prevent 1.4 million deaths among children due to diarrheal diseases. It was recommended in the UN conference held in 1977 at Argentina that there should be provision of safe water supply and sanitation for all.

Medical Care Problems India has a good national policy but does not have “National Health Service”. India is unable to run national health services due to inadequate financial resources. Eighty percent of health facilities of India are available in urban area where only 28% of population lives and the remaining 20% of the health facilities seen in rural area where 72% of population lives. Most hospitals, from small to high-tech are available in urban areas. Urbanization and migration from rural to urban areas have triggered urban health problems: overcrowding, poor housing, communicable diseases, shortage of health care professionals and other workers, inadequate supplies and high charges in the hospitals. Most villages depend upon indigenous practitioners available locally for meeting the health care needs; most often rural men and women end up in grave problems due to poor health practices by quacks and other unqualified practitioners. The basic problem in our health care is imbalanced distribution of health services 43

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students to urban and rural. The “Primary health care approach” and “Health for all by 2000 AD” movement explicitly provided significant importance to equitable distribution of health care, community participation, and intersectoral coordination to combat the imbalances.

Population Problems India takes the share of 17.31% of the world’s population. In fact, one out of six people in the world is an Indian. The population density of India shows increasing trend. According to the records of population density (2011), population density of India has increased from 324 to 382 per square kilometer, which is higher than the average population density of the world (2011), i.e., only 46 per square kilometer. There are big differences found in the population density of the various states of India. Delhi had showed the highest population density in the year 2011 among all the states of India with 11,297 people per square kilometer. India had set the goal to attain 1% population growth rate by 2000 AD, but has not attained it yet. India’s present population growth rate is 1.2%. Population explosion is everyone’s problem; hence, it has become a social and economic hindrance. Great coordination is essential from all sectors and families in control of population.

MOVING INTO THE FUTURE Health is created and lived by people within the settings of their everyday life where they learn, work, play and love. Health addresses for caring oneself and others; by being able to take decisions and have control over one’s life circumstances, and by ensuring that the society one lives-in, creates conditions that allow the attainment of health by all people. As the novice-nursing students get in to the real world of community, they may have to explore too many things in the community. This chapter introduced the students to the basic concepts of health, community health and community health nursing. This would give them a base to accumulate further learning about community health nursing.

TWENTY-FIRST CENTURY AND CHALLENGES FOR COMMUNITY HEALTH NURSING • Many unexpected changes may occur in this 21st century all over the world in the field of health/nursing/ community health nursing. There are chances for serious transformation that may dominate the environment along with the changes in other areas like culture, beliefs, practice, technology and economy.

44

• In this fast growing customer-oriented quality driven

world, the major weapon to be used in practice is “evidence-based practice”. Evidence-based public health is a public health venture in which there is cautious use of evidence derived from a variety of science and social science research. Most often community health nurses use the evidences from the field of epidemiologic research to assess their clients and for planning and implementing care in the community. Updating of knowledge and skill is essential to function as a real-time clinician. • Growing cultural interaction: This is one of the issue in the front line which seeks the nurses to be culturally competent as well recognize the needs pertaining to increasing interaction among different cultures. • Media that cause awareness: One of the health educational principles is “known to unknown”. Traditionally we follow it, however, in present days’ world we need to be extra cautious in allotting more time to the individual/family before we step our health talk, instructions, or guidelines on any health-related issues. Even your opposite end may know or collected more information than you are about to convey. This is mainly the effect of taking responsibility on personal care that motivates people to seek more information. Exercise: Having learnt the historical development of community health nursing, learners can discuss the happenings of community health nursing in 21st century. • Consumer first: Anything that is purchased gives ownership to the consumer. Here again, patients pay for their health, become consumers. There is no surprise consumer (patient) looks for “quality” in the care delivered to them. • Societal needs and growing specializations: Curriculum planning needs to show higher concentration on societal needs and job opportunities. Redesigning the general specialties into more specific ones and providing some crash courses as an addition in each specialty will be an expected change in the curriculum to meet the present and future challenges. • Primary health care nurse practitioners: To shoulder the huge health care load and responsibilities in community “master level qualified primary health care nurse practitioners” are the right choice. • Interdisciplinary approach: Community health nurse never practice in isolation. But still giving a strong identity to interdisciplinary care through interdisciplinary research works will be complementing practice of in community health nurses. • Healthy lifestyle—a slogan that is “must for children”: Inculcation of “Healthy behavior” among children equals

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing healthy future nation. It is a mandatory challenge on community health nurses to grow and nurture healthy India.

SUMMARY A large part of what we do help people regain and maintain health. It is important to explain what health is. There are no easy, straightforward answers to this. In addition, some people use entirely different words when they actually mean what others would call “health”. Health is highly individual perception. Health is not something that a person achieves suddenly at a specific time. It is an ongoing process. Health in the abstract refers to a person’s physical, mental, and spiritual state; it can be positive (as being in good health) or negative (as being in poor health). The health of individuals and our nation are dependent on public health practice. Populationbased public health practice provides one paradigm that can influence the health of multiple communities within our nation. Community health refers to the health status of a defined group of people and the actions and conditions, both private and public (governmental), to promote, protect, and preserve their health. Population health refers to the health status of people who are not organized and have no identity as a group or locality and the actions and conditions to promote, protect, and preserve their health. Perception of the concept of health differs from one individual to another, one professional community to another. Many scholars contributed volumes in explaining the various dimensions of health. Health is explained under various dimensions like Physical, mental, social, intellectual, spiritual, emotional, vocational and environmental. Wellness is a relative concept, not an absolute, and illness is a state of being relatively unhealthy. The term community refers to a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging. There are three types of community: (1) geographic community, (2) common-interest community and (3) community of solution. Many factors affect the health of a community: Physical factors, social and cultural factors, community organization and individual behaviors. Community health nursing is a synthesis of nursing practice and public health practice, applied to promoting and preserving the health of populations. The health continuum applies not only to individuals but also to families and communities. People are either well or ill. Yet wellness is a relative concept, not an absolute, and illness is a state of being relatively unhealthy. There are many levels and degrees of

wellness and illness. A community, as a collection of people, may be described in terms of degrees of wellness or illness. The health of an individual, family, group, or community moves back and forth along this continuum throughout life. Community health nursing has a wider scope. They can play many roles like nurse clinician, nurse educator, nurse advocate, nurse manager, nurse collaborator, nurse leader and nurse researcher, etc. There are three levels of prevention that can be utilized at different levels of a course of disease progression. Three levels of prevention: Primary, secondary and tertiary. Learning about the history helps us to know what took place in the profession before, what is happening now and what are all the challenges for future. Natural history of disease is described in two phases: (1) prepathogenesis (i.e., the process in the environment) and (2) pathogenesis (i.e., the process in man). Traditionally the “Epidemiologic triad” model was used to explain the infectious disease causation. This triad elaborates on how the interaction occurs between external agent, a susceptible host, and an environment. There need to be interaction of these three factors to initiate the disease process in man/host. The term “risk factor” is defined as an attribute or exposure that is significantly associated with the development of a disease. The four levels of prevention, corresponding to different phases in the development of disease: (1) primordial prevention, (2) primary prevention, (3) secondary prevention and (4) tertiary prevention. There are five interventions corresponding to the progression of natural history of disease. They are: (1) health promotion, (2) specific protection, (3) early diagnosis and treatment, (4) disability limitation and (5) rehabilitation. Caring for the sick people confined to bed was the realm of the family. The Sushruta Samhita, (600–350 BCE) described four types of midwives and among which one was “good at giving birth to a child (prajananakusalah)”. British officials wanted to admire idealized cleanliness and rationality whereas the dai was an ignorant, superstitious lady who never gave importance for cleanliness or hygiene in her care practices. The Government of Madras sanctioned a training school for midwives in the year 1854. These modern nursing thoughts developed from Florence Nightingale played a significant role in professionalizing and inculcating nursing culture in India. Consequent to the report of Royal Sanitary Commission in 1863, the Indian Nursing Service (INS) was created in 1888 to provide proper nursing care for British soldiers. The Vicereine, Lady Dufferin, in 1883 established “Dufferin Fund”. The Vicereine, Lady Minto, launched the Indian Nursing Association in 1906. The Trained Nurses’ Association of India (TNAI) formed in 1908. In 1918, Lady Chelmsford provided great support in starting training courses for health visitors and maternity supervisors. 45

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students A “Health school” was opened in Delhi with the grants from government, which was later named as “Lady Reading School”. In 1922, Griffin launched a new wing for Health visitors under TNAI in the name of “Health Visitors’ League”. This was renamed as “association for ANMS” from 1970 onward. In 1938, Florence Nightingale memorial scholarship to pursue further training in England announced. Diana Hartley, a British nurse, the editor of “Nursing Journal of India”. With the support from the Rockefeller Foundation, seven health centers were established from 1931 to 1939 in the cities of Delhi, Madras, Bangalore, Lucknow, Trivandrum, Pune and Calcutta. Development of community health nursing: Postindependence In 1946, Bhore Committee gave the recommendations on nurse to population ratio. In 1947, nurse leaders from the Nurses’ Auxiliary of the CMAI openly conveyed about the fact that nursing is not publicly accepted as a profession. On December 31, 1947, an ordinance passed to start “Indian Nursing Council” and constituted in the year 1949. Christian missionaries made enormous contribution toward the development of community health nursing. In 1952, international tutors (4 in number) were appointed in Calcutta to train nurses in general nursing, nursing arts, midwifery and pediatric nursing. In 1959, the first Master’s degree course for 2 years of duration was developed in India at the University of Delhi. In 1959, Rockefeller provided 2 nursing fellowships and the Colombo plan sent 29 Indian nurses to abroad to pursue higher education. Kartar Singh Committee in 1973 had recommended converting auxiliary nurse midwives into MPW (F) and the basic health workers to MPW (M); in addition, the designation of “health visitor” was changed into “health supervisor”. In 2008, the Global Fund to Fight AIDS, tuberculosis and malaria (GFATM) project was taken up by Indian Nursing Council (INC) in coordination with National AIDS Control Organization (NACO). In 2016, INC has drafted “Primary Health Care practitioner” course in order to develop nurses

46

with advanced skills to function efficiently in community. Many unexpected changes may occur in this 21st century all over the world in the field of health/nursing/community health nursing. There are chances for serious transformation that may dominate the environment along with the changes in other areas like culture, beliefs, practice, technology and economy. 2019 updates: RNTCP renamed as National Tuberculosis Elimination program (NTEP) in 2019, a new Mid-level Health Care Provider role was introduced in India, also known as Community Health Officer/Community Health Provider. 2020 updates: New commission (NMC) National Medical commission replaced MCI on 25/9/2020. COVID-19 Viruspandemic took toll on many lives. Government of India repealed the existing Indian Nursing Council Act and replaced it with the National Nursing and Midwifery Commission Bill, 2020. There are many major health problems prevailing in India— communicable diseases, noncommunicable diseases and others. Respiratory diseases, tuberculosis, malaria, leprosy and diarrheal diseases are some common communicable diseases found in India. 21st century and challenges for community health nursing Many unexpected changes may occur in this 21st century all over the world in the field of health/nursing/community health nursing. There are chances for serious transformation that may dominate the environment along with the changes in other areas like culture, beliefs, practice, technology and economy. In this fast growing customer-oriented quality driven world, the major weapon for practice is “evidencebased practice”. Evidence-based public health is a public health venture in which there is cautious use of evidence derived from a variety of science and social science research. Most often community health nurses use the evidences from the field of epidemiologic research to assess their clients and for planning and implementing care in the community. Updating of knowledge and skill is essential to function as a real-time clinician.

CHAPTER 1:  Concepts of Health, Community Health and Community Health Nursing

ASSESS YOURSELF I.  Short Answer Questions: 1. Define health. 2. Define public health. 3. Define community health. 4. Define community health nursing. 5. Define health promotion. 6. Define population health. 7. List the changing concepts of health. 8. State two dimensions of health. 9. Give two differences between health promotion and health protection. 10. Define two different types of communities. 11. State the concept of “Right to health”. 12. List four sites for health promotion activities.

II.  Write Short Notes on: 1. Dimensions of health 2. Changing concepts of health 3. Types of communities 4. Wellness-illness continuum 5. Health promotion 6. Levels of prevention 7. National Immunization Schedule 8. Health promotion logo of Ottawa Charter 9. Sites for health promotional activities 10. Health problem profile of India 11. Natural history of the disease 12. Scope of community health nursing

III.  Long Answer Questions: 1. Define community health. Describe the factors affecting community health. 2. Define community health nursing. List down the principles of community health nursing. 3. Define health. Describe the changing concepts of health. 4. Describe the various dimensions of health. 5. Define health promotion. Describe the three levels of prevention. 6. Define communication. Describe the factors influencing communication. 7. Define community. What are all the principles of community health nursing? State the types of communities. 8. Describe national health problems in India. 9. Explain briefly on significant events of community health development in the world. 10. Describe in detail about the scope of community health nursing. 11. Explain the various roles of community health nurse. 12. Describe various work settings of community health nurses. 13. Describe the development of community health nursing in India during pre-independence.

14. Describe the development of community health nursing in India during post-independence. 15. Write an essay on historical milestones in the development of community health nursing in India.

IV.  Multiple Choice Questions: 1. Which of the following years the “Royal Commission” appointed in India? a. 1829 b. 1839 c. 1849 d. 1859 2. Which of the following years the “Vaccination Act” introduced in India? a. 1870 b. 1880 c. 1890 d. 1900 3. Which of the following years the “Indian Factories Act” introduced? a. 1861 b. 1871 c. 1881 d. 1891 4. Which of the following years the “Local Self-Government Act” launched? a. 1885 b. 1895 c. 1905 d. 1915 5. Which of the following years the “Epidemic Diseases Act” passed? a. 1867 b. 1877 c. 1887 d. 1897 6. The “Lady Reading Health School” at Delhi, established to train: a. Health visitors b. Staff nurses c. Village health nurses d. Doctors 7. The All India Institute of Hygiene and Public Health was established in: a. Delhi b. Chennai c. Calcutta d. Mumbai 8. Which of the following years the “Child Marriage Restraint Act” launched? a. 1920 b. 1930 c. 1940 d. 1960 9. Which of the following years the “Tuberculosis Association of India” established? a. 1939 b. 1949 c. 1959 d. 1969 10. Which of the following years the “Health Survey and Development Committee (Bhore Committee)” appointed? a. 1943 b. 1953 c. 1963 d. 1973 11. Which of the following years the “Drugs Act” passed? a. 1930 b. 1940 c. 1950 d. 1960

47

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students 12. India became a member state in World Health Organization in the year: a. 1948 b. 1958 c. 1968 d. 1978 13. The Employees State Insurance Act was passed in the year: a. 1948 b. 1958 c. 1968 d. 1978 14. The Planning Commission of India was set up in the year: a. 1940 b. 1950 c. 1960 d. 1970 15. India became a Republic from the Commonwealth countries in the year: a. 1930 b. 1940 c. 1950 d. 1960 16. The BCG vaccination program implemented in the country to prevent tuberculosis in the year: a. 1951 b. 1961 c. 1971 d. 1981 17. The Community Development Program launched in the year: a. 1952 b. 1962 c. 1972 d. 1982 18. The first district nurse appointed by William Rathbone is: a. Clara b. Mary Robinson c. Minto d. Mary Williams 19. Which of the following nursing leaders found the “National Organization for Public Health Nursing”? a. Wald b. Clara Barton c. Florence Nightingale d. Diana Hartley 20. An ordinance passed to start “Indian Nursing Council” in the year: a. 1929 b. 1939 c. 1949 d. 1959 21. The Population Council initiated the “International Postpartum Family Planning Program” in the year: a. 1946 b. 1956 c. 1966 d. 1976 22. Indian Nursing Association launched in the year 1906 by: a. Lady Minto b. Lady Dufferin c. Lady Chelmsford d. Queen Victoria 23. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) project in India was initiated by: a. UNICEF and NACO b. INC and NACO c. USAID and NAC d. USAID and INC 24. The Trained Nurses’ Association of India (TNAI) formed in the year: a. 1908 b. 1918 c. 1928 d. 1938

25. The Baby-Friendly Hospital Initiative (BFHI) was launched by WHO and UNICEF to promote and support breastfeeding in the year: a. 1971 b. 1981 c. 1991 d. 2001 26. “The great sanitary awakening” took place in: a. 17th century b. 18th century c. 19th century d. 20th century 27. World Health Organization published “a framework for community health nursing education” in the year: a. 1980 b. 1990 c. 2000 d. 2010 28. Which of the following committees had recommended on converting auxiliary nurse midwives into MPW(F)? a. Mudaliar committee b. Bhore committee c. Bajaj Committee d. Kartar Singh committee 29. “Swatchh Bharat Abhiyan” initiated by the Prime Minister Modi in the year: a. 2011 b. 2012 c. 2013 d. 2014 30. NITI Aayog replaced Yojana Aayog on 1st January: a. 2012 b. 2013 c. 2014 d. 2015 31. Collection of people who interact with one another and whose characteristics form the basis for a sense of belonging appropriately refers to: a. Population b. Aggregate c. Community d. None of these 32. Tertiary prevention attempts to: a. Detect and treat problems b. Minimize disability and restore function c. Prevent disease occurrence d. Diagnose the disease 33. The efforts to detect and treat existing health problems at the earliest possible stage when disease or impairment already exists is referred to: a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Optimum prevention 34. The broader concepts of health promotion are: a. Early diagnosis and treatment b. Health education and health maintenance c. Diagnosis and disability prevention d. Health education and disability prevention

Answer Key 1. a

3. c

4. a

5. d

6. a

7. c

8. b

10. a

11. b

12. a

13. a

14. b

15. c

16. a

25. c

26. c

27. d

28. d

29. d

30. d

31. c

32. b

17. a 33. b

48

2. b

9. a

18. b 34. b

19. a

20. c

21. c

22. a

23. b

24. a

C H A P T E R

Health Care Planning and Organization at Various Levels

2

  LEARNING OBJECTIVES This chapter is designed to enable the learner to: ˆ ˆ ˆ

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ˆ ˆ

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Define health care planning. Describe the steps in “health care planning cycle”. List down the names of the committees contributed to health care planning in India. Describe the purposes/objectives and recommendations of various health committees. List down the various functions of Planning Commission of India. List down the objectives of National Institution for Transforming India (NITI) Aayog. State the objectives of various Five-Year Plans of India. State the health-related goals of 12th Five-Year Plan. State the goals related to communicable disease in 12th Five-Year Plan.

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State the key features of National Health Policy 1983, 2002 and 2017. Describe the National Population Policy 2000. Describe the National Health Problems in India. Discuss the community participation in health care planning. Describe the health care delivery infrastructure. Describe the health sectors rendering health care in India. Describe the delivery of health services at various levels. Enlist the functions of subcenter, primary health center and community health center. Explain the sustainable development goals.

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Health Care Delivery System in India: Infrastructure and Health Sectors in India Sustainable Development Goals Concepts of Primary Health Care Ayushman Bharat Health Promotion and Behavioral change Communication under CPHC National Health Policy, 1983 National Health Policy, 2002

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ˆ

ˆ ˆ ˆ ˆ ˆ ˆ

State concepts of primary health care. Describe the Comprehensive Primary Health Care (CPHC) through Health and Wellness Centers (HWCs). Describe the role of mid-level health provider. Describe the components of Ayushman Bharat. Describe the National Health Policy. Comprehend the National Health Mission (NHM). Comprehend the National Rural Health Mission (NRHM). Explain the universal health coverage (UHC).

  CHAPTER OUTLINE ¬ ¬ ¬ ¬

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Health Care Planning in India Definitions Steps in Health Care Planning Various Committees and Commissions on Health and Family Welfare and Five-Year Plans Central Council for Health and Family Welfare Participation of Community and Stakeholders in Health Care Planning

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National Health Policy, 2017 National Population Policy, 2000 Millennium Development Goals National Health Mission Universal Health Coverage

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

  KEY TERMS ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬ ¬

Health care planning Bhore Committee Mudaliar Committee Chadha Committee Mukherjee Committee (1965) Mukherjee Committee (1966) Jungalwalla Committee Kartar Singh Committee Shrivastav Committee Bajaj Committee Krishnan Committee Planning Commission of India NITI Aayog Five-Year Plans Health care delivery system

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Health care delivery model Levels of care Infrastructure Health sectors Public sectors Subcenter Primary health center Community health center Maternal health center Subdistrict hospital District hospital Railways Defense services Private sectors Indigenous system of medicine

HEALTH CARE PLANNING IN INDIA There is a universal saying, “Failing to plan is planning to fail.” Planning is the word used from gross level to the topmost plans. In our daily life, planning takes its place with no alarm or alert. Yes, many of us make “mental plans” on our daily routines and special tasks consciously or unconsciously. The plan of individual or a family does not have the schedule or record but lies tacit and helps implementing our tasks. However, we happen to see family members make their monthly budgets sitting with a paper and pen. This is one of the typical examples of planning consciously to control the expenses within their capacity to spend. Therefore, planning is the most important task of individual, family and the country. India, the second most populous country of the world, tries the effective means and measures to utilize its men, money, material and time, since many years now. Indian government appointed many committees from time to time to provide advice on huge number of health problems. The reports of these committees have served important platform for “health care planning in India”. Health care planning in India and a brief account on various committees and their significant recommendations are explained here.

DEFINITIONS • Planning is the orderly process of defining health

problems, identifying unmet needs and surveying the resources to meet them, establishing priority goals that are realistic and feasible, and projecting administrative

50

• •

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Voluntary health services National Health Programs Sustainable development goals Ayushman Bharat Comprehensive primary health care Health and wellness centers Mid-level health provider Pradhan Mantri Jan Arogya Yojana National Health Policy National Health Mission National Rural Health Mission Universal health coverage

action, concerned not only with the adequacy, efficacy and efficiency of health services but also with those factors of ecology and of social and individual behavior that affect the health of the individual and the community.  —WHO, 1975 It is the process of organizing decisions and actions to achieve particular ends, set within a policy.   —WHO, 1988 It is a code word for public decision making toward the future. —WHO, 1984

STEPS IN HEALTH CARE PLANNING Health care planning runs in systematic cyclical steps (Fig. 2.1). 1. Analysis of the situation: The first and foremost step in health care planning process is the analysis of the existing health situation of a given region or country. The study analysis and interpretation of the following gives us elaborate picture on health problems, health needs and health demands of the population: ƒ Population, age and sex composition ƒ Morbidity and mortality data ƒ Epidemiology and geographical distribution pattern of the diseases ƒ The available facilities like hospitals, health centers and other health agencies, etc. ƒ Availability of technical manpower ƒ Available training facilities ƒ Community awareness and their beliefs and attitudes of disease, its cure and preventive measures

CHAPTER 2:  Health Care Planning and Organization at Various Levels action. Improper implementation may collapse the entire program. A careful implementation is fully based on guiding administration. 7. Monitoring: One should show a keen interest in monitoring the work on day-to-day basis and take necessary action whenever needed. Keep the record of all activities based on your observation and give necessary feedback on continuous basis. 8. Evaluation: Outcome measurements with the set objectives help in knowing how far the program process has done justice at all the steps. Any program planning must have an inbuilt evaluation system to assess the achievement of set objectives of the program, its adequacy, its efficiency and acceptance by all parties involved.

Fig. 2.1: Health care planning cycle

2. Setting of objectives and goals: Setting clear goals and objectives will guide the planning process in an efficient manner. At the beginning of the planning process, objectives at the central level are broader and general and the objectives at later levels are more specific. Objectives help in measuring and assessing the work undertaken. 3. Assessment of resources: The available resources like money, material, human resources should be assessed; in addition, the knowledge, skill and technical expertise should also be assessed. 4. Set priorities: Not all problems can be attended at the same time. The planners should list and rank the problems based on their priority considering the availability of the resources, magnitude and urgency of the problem. After setting down the priorities, alternate plans must also be formulated and checked for the practicality and feasibility. 5. Pen the plan: After setting the priorities, a neat systematic plan should be drawn including the resources needed and the results expected. The plan must a good and crystal clear guide for implementation. Detailed plan should include project flow, funding resources allocated for every phase, timeline and working guidance to all members of the project. Each phase of the project/program needs to be evaluated and feedback included for further planning. Central planning authority and government holds the responsibility in considering modifications in relation to allocation of resources. 6. Put into action (implementation): Here actually the rubber meets the road that is to put the actual plan into

VARIOUS COMMITTEES AND COMMISSIONS ON HEALTH AND FAMILY WELFARE AND FIVE-YEAR PLANS Committees Bhore Committee (1946) This committee, popularly known as the “Health Survey and Development Committee” appointed in 1943 under the Chairmanship of Sir Joseph William Bhore, an Indian civil servant (Fig. 2.2). Major Purposes

• To survey the existing conditions and organization and to •

give suggestions for future development Primarily to review those activities within the scope of health administration

Fig. 2.2: Sir Joseph William Bhore

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Bhore committee submitted its report in 1946. The report consisted of four volumes: 1. A survey of the state of the public health and the existing health organization 2. Recommendations 3. Appendices and 4. Summary. Recommendations It stressed on the importance of integration of curative and preventive medicine at all levels. The committee recommended short- and long-term plans toward setting up of primary health centers.

of Bhore committee provided a major platform for further health care planning and development in India.

Mudaliar Committee (1962) Government of India constituted Mudaliar Committee in the year 1959 under Chairmanship of Dr A Lakshmanaswami Mudaliar, Vice Chancellor, Madras University (Fig. 2.4). The committee is popularly known as “Health Survey and Planning Committee”. The committee submitted its report in 1962. Objectives

• To make an assessment about the implementation of Bhore

Short-term plan

• To be implemented within 5–10 years. • • Each primary health center in the rural area to cater to a population of 40,000.

• It should have a secondary health center to serve as a

•

supervisory, coordinating and referral institution.

• For each primary health care (PHC): 2 medical officers,

4 public health nurses, 1 nurse, 4 midwives, 4 trained dais and 15 class IV employees.

Long-term plan

Major Observations

• It was found that the basic health facilities had not reached •

• Health care system in three tiers (Fig. 2.3). • Three months training in preventive and social medicine • • • • •

to prepare “social physicians”. Special emphasis on preventive work (Integration of curative and preventive services). Village health committee consisting of 5–7 individuals for procuring the active participation of the people in the local health program. Intersectoral coordination. The Bhore committee focused on many issues; however, it was failed to include any component toward comprehensive national socioeconomic development. In spite of this criticism, no one denies the fact that the recommendations

Fig. 2.3: Three-tier health care system

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Committee’s recommendations in the field of medical relief and public health since the time of submission of the report. To review the First and Second Five-Year Plan—health projects. To make further recommendations for health and development of the country.

at least half of the nation. Gross maldistribution in allocating hospitals and beds that favored urban areas. Poor functioning of primary health centers with lack of referral system and gross under-staffing due to insufficient resources.

Recommendations

• To consolidate the advances made in the period of first •

two Five-Year Plans To strengthen district hospitals to function as central base for providing specialist services.

Fig. 2.4: Dr AL Mudaliar

CHAPTER 2:  Health Care Planning and Organization at Various Levels

• Each primary health center should cover the population Mukherjee Committee (1966) • • •

not exceeding 40,000 and should 1 basic health worker (BHW) per every 10,000 population. To improve the quality of health services at primary health centers. Improve secondary level services. Integration of medical and health services.

Chadha Committee (1963) Initially, the health administrators and malariologists who reviewed the National Malaria Eradication Program suggested to appoint a special committee to study and plan the activities required to be adopted in the maintenance phase of malaria. The Government of India constituted Chadha committee in the year 1963 under the chairmanship of Dr MS Chadha, the then Director General of Health Services.

States were discussed their difficulties in taking up the burden of maintenance phase of malaria and other programs like smallpox, leprosy, family planning and trachoma during the meeting of the Central Council of Health held at Bangalore (now Bengaluru) in June, 1966. Following this Government of India constituted a committee in 1966 under Shri B Mukherjee, the then Union Health Secretary. Recommendations

• Basic health services at block level. • Any attempt to give more work to the BHW would •

endanger malaria vigilance work or would need large numbers of BHWs than recommended. Health workers at the lower levels should become increasingly oriented to multipurpose. Adopt integrated approach in the entire health field.

Recommendations

•

• Maintenance phase of malaria should be carried by

Jungalwalla Committee (1967)

• • •

general health services at block level and district level through BHWs (1 per 10,000 population). Basic health workers should make home visits once in a month to perform malaria activities. Apart from malaria vigilance activities, the BHWs are envisaged as multipurpose health workers (MPHWs) to work for family planning and collection of vital statistics. Each family planning health assistant (FPHA) to supervise 3–4 BHWs.

Jungalwalla Committee was constituted under the chairmanship of Dr N Jungalwalla, additional Director General of Health Services and referred as “Committee on Integration of Health Services”. This committee had submitted its report in 1967. Objectives

• To study the problems of the health services and its conditions.

• Integrate health services. After 2 years of implementation of Chadha Committee’s • Eliminate private practice by government doctors. Mukherjee Committee (1965)

recommendations, it came to the light that the BHWs could not function effectively in the designation of MPHWs. As a result, the family planning program and the malaria vigilance operations both were disturbed and failed to bring desired outcome. Following a meeting with the Central Council of Health, a committee was constituted in 1965 under the chairmanship of Shri Mukherjee, the then Secretary, Ministry of Health and Family Planning, India. Recommendations

Recommendations

• Use unified approach instead of segmented approach in serving for all the problems.

• Medical care and health programs to function under a single administrator.

• Operating in unified manner at all levels of hierarchy with •

• To set up strong executive agency in health directorate • • • •

of each state government to exclusively deal with family planning. Approval of existing urban family welfare planning center. Basic health workers to be utilized as MPWs for general services. Family planning health assistants to undertake only their duties and no need to supervise BHWs. Delink malarial activities from family planning activities.

•

due priority for each program. The integration of services from the lowest to the highest level should include: ƒ Unified cadre ƒ Common seniority ƒ Recognition of extra qualifications ƒ Equal pay for equal work ƒ Special pay for specialized work ƒ No private practice among government doctors and good service conditions States were permitted to work out their own strategy.

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Kartar Singh Committee (1973)

Recommendations

In 1972, the Government of India during Central Family Planning Council meet, appointed a committee called “the committee on multipurpose workers under Health and Family Planning” under the chairmanship of Kartar Singh, the then Additional Secretary of Health and Family Welfare. This committee had submitted its report in 1973. This committee was given the following terms of reference to initiate the study: • The structure of integrated service at the peripheral and supervisory levels. • The feasibility of having multipurpose and bipurpose workers in the field or each worker • The training requirements for such workers • The utilization of mobile service units operating in the field.

• Organization of the basic health services (including

Recommendations

•

• Multipurpose workers—feasible and desirable. • Redesignation: ƒ

• • • • • • • • •

Auxiliary nurse midwives (ANMs) should be replaced by female health workers (FHWs) ƒ Basic health workers, Malaria surveillance workers, vaccinators, FPHAs should be replaced by male health workers (MHWs) ƒ Lady health visitors (LHVs) should be designated as female health (FH) supervisor These MPHWs should be initially introduced in malaria maintenance phase areas and smallpox controlled areas. Clearly spelt out the job responsibilities of HWs and Supervisors. One primary health center (PHC) per 50,000 population One primary health center will have 16 health subcenters. Each health subcenter to provide service to 2,000–3,500 population. One health subcenter will have one MPHW one male and one female MPHWs. One male supervisor for every four MHWs male. One female supervisor for every four FHWs female. Doctor will be in charge of all supervisors. All these to be implemented in Fifth Five-Year Plan.

Shrivastav Committee (1975) In 1974, Government of India assigned a group named “group on medical education and support manpower” known as Shrivastav Committee. The group had submitted its report in 1975. 54

•

• • •

• • •

nutrition, health education and family planning) within the community to impart training to the personnel required for these purposes. Introduction of paraprofessional and semi-professional health workers like teachers, postmasters, gram sevaks who can provide comprehensive health services as paraprofessionals. Placing the health in community’s hands by involving the people within the community. Organization of economically efficient health services to link the community with the first level referral center— the PHC. Creation of MPHWs and health assistants (HAs) in between the village health guides (VHGs) and medical officer (MO) in charge of PHC. One male and one female health worker for every 5,000 population. Reorganization of the medical program and health education. Establishment of “the Medical and Health Education Commission” Based on these recommendations, “Rural Health Scheme” was launched by the Government of India in the year 1977–78.

Rural health scheme (1977–78) The major steps taken under this scheme are as follows: • Involvement of medical colleges in health care was assessed with the objective of reorienting medical education according to rural population need called “Reorientation of Medical Education” (ROME). • Under this scheme train all the undergraduate students and interns at PHCs. • Reorientation training to all multipurpose workers and training of Village Health Guides and utilizing their services in the general health service system.

Bajaj Committee (1987) The Bajaj committee constituted under Dr JS Bajaj, Professor of Medicine. The committee was popularly known as “health manpower planning, production and management”. Following areas were emphasized by the committee: • Procedures relating to admissions to undergraduate courses. • Procedures relating to admissions to the postgraduate courses.

CHAPTER 2:  Health Care Planning and Organization at Various Levels

• • • •

Duration of the undergraduate course and internship Duration of the postgraduate courses and thesis Review of the residency scheme Measures to bring about overall improvement in the undergraduate and postgraduate education.

Krishnan Committee Health Report 1992 This committee worked under the chair of Dr Krishnan to review the recommendations and achievements of previous health committees and comment on any deficits. Consequent to this the committee devised the health post scheme for urban slum areas. Recommendations The committee recommended one voluntary health worker (VHW) per 2,000 population with an honorarium of `100. Its report specifically outlines which services have to be provided by the health post. These services have been divided into outreach, preventive, family planning, curative, support (referral) services and reporting and record keeping. Outreach services include population education, motivation for family planning, and health education. In the present context, very few outreach services are being provided to urban slums.

Health Commissions National Commission on Macroeconomics and Health (2005) National commission was formed under the Chairmanship of P Chidambaram, the then Finance Minister and Dr Anbumani Ramadoss, the then Health Minister with the objectives of: • Promoting equity by reducing household expenditure on total health spending and experimenting with alternate models of health financing • Restructuring the existing primary health care system to make it more accountable • Reducing disease burden and the level of risk • Establishing institutional frameworks for improved quality of governance of health • Investing in technology and human resources for a more professional and skilled workforce and better monitoring.

Planning Commission of India Primarily the economic planning of India that gave authority to state began in 1930s during British period. Initially the formal planning board of colonial Government of India existed from the year 1944 to 1946. India became “independent country” on August 15, 1947 and became “Republic India” on

Fig. 2.5: Planning Commission of India—under the Chairmanship of Prime Minister Jawaharlal Nehru

January 29, 1950. Following which “Planning Commission” was established on March 15, 1950 adopting a formal functioning model under the Chairmanship of Prime Minister Jawaharlal Nehru. After the establishment of the formal Planning Commission (Fig. 2.5), it started to report directly to the Prime Minister of India. Structure Planning Commission included a Chairman, Deputy Chairman, and five members and functioned through Program Advisors, General Secretariat and Technical Divisions. A senior officer headed each of this division. The major task of Planning Commission was formulation of Five-Year Plans to guide the country in a developing path. Planning Commission adopted “decentralized approach” in planning process in view to achieve decentralized district planning. Functions The 1950 resolution on establishment of the Planning Commission framed its functions as given here: • Assessment on existing resources of the country like manpower, money and material and augment these resources in areas of deficiencies. • Formulates plan for the appropriate and balanced use of resources of the country. • Sets priorities and allocates resources in a phased manner for fulfilling the work at each phase. • Alerts the factors that may impede the process of economic growth of the country and identifies suitable conditions for successful implementation of the plan. • To decide upon the equipment and technology required for the implementation of plan. • Continuous monitoring, assessment and feedback on each stage with appropriate changes and modifications in the policies. 55

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

• Make interim plans and recommendations to make •

appropriate changes in the existing policies and to seek advice from Central and State government. Planning Commission plays a mediatory and facilitating role in the best interest of all state and central government.

National Institution for Transforming India Aayog Government of India dissolved the “Planning Commission” that was in function since 1950 and formulated “National Institution for Transforming India (NITI) Aayog” on January 1, 2015 by the Prime Minister Narendra Modi. NITI Aayog has been assigned the role to coordinate “Transforming our world: the 2030 Agenda for Sustainable Development”. Objectives of NITI Aayog

Fig. 2.6: Health sector planning

Five-Year Plans The Five-Year Plans provide a basic framework and help in

• To have a shared vision in developmental priorities of the providing overall directions for making policies, procedures, • • • • • • •

nation by involving state governments and other sectors in achieving national objectives. To encourage accommodating federalism through structured support initiatives. To build practical ways to draw realistic plans initially at the village level and implement the same at higher levels of government. To pay special attention to the weaker sections of our society in view of economic progress of the country. To pay attention on intersectoral and interdepartmental issues to gear up the execution of the development agenda. To adopt best practices that would promote sustainable and equitable development and help their dissemination to stakeholders. To monitor continuously on the execution of programs and initiatives and receive feedback for planning. To focus on capacity building through necessary technology upgradation.

and programs that lead to the development of the country.

First Five-Year Plan (1951–1956) Since the time of independence, India concentrated mainly on bringing about a fast and balanced economic development. Shri Jawaharlal Nehru, the first Indian Prime Minister presented the First Five-Year Plan to the Parliament of India on December 8, 1951. A total of 206.8 billion allocated in the First Five-Year Plan for developing and modifying various sectors (Table 2.1). The first plan initiated in the year 1951 with the focus on primary sector. Objectives

• To reinstate the financial system and overcome the •

pressures of inflation, establish the transport system and enhance the state of availability of food and raw material. To promote the progress by activating substantial development programs.

Planning Commission and Health Sector Planning Health is the major phenomenon of interest in the developmental representation of the country. Consequently, Planning Commission of India gave significant importance in including and allocating the resources on various health programs across Five-Year Plans. A Planning Bureau under “Ministry of Health” was introduced in the year 1965 to enhance coordination between central and state governments and to compile Five-Year Plans. The Planning Commission divided the priority areas of health for the purposes of planning and providing specific attention on each (Fig. 2.6).

56

Table 2.1: Budget allocation during the First Five-Year Plan A total of 206.8 billion allocated during the First Five-Year Plan

• • • • • • •

Irrigation and energy—27.2% Agriculture and community development—17.4% Transport and communications—24% Industry—8.4% Social services—16.64% Land rehabilitation—4.1% Others—2.5%

CHAPTER 2:  Health Care Planning and Organization at Various Levels

• To initiate measures of social justice on a wider scale. • To establish relevant administrative changes for

development purposes. Various aspects considered to enhance health: • Water supply and sanitation. • Control/Eradication of common communicable diseases. • Maternal and child health services and health education. • Strengthening rural health facilities by establishing health subcenters and primary health centers and develop health manpower resources. • Preventive health care of the rural population through health units and mobile units. • Family planning. • Self-sufficiency in drugs and equipment.

gross domestic product rate to 2.7%. Third plan initiated with a total outlay of about `342 crore, about `297 crore to States and the rest to the Center. Aims

• To maintain 5–6% annual increase in national income and to sustain the same in further plans.

• To become self-sufficient and increase agricultural • •

production in order to meet the needs of industry and the growing population. To increase major industries like steel, fuel, power and chemical thereby enhance the use of our resources for industrialization. To utilize manpower effectively and substantiate employment opportunities. To bring down the disparities in income and wealth to create economic power among people.

Second Five-Year Plan (1956–1961)

•

The Second Five-Year Plan was more ambitious with twice the budget provision for development than the First Five-Year Plan. The Second Five-Year Plan was concentrated on development of public sector.

Aims for Health Sector

Aims

• Improvement of environmental sanitation, and safe water • •

• National annual income to increase 5%. • Additional employment facilities for 10 million people. • Rapid industrialization with specific attention to the • production of iron and steel.

• Empowerment of people by reducing inequalities in income and wealth.

Objectives

• Establishment of institutional facilities to serve people. • Development of technical manpower through training programs and provision of employment for those trained.

•

supply. Control of communicable diseases. Organization of institutional facilities for providing care and for the training of medical and health personnel. Provision of services like maternal and child welfare, health education and nutrition. High priority to family planning.

Fourth Five-Year Plan (1969–1974) The Fourth Five-Year Plan deferred for 3 years because of the operational difficulties faced and inadequate growth of the economy. A total of 433.53 crore was the outlay assigned for health and family planning in the Fourth Five-Year Plan.

• Measures to control communicable diseases prevalent in General Objectives •

community. Create awareness on environmental hygiene, family planning and other supporting programs.

Third Five-Year Plan (1961–1966) The Third Five-Year Plan gave larger importance to the development of agriculture to improve production of rice, but due to the economic threat caused by Sino-India War (1962) the focus of the country was shifted toward defense. During 1965–1966, the Green Revolution in India boosted agriculture development in India. As a measure to disseminate democracy, Panchayat elections were conducted. Sino-Indian War (1962) and Indo-Pakistan War (1965) brought down the

• To enhance stability and self-reliance in various productive • • • • •

activities of the country. To emphasize on productive activity, principally on agricultural production. To enhance technological advancement in industrial activity and enterprise. To extend help to small producers and increase job opportunities for present and future. To make supplies available evenly. To include “Panchayati Raj Institutions” for planning toward integrated cooperative structure and building social and economic democracy. 57

Comprehensive Textbook of Community Health Nursing for BSc Nursing Students Health-Related Objectives

• To eradicate communicable diseases. • To establish primary health centers in each community • •

development block. Family planning program. Expand medical and nursing education and training of paramedical personnel to meet the technical manpower requirements.

Fifth Five-Year Plan (1974–1978) The Fifth Five-Year Plan focused on employment, poverty alleviation, and justice. The plan continued to pay attention on self-reliance in agricultural production and defense. The Morarji Desai government took over in the year 1978 following which the plan was rejected. Major Objectives

• Elimination of poverty. • Realization and attainment of self-reliance. Sixth Five-Year Plan (1980–1985) The Sixth Five-Year Plan was started on April 1, 1980, which continued till March 31, 1985. Sixth plan aimed at rapid industrial development specifically in the area of information technology. Family planning activities geared up in order to prevent overpopulation. General Objectives

• To bring down poverty and unemployment rate • • • • •

progressively. Saving and development of indigenous sources of energy with efficiency. Progressive reduction of regional disparities to enhance technological benefits. Population control policies and procedures toward voluntary acceptance of the small family norm. Promote, protect and improve ecological and environmental assets through harmonious short- and long-term goals. Promote the involvement of people from all sections of the society through education, communication and other strategies of the institutions.

Health-Related Objectives

• Increasing the accessibility of health services to rural areas. • Correcting regional imbalances. • Further development of referral services by removal of 58

deficiencies in District/Subdivisional hospitals.

• Intensification of the control/eradication of communicable • •

diseases especially malaria and smallpox. Qualitative improvement in the education and training of health personnel. Development of referral services by providing specialist attention to common diseases in rural areas.

Seventh Five-Year Plan (1985–1990) The Seventh Five-Year Plan was focused on steady growth with significant importance to self-reliance and improved efficiency in productivity. Equity and social justice were the elements used for distributing the benefits yielded. The total outlay for the health sector was `3,392.89 crore. General Objectives

• To support and speed up the production of food grains. • To implement various programs that would facilitate meeting the basic requirements.

• To boost self-reliance and increase job opportunities to •

people. To gear up the process of expansion of scientific and technological capabilities.

Health-Related Objectives

• Coordination and coupling of health and health-related • • • • •

services and activities, e.g., nutrition, safe drinking water, etc. Special efforts on urban health services, school health services and mental and dental health services to ensure comprehensive coverage. Community participation and intersectoral coordination Control and eradication of communicable diseases. Training and education of doctors and paramedical personnel. Rural health programs.

Annual Plans (1990–1992) There were no Five-Year Plans between the years 1990 and 1992 due to disturbed political situation. The country had only annual plans for the years 1990–1991 and 1991–1992. Following to that the Eighth Five-Year Plan was launched in 1992. Dr Manmohan Singh gave greater attention on India’s free market reforms that brought about the economic stability. During this plan period, privatization and liberalization began in India.

Eighth Five-Year Plan (1992–1997) The Eighth Five-Year Plan was started on April 1, 1992 with major concern of modernizing the industries. The major

CHAPTER 2:  Health Care Planning and Organization at Various Levels components of eighth plan include strengthening the infrastructure, check on population growth, poverty reduction and people’s participation. General Objectives

• Creation of adequate job opportunities to achieve near full employment by the turn of the century.

• Universalization of elementary education and eradication • • •

of illiteracy among the age group of 15–35 years. Control population growth by voluntary acceptance of family planning and through incentives and disincentives. Provision of safe drinking water and primary health care to the entire population. Develop and strengthen the areas like communication infrastructure, irrigation and energy production to enhance the growth of the country.

Health-Related Objectives

• Containing population growth with the goals: ƒ

• • •

Reducing the birth rate from 29.9 per 1,000 in 1990 to 26 per 1,000 by 1997 ƒ The infant mortality rate (IMR) will also be brought down from 80 per 1,000 live births in 1990 to 70% by 1997. Convergence of health services provided by various sectors, e.g., welfare, human resource development, nutrition, etc. Consolidation and operationalization of subcenters, PHCs and CHCs so that their performance is optimized The health for all (HFA) paradigms must take into account not only high risk but also vulnerable groups, i.e., mothers and children.

Ninth Five-Year Plan (1997–2002) The ninth plan came to act from April 1, 1997. Main Objectives

• • • • • • • •

Agriculture and rural development. Generate adequate employment and eradicate poverty. Increase economic growth rate with stable prices. Ensuring food and nutritional security for all. Provision of basic services like safe drinking water, primary health care, universal primary education, etc. Containing the growth rate of population. Empowerment of women and socially disadvantaged. Promotion of people’s participation through Panchayati Raj Institutions and self-help groups.

Health-Related Objectives

• Ensure existing SC, PHC are fully operational • Fill the gaps in CHCs through restructuring existing block level PHC, Taluk, and Subdivisional hospital

• Establish functional referral linkages • Local recruitment of doctors, if necessary, on part-time • •

basis Provide adequate diagnostics, consumables and drugs Strengthen emergency services.

Tenth Five-Year Plan (2002–2007) Apart from economic growth, the “Tenth Five-Year Plan” (2002–2007) also aimed at improving the quality of life of the people. Main Objectives

• Reduction in poverty ratio 5% by 2007. • Providing gainful high-quality employment to the • • • • • • •

additional labor force. All children to be enrolled in schools and complete 5 years of schooling. Reduction of gender gaps in literacy and wage rates by at least 50%. Reduction in decadal rate of population growth between 2001 and 2011 to 16.2%. Increase in literacy rate to 75% within the plan period. All villages to have sustained access to potable drinking water within the plan period. Cleaning of major polluted rivers and other notified stretches. Reduction in IMR and maternal mortality rate (MMR).

Health-Related Objectives

• Reorganization and restructuring of the existing • • • • • •

government health care system with appropriate referral linkages. Efficient and effective logistics system for the supply of drugs, and consumables based on need and utilization. Improving content and quality of education for health professionals. Skill upgradation of all health care providers. Promotion of the rational use of diagnostics and drugs. Research and development. Strengthening and sustaining civil registration and sample registration system.

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Comprehensive Textbook of Community Health Nursing for BSc Nursing Students

Eleventh Five-Year Plan (2007–2012) Objectives

• • • • • • •

To accelerate GDP growth from 8% to 9% To create 70 million new work opportunities To reduce educated unemployment to below 5% To raise real wage rate of unskilled workers by 20% Attain WHO standards of air quality in all major cities by 2011–2012 Attention on taking care of the older persons Reducing disability and integrating disabled

Health-Related Objectives

Planning Commission has constituted a High Level Expert Group (HLEG) on universal health coverage, seven working groups and two steering committees to define the appropriate strategy for the health sector for the 12th plan. Goals Related to Health Sector

• • • • •

• Reducing maternal morality ratio (MMR) to 1 per 1,000 • live births.

• Reducing infant mortality rate (IMR) to 28 per 1,000 live • • • • • • • •

births. Reducing total fertility rate (TFR) to 2.1. Providing clean drinking water for all by 2009 and ensuring no slip-backs. Reducing malnutrition among children of age group 0–3 to half from its present level. Reducing anemia among women and girls by 50%. Raising the sex ratio for age group 0–6 to 935 by 2011–12 and 950 by 2016–17. Improving medical, paramedical, nursing, and dental education and then availability. Reorienting AYUSH education and utilization.

Twelfth Five-Year Plan (2012–2017) The Twelfth Five-Year Plan is a centralized and integrated national economic program depicted its broad vision and aspirations in the subtitle: “Faster, sustainable, and more inclusive growth”. Initially, the Planning Commission estimated to register an average growth rate of 8.2% in the Twelfth Plan (2007–12) but later fixed at 8% target that was more feasible. Goals Related to Energy and Production

• Increasing green cover by 1 million hectare every year • • • • 60

and adding 30,000 MW of renewable energy generation capacity in the plan period. To reduce emission intensity of the GDP in line with the target of 20–25 reduction by 2020 over 2005 levels. Raising agriculture output to 4% for the full plan. Manufacturing sector growth to 10% for the full plan. Target of adding over 88,000 MW of power generation capacity in the 12th Five-Year Plan.

•

Reduction of IMR to 25 per 1,000 live births Reduction of MMR to 100 per 100,000 live births Reduction of TFR to 2.1 Prevention and reduction of under-nutrition in children under 3 years to half of NFHS-3 (2005–06) levels Prevention and reduction of anemia among women aged 15–49 years to 28% Raising child sex ratio in the 0- to 6-year age group from 914 to 950 Prevention and reduction of burden of communicable and noncommunicable diseases (including mental illnesses) and injuries Reduction of poor households’ out-of-pocket expenditure.

National Health Goals for Communicable Disease in the 12th Five-Year Plan The national health goals for communicable disease in the 12th Five-Year Plan are given in Table 2.2.

Summary of Investment during Annual and Five-Year Plan The summary of investment during Annual and Five-Year Plan has been given in Table 2.3. Table 2.2: National health goals for communicable disease in the 12th Five-Year Plan Diseases

Goals

Tuberculosis

Reduce annual incidence and mortality by half

Leprosy

Reduce prevalence to