Community and Public Health for MLS 1

Health Care Delivery System

Introduction: • Consist of all organizations, people, and actions whose primary
The Philippines intent is to promote, restore, or maintain health
• an archipelago with 7,100 islands Has 6 building blocks or components:
• has a population of around 97 million in 2012 1. Service delivery
• a population growth rate of 1.9%. 2. Health workforce
Geographically 3. Information
• it is divided into three main islands: 4. Medical products, vaccines, and technologies
o Luzon 5. Financing
o Visayas 6. Leadership and governance or stewardship
o Mindanao Health Care System
• There are 17 regions, including the Autonomous Region of • an organized plan of health services (Miller-Keane, 1987)
Muslim Mindanao (ARMM), 82 provinces, 135 cities, and 1,493
municipalities. Health Care Delivery
Functional literacy rate • rendering health care services to the people (Williams-Tungpalan,
• high at 86%. In 2011, 1981).
• the country was categorized as a low-to middle-income Health Care Delivery System
country with gross national income per capita of $4,160. • the network of health facilities and personnel which carries out
The Decentralized Health Care System the task of rendering health care to the people. (Williams-
• managed, coordinated and regulated by the Department of Tungpalan, 1981)
Health (DOH) Philippine Health Care System
Department of Health (DOH) that is composed of • is a complex set of organizations interacting to provide an array
• the Central Office of health services (Dizon, 1977).
• 17 Regional Offices (ROs) Department of Health (DOH)
• retained hospitals. • serves as the main governing body of health services in the
Integrated basic health services are provided by: country
• 2,314 rural health units (RHUs)/health centers (HCs) • responsible for ensuring access to basic public health services to
• 16,219 barangay health stations (BHS) all Filipinos through the provision of quality care and regulation of
• Under the local municipal/city government units. providers of health goods and services
The locally-managed provincial health office (PHO)/city health office The Department of Health shall be responsible for the following:
(CHO) • formulation and development of national health policies, guidelines,
• provides technical oversight over these peripheral health standards and manual of operations for health services and
units. programs
Communities • issuance of rules and regulations, licenses and accreditations
• support these health units through the community health • promulgation of national health standards, goals, priorities and
teams (CHTs) that include barangay health workers (BHWs). indicators
The private sector • development of special health programs and projects and
• also engaged in the production and provision of health goods advocacy for legislation on health policies and programs
• services through private clinics, hospitals and laboratories,
drugstores, and other facilities. The primary function of the Department of Health is
The DOH encourages… the promotion, protection, preservation or restoration
• public-private sector collaboration in health. of the health of the people through the provision and
DOH priorities and strategies: delivery of health services and through the regulation
• are contained in its health agenda called Universal Health Care and encouragement of providers of health goods and
(UHC) or Kalusugang Pangkalahatan (KP) services (E.O. No. 119, Sec. 3).
Universal Health Care (UHC) or Kalusugang Pangkalahatan (KP)
• aims to ensure financial risk protection for the poor, provide VISION:
access to quality health services “Health as a right. Health for all Filipinos by the year 2000 and
• attain health-related Millennium Development Goals (MDGs). Health in the Hands of the People by the year 2020.”
National Objectives for Health. MISSION:
• Specific health targets including that for TB control “In partnership with the people to ensure equity, quality and
access to health care by:”
• making services available
• arousing community awareness
• mobilizing resources
• promoting the means to better health
 Community and Public Health for MLS 2

In the pursuit of its vision and execution of its mission the DOH has the 1.
Laboratory
following major roles: 2.
Radiologic
• Leader in health 3.
Nuclear medicine
• Enabler and capacity builder D. Specialized out-patient facility
• Administrator of health services • dialysis clinic, ambulatory surgical clinic, cancer
chemotherapeutic center/clinic, cancer radiation facility, and
The Philippine Health Care Delivery System physical medicine and rehabilitation center/clinic.
Devolution The Rural Health Unit
• refers to the act by which the National Government confers •
Commonly known as a health center, a primary level health
power and authority upon the various LGUs to perform facility in the municipality
specific functions and responsibilities. Focus: preventive and promotive health services and the supervision of
BHSs under its jurisdiction
RA 7160 : LOCAL GOVERNMENT CODE OF 1991
• Recommended ratio of RHU to catchment population is 1
• Legal basis of Devolution
RHU:20,000 population (DOH, 2009)
• It devolved the following basic services:
o Agriculture Barangay Health Station
o Forest Management • The BHS is the first-contact health care facility that offers
o Health Services basic services at the barangay level.
o Social Welfare • It is a satellite station of the RHU.
o Barangay Level Roads • It is manned by volunteer BHWs under the supervision of RHM.
• LGUs were given increased powers to mobilize resources The RHU Personnel
Devolution of basic health services A. The MHO or Rural Health Physician heads the health services at
• LGUs have the autonomy and responsibility to plan and the municipal level and carries out the following roles:
implement basic health services • Administrator of the RHU
Provincial gov’ts • Community Physician
• provincial and district hospitals • Medico-legal officer of the Municipality
Municipal and city gov’ts The revised IRRs of RA 7305 or the Magna Carta of Public Health
• primary care through RHUs or health center Workers
2 MAJOR PLAYERS OF HEALTH SERVICE DELIVERY • stipulate that there be 1 rural health physician to a population of
a. Public Sector 20,000.
B. Public Health Nurse (PHN)
• Is financed through a tax-based budgeting system at both
1. Supervise and guides all RHMs in the municipality;
national and local levels where health care is generally given
2. Utilizes the nursing process in responding to health care
free at the point of service
needs, including needs for health education and promotions of
• The DOH is the leading health agency
individuals, families, and catchment of community;
• Regional, local health care centers, and the PGH
3. Collaborates with the other members of the health team,
b. Private Sector government agencies, private business, NGOs, and people’s
• Consists of the profit and non-profit providers organizations to address the community’s health problems.
• It is market-oriented and where health care is paid through C. RHM (1 RHM:5,000 population)
user fees at the point of service 1. Manages the BHS and supervises and trains the BHW;
2. Provides midwifery services and executes health care
Classification of Health Facilities programs and activities for women of reproductive age,
A. According to ownership including FP counseling and services;
a. Government 3. Conducts patient assessment and diagnosis for referral or
b. Private further management;
B. According to scope of services 4. Performs health information, education, and communication
a. General Facilities/Hospitals activities;
•
PGH, JRMMC 5. Organizes the community; and
b. Specialty Centers/Hospitals 6. Facilitates barangay health planning and other community
health services
• PHC, NKTI
D. Rural Sanitary Inspector
Other Health Facilities: • Directed towards ensuring a healthy physical
A. Primary Care Facility environment in the municipality
• health centers, dental clinics, infirmaries, lying-in facilities • This entails advocacy, monitoring, and regulatory
B. Custodial care facility activities such as inspection of water supply and
• custodial psychiatric facilities, substance/drug abuse unhygienic household conditions
treatment and rehabilitation centers, sanitaria/leprosaria, and E. Barangay Health Workers
nursing homes
C. Diagnostic/Therapeutic facility
 Community and Public Health for MLS 3

• Are trained in preventive health care, with strong emphasis •

the patient is referred to another MD, once accepted, the
on maternal and child care, FP and reproductive health, referring MD has no more responsibility in the patient
nutrition, and sanitation. 4. Split Referral
1. BHW: 20 households • the responsibility is divided between 2 or more MD
Local Health Boards TWO-WAY REFERRAL SYSTEM (Niace, et. al. 8th edition 1995)
RA 7160 or Local Government Code • A two-way referral system need to be established between
• It mandates devolution of basic services from the national each level of health facility
government to LGUs. • e.g. barangay health workers refer cases to the rural health
DEVOLUTION team, who in turn refer more serious cases to either the
• is the act by which the national government confers power district hospital, then to the provincial, regional or the whole
and authority upon the various LGUs to perform specific health care system.
functions and responsibilities.
RA 7160
• provided for the creation of the Provincial Health Board and
the City/Municipal Health Boards, or the Local Health Boards.
Chairman of the Board is the local executive Health Promotion
• Provincial Governor/Mayor Green and Kreuter, 1991
A. Vice Chairman • Any combination of health education and related
• Provincial/City/Municipal Health Officer organizational, economic and environmental supports for
B. Members behavior of individuals, groups or communities conducive to
• Chairman of the committee on health of the Sanggunian, health (Green and Kreuter, 1991)
representative from the private sector or NGO involved in • Behavior that is motivated by the desire to increase well-
health services, and a representative from the DOH. being and to reach the best possible health potential (Parse,
Functions: 1990) Health Protection
• Proposing to the Sanggunian annual budgetary allocations for • Refers to behaviors in which one engages with the specific
the operation and maintenance of health facilities and intent to prevent disease, to detect disease in the early
services within the province/city/municipality; stages, or to maximize health within the constraints of
• Serving as an advisory committee to the Sanggunian on health disease (Parse, 1990)
matters; and Example:
 immunization- protects against specific diseases
• Creating committees that shall advise local health agencies on
 cervical cancer screening- early detection
various matters related to health service operations.
RISK AND HEALTH
REFERRAL
• is a set of activities undertaken by a health care provider or
Risk
Oclekno,2002
facility in response to its inability to provide the necessary
health intervention to satisfy a patient’s need. • the probability that a specific event will occur in a given time
frame
MAY BE INTERNAL OR EXTERNAL
A. Internal RISK FACTOR
• occur within the health facility; from one health personnel to Friis, 2004
another • an exposure that is associated with a disease
B. External
• movement of patient from 1 health facility to another 3 CRITERIA FOR ESTABLISHING A RISK FACTOR:
Referral System 1. The frequency of the disease varies by category, or amount of
the factor.
• An organizational structure for coordinating, linking, and
2. The risk factor must precede the onset of the disease.
transferring responsibility of care.
3. The association concern must not be due to any source of error.
May be done by:
• a generalist to a specialist Other criteria by Friis and Sellers (2004)
• a specialist to a specialist • Strength of the associatio
• one hospital to another • Consistency with repetition
Types of Referrals • Specificity
1. Interval Referral • Plausibility
• the patient is referred for complete care for a limited period
2. Collateral Referral
• the referring medical doctor retains overall responsibility but
refers patient for care of some specific problems
3. Cross Referral
 Community and Public Health for MLS 4

RISK ASSESSMENT • The problem of being overweight and obese in the country is
• is a systematic way of distinguishing the risks posed by potentially alarmingly increasing in number, affecting about 7 out of 10
harmful exposures. women and about 1 out of 10 men.
4 Main Steps of Risk Assessment • Obesity affecting Filipino adults is known as the android or apple-
Savitz, 1998 shaped type, where abdominal fat accumulation is measured
using waist-to-hip ratio.
1. Hazard identification
2. Risk description • WHR recommended by the WHO is considered as a sensitive
3. Exposure assessment measure for risk to cardiovascular diseases.
4. Risk estimation Food and Nutrition Research Institute – FNRI, 2012
• ≥ 1.0 in men or ≥ 0.85 in women is considered android or apple-
The relationship of risk to health and health promotion activities: shaped obese
• Health is directly related to the activities in which we participate, Centers for Disease Control and Prevention, 2011
the food we eat, and the substances to which we are exposed • An individual’s body weight is determined by a
daily. complex interplay among metabolism, genetics, behavior, environment,
• Gender, age, genetic make-up, and environment impact health culture, and socioeconomic status, making the problem of being
overweight a difficult one to study and to impact
2 TYPES OF RISKS
Modifiable risk factors PHYSICAL ACTIVITY AND HEALTH
• those aspects of health risk over which an individual has some Reasons why people engage in physical activity:
control. • to achieve weight management
Example: • increased energy
 smoking, a sedentary or active lifestyle, type and amount of food • better appearance
eaten, and type of activities in which one engages
• to fit into favorite clothes
Nonmodifiable risk factors • to prevent development or worsening of a chronic health
• are those aspects of risk over which one has little or no condition
control • to manage stress
Example: • to improve mood and self-esteem
 genetic makeup, gender, age, and environmental exposures
FNRI, 2008
• The physical activity of Filipino adults aged 20 years and above is
RISK REDUCTION
low.
Pender, 1996
o About 92.7% have low leisure-related physical activity.
• is a proactive process in which individuals participate in behaviors o About 94.5% have low travel-related physical activity.
that enable them to react to actual or potential threats to their o 75.4% have low nonwork-related physical activity.
health o 76.3% have low work-related physical activity.
RISK COMMUNICATION Clean Air Asia has developed a tool to rate Asian cities for
•the process through which the public receives information suitability for walking:
regarding possible or actual threats to health a. Walking path modal conflict:
•
Extent of conflict between pedestrians and other modes on the
Health risk sources:
road, such as bicycles, motorcycles and cars.
o health care professionals
b. Availability of walking paths
o internet
c. Availability of crossings
o newspapers, periodicals, radio, TV, billboards
d. Grade crossing safety:
Note: • the exposure to other modes when crossing roads, time spent
(Finnigan and Vinswanath, 2008). waiting and crossing the street and the amount of time given to
• Although the purpose of these sources is information pedestrians to cross intersections with signals
e. Motorist behavior
dissemination so that people can participate in risk reduction,
f. Amenities
risk communication is affected by the way g. Disability infrastructure
• individuals and communities perceive, process, and act on their h. Obstructions
understanding of risk i. Security from crime

DIET AND HEALTH SLEEP

• Diet is one of the most modifiable of risk factors. • Is an essential component of chronic disease prevention and
health promotion
• A healthy diet contributes to the prevention of chronic diseases
such as type 2 diabetes, hypertension, heart disease, and some • As we age, sleep is often interrupted by pain, trips to the
cancers. bathroom, medications, medical conditions, and sleep disorders.
 Community and Public Health for MLS 5

How much sleep do you really need? ALCOHOL CONSUMPTION AND HEALTH
AGE SLEEP NEEDS • Alcohol is the most commonly abuse drug.
Newborns (1-2 months) 10.5-18 hours In 2003-2005s
Infants (3-11 months) 9-12 hours during night and • consumption of alcohol by Filipinos age 15 years and older was
30-minute to 2-hour naps, 1-4 estimated at 6.4 liters per capita.
times • Drinkers had a per capita consumption17 liters with:
a day o male drinkers consuming 19 liters
Toddlers (1-3 years) 12-14 hours o female drinkers 10.9 liters.
Preschoolers (3-5 years) 11-13 hours A drink is the amount of any alcoholic beverage that delivers half-
School-aged children 10-11 hours
(5-12 years)
ounce (around 15 mL) of pure ethanol, which is equivalent to the
Teens (11-17 years) 8.5-9.25 hours following:
Adults and older adults 7-9 hours • 4-5 ounces (around 120-150 mL) of wine
• 10 ounces (around 300 mL) of cooler
Sleep Requirement
• 12 ounces (around 360 mL) of beer
• Change as people age depending on life circumstances
• 1.25 ounces (around 40 mL) of distil ed liquor
• One may require more than the minimum hour listed if the
• (80 proof of whisky, scotch, rum, or vodka)
person is tired and sleepy that it interferes its daily activity
then he/her need more sleep
FACTS:
The need for sleep is regulated by two processes: LIVER
a. The number of hours we are awake
o can process about half-ounce ethanol per hour depending on
b. Circadian biological clock in the brain, the suprachiasmatic nucleus,
the person’s body size, previous drinking experience, food
which responds to light
intake, and general health.
o The circadian rhythm is why we are sleepiest between 2:00 and
4:00 am and in between 1:00 and 3:00pm. One practical tip:
o drink slowly enough to allow the liver to keep up which is no
Practicing sleep hygiene will help achieve optimum sleep more than 1 drink per hour.
National Sleep Foundation,2010
1. Avoid caffeine and nicotine close to bedtime.
Moderation
Health authorities defined
2. Avoid alcohol as it can cause sleep disruptions.
• as not more than two drinks a day for man and not more than
3. Retire and get up at the same time every day.
one drink a day for woman.
4. Exercise regularly, but finish all exercise and vigorous activity at
least 3 hours before bedtime.
5. Establish a regular, relaxing bedtime routine (a warm bath, reading DEFINITION OF TERMS:
a book) HEAVY DRINKING
6. Create a dark, quiet, cool sleep environment. • consuming more than 2 drinks per day on average for men or
7. As much as circumstances allow, have comfortable beddings. more than 1 drink per day for women
8. Use the bed for sleep only; do not read, listen to music, or watch
TV in bed. BINGE DRINKING
9. Avoid large meals before bedtime. • drinking 5 or more drinks on a single occasion for men or 4 or
more drinks on a single occasion for women
TOBACCO AND HEALTH RISK EXCESSIVE DRINKING
• Smoking cessation is an important step in achieving optimum • take the form of heavy drinking, binge drinking, or both.
health. Those who should not drink at all include:
• The economic impact is estimated at 1-2% of GDP spent for
tobacco-related disease, loss productivity and death. CDC,2011
Prevalence rate (age 15 and older): 28% • Pregnant or trying to become pregnant women
o 48% male • People taking prescription or OTC medication that may cause
o 9% female harmful reactions when mix with alcohol
• Smokers who are trying to quit experience withdrawal • People younger than 21 years
symptoms such as anxiety, increased appetite, irritability, and • People recovering from alcoholism or are unable to control the
difficulty concentrating. amount that they drink
• Nicotine replacement, pharmaceutical alternatives, hypnosis, • People suffering from a medical condition that may be worsened
and acupuncture may be helpful in the attempt to quit by alcohol.
smoking. • Anyone driving, planning to drive or participating in other activities
requiring skills, coordination, and alertness.
 Community and Public Health for MLS 6

THE OTTAWA CHARTER FOR HEALTH PROMOTION • HP works through concrete and effective community actions
in setting priorities, making decisions, planning strategies, and
implementing them to achieve better health.
• At the heart of this process is the EMPOWERMENT OF THE
COMMUNITIES
EMPOWERMENT OF THE COMMUNITIES
• their ownership and control of their own endeavors and
destinies.
4. Develop personal skills.
• HP supports personal and social development through providing
information education for health and enhancing life skills.
• It increases the options available to people to exercise more
control over their health and their environments to make
choices conducive to health.
Organized by the WHO 5. Reorient health services.
• the first International Conference on Health Promotion was held • The responsibility for HP in health services is shared among
at Ottawa, Canada on Nov. 17-21, 1986 individuals, community groups, health professionals, health
• The charter signed calls for a commitment to health promotion service institutions and governments.
to achieve the goal of Health for All by the year 2000 and • They must work together towards a health care system that
beyond. contributes the pursuit of health.

HEALTH PROMOTION
• It is a process of enabling people to increase control over and HEALTH EDUCATION
to improve their health, which requires that an individual or • It is the process of changing people’s knowledge, skills, and
group must be able to identify and realize aspirations, to satisfy attitudes for health promotion and risk reduction.
needs, and to change or cope with the environment. Philippine Heath Workers (PHW) participates in health
PREREQUISITES: education…
• Fundamental conditions and resources for health are: • By empowering people so that they are able to achieve
o Peace optimum health and prevent disease by bringing about lifestyle
o Shelter changes and reducing exposure to health risk in the
o Education environment
o Food • Health Education (HE) includes risk communication.
o Income
o Stable ecosystem PATIENT EDUCATION
o Sustainable resources • usually refers to a series of planned teaching-learning activities
o Social justice and equity design to individuals, families, or groups with an identified
3 Basic Strategies for Health Promotion: alteration in health
1. Advocacy for health to provide for the conditions and resources Purpose:
essential for health • aid the client in coping the event, to prevent complications or
2. Enabling all people to attain their full health potential. deterioration of the client’s condition, and, in cases of
3. Mediating among the different sectors of society in efforts to communicable diseases, the prevent transmission of the disease
achieve health.
HEALTH EDUCATION PATIENT EDUCATION
• Teaching a woman on the • Instructing the mother
5 Priority Action Areas:
need for regular prenatal how to prepare and
1. Build healthy public policy. consultations, administer oral
• HP puts health on the agenda of policy-makers in all sectors rehydrating solution to a
and at all levels, directing them to be aware of health • Instructing a family on child with diarrhea
consequences of their decisions and to accept the the methods of water • Conducting a group
responsibilities for health. purification that can be session on diabetic care
2. Create supportive environment. done at home in
• The inextricable links between people and their environment instances when water
constitute the basis for socio-ecological approach to health. sanitation is uncertain
• The overall guiding principle for the world, nations, regions, and
communities alike is the need to encourage reciprocal • Holding a class on
maintenance. breastfeeding for first-
3. Strengthen community actions. time pregnant women
 Community and Public Health for MLS 7

Basic principles that guide the effective PH educator

Stanhope & Lancaster, 2010
1. Message
2. Format
3. Environment
4. Experience
5. Participation
6. Evaluation
Effectiveness of Health Education:
• Printed materials, audiovisual presentations, face-to-face
lecture-discussions, demo with return demo, and online
resources
ners
(developmental and educational levels)
ms

Competency-Based Training of Community Health

Worker /Barangay Health Workers
CHWs in the Philippines BHWs
Role of CHWs:
• to develop competencies that will enable them to provide
primary care services to their own community or
neighborhood
• must be knowledgeable about the community, health issues
such as common illnesses and communicable diseases, and
available resources including the referral system
 Community and Public Health for MLS 8

b. High Fowler’s
o Head of bed raised at 80-90 degrees angle.

5. Lithotomy
CHAPTER 1: HEALTH MANAGEMENT AND • Back-lying position with feet supported in stirrups
PHYSICAL EXAMINATION 6. Genupectoral/Knee-Chest Kneeling position
• with torso at 90 degrees angle to hip
HEALTH ASSESSMENT VS PHYSICAL EXAMINATION
Health Assessment 7. Lateral/Side-lying position
• is a collection of data about an individual’s health 8. Sim’s position/Semi prone position
Physical Examination
• is a head to toe review of each body system that offers 9. Prone/Face lying position
objective information about the client and allows the health • with the head turned to side; aka abdominal-lying position
care provider to make clinical judgments.
A comprehensive health assessment encompasses the dimensions
of a person:
• Physical
• Psychological
• Social
• Spiritual

Purpose of Health Assessment:

1. To make a clinical judgment or diagnosis about the individual’s
health state or condition.
2. To obtain baseline data about the client’s functional abilities.
Purpose of Physical Examination:
1. For routine screening to determine the client’s eligibility for
health insurance
2. For acquiring a new job
3. For client’s admission to the hospital

Modes of Examination
Inspection: Assessing using the sense of sight.
Palpation: Examining the body using the sense of touch. Use the fat
pads of the fingers.
Assessing the general appearance and behavior of
Percussion: Tapping body parts to produce sounds. an individual:
• Age, sex, race
Auscultation: Listening to body sounds with the use of stethoscope • Body built, height, weight: in relation to the client’s age, lifestyle
and health
Positions in Physical Examination • Posture and gait
1. Dorsal Recumbent • Hygiene and grooming
• Back lying position with knees flexed and hips externally • Body and breath odor
rotated.
• Signs of distress
2. Dorsal/Supine • Obvious sign
• Back lying position with or without a pil ow. • Attitude
• Affect and mood
3. Sitting or seated position • Speech
• Back unsupported and legs hanging freely.
• Thought process
4. Fowler’s position
a. Semi-Fowler’s
o Head of bed is elevated 15-45 degrees angle.
 Community and Public Health for MLS 9

Laboratory and Diagnosis Examinations Assessing Vital Signs

Specimen used: vital signs or cardinal signs
1. Urine • body temperature
2. Stool • Pulse
3. Blood • respiration and;
4. Other body secretions • blood pressure

Framework for Health Assessment A. Body Temperature

A. Functional Health Framework Types of Body Temperature:
• Evaluates the effects of the mind, body and environment in 1. Core Temperature
relation to a person’s ability to perform the task of daily living. • Temperature of the deep tissue of body
• Measured by taking oral and rectal temperature
Data Collection in termS of Gordon 11 Functional Patterns:
1. Health perception and health management 2. Surface Temperature
2. Activity and exercise • Temperature of the skin, subcutaneous tissue and fat
3. Nutrition and metabolisms • Measured by taking axillary temperature
4. Elimination • Body heat is primarily produced by metabolisms
5. Sleep and rest • The Heat regulating center is found in the Hypothalamus
6. Cognition and perception
7. Self-perception and self -concept Factors affecting the body’s heat production are as
8. Roles and relationships follows:
1. Basal Metabolic Rate (BMR)
B. Head to Toe Framework • The younger the person, the higher the BMR; the older the
person, the lower the BMR
• Collecting data from head and systematically to toe
• Therefore, the older persons have lower BT than the young
(Cephalo-Caudal Manner) person.
1. General health state: Vital sign, weight, nutritional status
2. Head: hair, scalp, eyes, ears, oral cavity, cranial nerves 2. Muscle Activity (exercise, swimming)
• Increases cellular metabolic rate. Therefore, exercise
3. Neck
increases body heat temperature.
4. Chest
5. Abdomen 3. Thyroxin Output
6. Extremities • Increase cellular metabolic rate (chemical thermogenesis)
7. Genitals • Hyperthyroidisms is characterized by increase body
8. Rectum temperature.

4. Epinephrine, norepinephrine and sympathetic stimulation

C. Body System Framework • Increase the cellular metabolisms. These in turn increase body
• This may be used during assessment especially among acutely and temperature.
critically ill clients/patient
o Respiratory 5. Increase temperature of the body cells (fever)
o Cardiovascular • increases the rate of cellular metabolisms
o Musculoskeletal
o Gastrointestinal Processes Involved in Heat Loss:
o Integumentary A. Radiation
o Endocrine • the transfer of heat from the surface of one object to the
o Reproductive surface of another without contact between two objects
o Psychosocial Example: It feels warm in a crowded room
o Neurologic
B. Conduction
o Sensory
• the transfer of heat from one surface to another
• It requires temperature difference between the two
surfaces
Example: Application of moist wash-cloth over the skin
 Community and Public Health for MLS 10

C. Convection 2. Remittent Fever

• the dissipation of heat by air currents • The temperature fluctuates within a wide range over the
Example: Exposure of the skin towards the electric fan 24-hour period but remains above normal range.

D. Evaporation 3. Relapsing Fever

• the continuous vaporization of moisture from the skin, oral • The temperature is elevated for few days, alternated with
mucus, respiratory tract (also insensible heat loss) 1- or 2-days normal temperature.
Example: Tepid Sponge bath increases peripheral circulation, thereby
increasing heat loss by evaporation. 4. Constant Fever
• Body temperature is consistently high. Very high fever
Factors affecting Temperature are: temperatures (41-42°C)
1. Age.
• The infant’s body temperature is generally affected by the Decline of Fever
temperature of the environment.
• Elder people are at risk of hypothermia due to: 1. Crisis of flush or defervescence stage
• the sudden decline of fever
o decreased thermoregulatory controls • indicates impairment of function of the hypothalamus
o decreased subcutaneous fat
o inadequate diet 2. Lysis
o sedentary activity • the gradual decline of fever
• indicates that the body is able to maintain homeostasis; the
2. Diurnal variations desired decline of fever
• Highest temperature is usually reached between 8:00 p.m to
12:00 noon
• the lowest temperature is reached between 4:00-6:00 a.m
Clinical Signs of Fever
A. Onset (cold or chill stage) of fever
3. Exercise • increased heart rate
• increased respiratory rate and depth
4. Hormones • Shivering
Example: progesterone, thyroxine, norepinephrine, and epinephrine • pale, cold skin
increase body temperature, estrogen decreases body temperature • Cyanotic nail bed
• complaints of feeling cold
5. Stress • “goose flesh” appearance of the skin
• cessation of sweating
Alterations in Body Temperature • rise in body temperature
1. Pyrexia
• body temperature above normal range B. Course of Fever
o Hyperthermia • absence of chills
o Fever • skin that feels warm
• feeling of being neither hot nor cold
2. Hyperpyrexia • increased pulse and respiratory rates
• Very high fever • increased thirst (mild to severe dehydration)
o 41°C (105.8 F) and above • drowsiness, restlessness, delirium and convulsions
• herpetic lesions of the mouth (fever blisters)
3. Hypothermia • loss of appetite
• subnormal core body temperature • malaise, weakness and aching muscles
• this may be caused by:
o excessive heat loss C. Defervescence (Fever abatement)
o inadequate heat production • skin that appears flushed and feels warm
o impaired hypothalamic function • sweating
• decreased shivering
Types of Fever • possible dehydration
1. Intermittent fever
• The temperature fluctuates between periods of fever and Interventions in clients with fever:
periods of normal/subnormal temperature. • Provide Tepid Sponge Bath (TSB)
• Administer antipyretics (38°C and above)
 Community and Public Health for MLS 11

• Tachycardia. PR above 100 beats/min. (Adult)

B. PULSE • Bradycardia. PR below 60 beats/min. (adult)
• It is a wave blood created by contraction of the left ventricle
of the heart. 2. Rhythm
• The pulse rate is regulated by the autonomic nervous system • The pattern and intervals of beat
(ANS) • Dysrhythmia à irregular rhythm

3. Volume (Amplitude)
Factors Affecting the Pulse RatES: • A normal pulse can be felt with moderate pressure.
1. AGE • Full or bounding pulse à It can be obliterated only by great
• Younger persons have higher pulse rate than older persons pressure
• Thready pulse à It can easily be obliterated (also weak, feeble)
2. Sex/Gender
• Puberty females have higher pulse rate than the males 4. Arterial Wall Elasticity
• The artery feels straight, smooth, soft and pliable.
3. Exercise
4. Fever 5. Presence/Absence of bilateral equality
• Absence of bilateral equality indicates cardiovascular disorder
5. Medications
• Digitalis, beta blocker decreases pulse rate; epinephrine, C. Respiration
atropine sulfate increase pulse rate • The act of breathing

6. Hemorrhage Three (3) Process:

• Increase pulse rate as compensatory mechanisms for the 1. Ventilation
blood loss • The movement of gases in and out of the lungs.
o Inhalation (Inspiration)
7. Stress o Exhalation (Expiration)
• Sympathetic nervous stimulation increases the activity of the
heart. 2. Diffusion
• The exchange of gases from an area of higher pressure to
8. Position changes an area of lower pressure.; it occurs at the alveolo-capillary
• In sitting or standing position there is a decreased venous membrane.
return to the heart
• decreases BP 3. Perfusion
• increases in the heart rate. • The availability and movement of blood for transport of gases,
nutrients and metabolic waste products.
PULSE SITES
1. Temporal Two Types of Breathing
2. Carotid 1. Costal (thoracic)
3. Apical • Involves movement of the chest
4. Brachial 2. Diaphragmatic (abdominal)
5. Radial • Involves movement of the abdomen
6. Femoral
7. Posterior Tibia Respiratory Centers
8. Popliteal 1) Medulla oblongata
9. Pedal (Dorsalis pedis) • the primary respiratory center

Assessment of the Pulse 2) Pons contains the following:

1. Rate a. Pneumotaxic center
• The normal rates per minute: o responsible for the rhythmic quality of breathing
o NB to 1 mo - - - - - - - - 80-180 beats /min b. Apneustic center
o 1 year - - - - - - - - - - - - 80-140 beats /min o responsible for deep, prolonged inspiration
o 2 years - - - - - - - - - - - 80-130 beats/min
o 6 years- - - - - - - - - - - - 75-120 beats/min 3. Carotid and Aortic bodies contain peripheral chemoreceptors
o 10 years - - - - - - - - - - - 60-90 beats/min
o Adult - - - - - - - - - - - - - 60-100 beats/min
 Community and Public Health for MLS 12

• These take up the work of breathing, when central

chemoreceptors in the medulla oblongata are damaged.
Diastolic Pressure
• Respond to low oxygen concentration in the blood. • is the pressure when the ventricles are at rest (60-90 mmHg)
• Responds to the pressures
Pulse pressure
Assessing Respiration • is the difference between the systolic and diastolic pressures
Rate: (30-40 mmHg)
• Normal: 12-20/minute in adult

Depth:
Determinants of Blood Pressure
1. Blood volume
• Observe the movement of the chest. o Hypervolemia raises BP.
• May be normal, deep and shallow o Hypovolemia lowers BP.
Rhythm: 2. Cardiac Output
• Observe for regularity of exhalations and inhalations • When the pumping action of the heart is weak (decreased CO),
BP decreases.
Quality or character:
• refers to respiratory effort and sound of breathing 3. Elasticity or Compliance of Blood Vessels
• In older people, elasticity of blood vessels decreases thereby
Major Factors Affecting Respiratory Rate increasing BP.
1) Exercise
4. Peripheral resistance
2) Stress
o Vasoconstriction elevates BP
3) Environment. o Vasodilation lowers BP
• high temp = decrease RR
• low temp = increase RR 5. Blood Viscosity (viscosity increases markedly
• when the Hct is more than 60-65%)
4) Medications (e,g narcotics decrease RR) • Increased blood viscosity raises BP
Must Know.... 6. Sex/Gender
Eupnea - normal respiration • After puberty and before age 65 years , male have higher BP
Tachypnea - rapid respiration, above 20 breaths per minute in adult • After age 65 years, females have higher BP due to hormonal
variations in menopause
Bradypnea - slow breathing, less than 12 breaths/minute in adult
7. Medications
Dyspnea - difficult and labored breathing
Orthopnea - Ability to breath only in upright position. 8. Diurnal Variations
• BP is lowest in the morning and highest in the late afternoon or
Apnea – absence of respirations early evening.
Platypnea – difficulty of breathing in an upright position
9. Diseases Process
Hyperventilation – deep rapid respiration, CO2 excessively exhaled • Diabetes Mellitus, Renal Failure, Hyperthyroidism, Cushing’s
Diseases cause increase BP.
(respiratory alkalosis).
Hypoventilation – slow, shallow respiration, CO2 excessively retained Factors Affecting Blood Pressure
(respiratory acidosis) 1. Age
• Older people have higher BP due to decreased elasticity of blood
vessels.
D. Blood Pressure
• is the measure of the pressure exerted by blood as it pulsates 2. Exercise
• Increase cardiac output, hence increase BP.
through the arteries.
3. Stress
Systolic Pressure • Sympathetic nervous system stimulation causes increased BP.
• is the pressure of blood as a result of contraction of the
ventricles (100-140 mmHg)
4. Race
5. Obesity
 Community and Public Health for MLS 13

CHAPTER 2: COMMUNITY ORGANIZING: 3. Deciding an appropriate course of actions or responses

ENSURING HEALTH IN THE HANDS OF THE 4. Mobilization of resources to address these needs, and
PEOPLE 5. Monitoring and evaluation by the people

COMMUNITY ORGANIZING 3 BASIC VALUES

Manalili, 1990 1. Human rights
• based on the worth and dignity inherent to all human beings
• As a process, consist of steps or activities that instil and o the right to life
reinforce the people’s self-confidence on their own collective o the right to development as persons, and as a
strengths and capabilities community
o the freedom to make decisions for oneself
• It is the development of the community’s collective capacities to
solve its own problems and aspire for development through its
own efforts. 2. Social justice
• entails fairness in the distribution of resources to satisfy
• It entails harnessing and developing the community’s capacities basic needs
to recognize a community problem, identify and implement • to maintain dignity as human beings
solution, and monitor and evaluate the efforts in resolving the Equitable access to opportunities for satisfying people’s basic needs and
problem. dignity; it requires equitable distribution of resources and power through
people’s participation in their own development
• It is a continuous process of educating the community.

• It is a means to build the community’s capacity to work for the 3. Social responsibility
common goal in general and health goals in particular. • an offshoot of the ethical principle of solidarity, which points to
people being part of one community and is reflected in concern
of one another
Emphases of Community Organizing in Primary
Health Care CORE PRINCIPLES IN COMMUNITY ORGANIZING
1. People from the community working together to solve their own • Community Organizing is PEOPLE-CENTERED
problems (Collaboration)
• Community Organizing is PARTICIPATIVE
2. Internal organizational consolidation as a prerequisite to external • Community Organizing is DEMOCRATIC
expansion
(organizer should have a well-established internal organization) • Community Organizing is DEVELOPMENTAL
• Community Organizing is PROCESS-ORIENTED
3. Social movement first before technical change
(Social transformation)
A. Community organizing is People-centered
4. Health reforms occurring within the context of broader social
transformation (Felix, 1998)
• the people are the means and ends of development and
community empowerment is the process and the outcome
COMMUNITY DEVELOPMENT
• improved access to resources (including health resources) that • with emphasis on the development of human resources
will enable the people to improve their standard of living and • Community Organizing is a process that promotes the
overall quality of life.
development of people’s autonomy and self-reliance, leading to
people empowerment.
END GOAL of COMMUNITY ORGANIZING:
• Community development • the organizer must bear in mind that the community is an active
• participation of the basic sector or stakeholders participant, learning more from what they do and experience,
rather than from what is said to them.

COMMUNITY DEVELOPMENT PROCESSES: • For people empowerment, community participation is a critical

condition for success.
1. Assessment of the current situation
2. Identification of needs
 Community and Public Health for MLS 14

B. Community organizing is Participative • Referrals from other communities or institutions or through a

• The participation of the community in the entire process- series of meeting
assessment, planning, implementation and evaluation- should be
ensured. • Consultation from the local government units (LGUs) or private
institutions.
• The community is considered as the prime mover and
determinant, rather than beneficiaries and recipients, of ocular survey
development efforts, including healthcare.
• may provide answers to essential questions that should include
• Decision making and responsibility are in the hands of ordinary the following:
people, not just the elite. o Does the community meet the “GIDA” criterion of the DOH?

o Do the members of the community perceive the need for

C. Community organizing is Developmental
assistance?
• Community organizing should be directed towards changing
current undesirable conditions. o Does the community show sign of willingness or hostility towards
the organizer of the organizing agency?
• Through the process, the community gains insights, hones their
capacities and develops their confidence in themselves and each o Is there no obvious threat to the safety of the community
other that will allow them to take the lead in the holistic organizer?
improvement of their community.
o Are there other individual, groups or agencies working in the area?
If so, are they using the community organizing approach? Will there
D. Community organizing is Process-oriented be duplication of services for the same target group?
• The community organizing goals of empowerment and
o Is the partnership among all potential stakeholders
development are achieved through a process of change.
• Community organizing is dynamic.
2. Entry into the Community
• With the evolving community situation, monitoring and periodic • Formalizes the start of the organizing process
review of plans are necessary.
• Stage where the organizers gets to know the community and
PHASES OF COMMUNITY ORGANIZING the community likewise gets to know the organizer

1) Pre-retry 6) Core Group Formation • Important point: make courtesy calls to local formal and informal
2) Entry into the community 7) Community Organization
3) Community Integration 8) Action Phase leaders
9) Evaluation
(Pakikipamuhay)
4) Social Analysis
10) Exit and Expansion Considerations in the Entry Phase
5) Identifying Potential Leaders
• Community organizer’s responsibility to clearly introduce
1. Pre-entry themselves and their institution to the community
• It involves preparation on the part of the organizer and choosing
• Clear explanation of the vision, mission, goals, programs and
the community for partnership.
activities must be given in all initial meetings and contacts with
the community.
• It may also be necessary to delineate criteria or guidelines for
site selection.
• Community organizers must have a basic understanding of the
target community.
• Making a list of sources of information and possible facility
resources, both government and private is recommended.
• Preparation for initial visit includes gathering basic information on
socioeconomic conditions, traditions including religious practices,
overall physical environment, general health and illness patterns
Communities may be identified through: and available health resources.
• Initial data gathered through ocular survey
• People must take care to avoid raising unrealistic expectations in
• Review of records of a healthy facility
the community.
• A review of the barangay/ municipal profile
• Organizer must keep in mind that the goal of the process is build
up the confidence and capacities of the people.
 Community and Public Health for MLS 15

2 strategies for gaining entry into a community 3. “Elitist” style

• The organizer lives with the barangay chairman, or some other
(Manalili,1990) prominent person in the community.
1. Padrino entry
• the organizer gains entry into the community through padrino or • The organizer is frequently seen in the company of local
patron, usually a barangay or some other local government officials.
officials.
o In meetings or assemblies with the people, the padrino, in • This style makes integration with the larger community
an effort to boost the organizer’s image, tends to present
the intended project output, thereby creating false hopes. 4. People-centered Approach in Integration
• This approach allows the organizers to develop a deeper
2. Bongga entry relationship with the whole community through various
• easiest way to catch the attention and gain the “approval” of techniques.
the community
• This is the approach that is recommended to guarantee
o Exploits the people’s weakness and usually involves dole- success of the organizing work.
outs, such as free medicines
o Creates unreasonable expectations and reinforces a dole-
out mentality, which contradicts the essence of CO
TECHNIQUES SUGGESTED BY MANALILI (1990) TO FACILITATE
COMMUNITY INTEGRATION:
3. Community Integration (Pakikipamuhay) 1. Pagbabahay-bahay or occasional home visits
• is the phase when the organizer may actually live in the • Effective way of developing a close relationship with the
community in an effort to understand the community better and community
imbibe community life
• Requires the organizer to observe the daily schedule of
• frequently requires immersion in community life activities of households to avoid inconvenience on the part of
the family
• the organizer must consciously discard the “visitor” or “guest”
image
2. Huntahan
• respect for community cultures and traditions • Informal conversations help a lot in integrating with the
community.
• manner of dressing must be in accordance with the norms of
the community Example: Village poso during laundry time, basketball court, and sari-sari
store.
3. Participation in the production process
INTEGRATION STYLES • Organizer participates in the livelihood activities, such as
Manalili (1990) farming in an agricultural community.
• describes the following styles of integration:
Purpose:
1. “Now you see, now you don’t” style • to allow the organizer to gain knowledge as a basis for
• The organizer visits the community as per schedule but is not understanding the production process and the economic
able to transcend the “guest” status. system

• As a result, the organizer cannot breakdown the barriers • to share the daily experiences of the ordinary people in the
between him/her and the people and does not get the change community
to better understand the villager’s way of life. 4. Participation in social activities
• Social functions and activities help the organizer and the people
2. “Boarder” style to get to know each other through face-to-face encounters.

• The organizer rents a room or a house in the village, lives his/her o fiestas, weddings, baptismal celebrations, funeral wakes,
own life and does not share the life of the community. etc.

• As a result, the organizer is regarded as a guest or boarder in

the house.
 Community and Public Health for MLS 16

4. Social Analysis • Collective decision making must dictate what projects and
• The process of gathering, collating and analyzing data to gain strategy must be undertaken.
extensive understanding of community conditions
• The organizer must remember that it is their project to be
• help in the identification of problems of the community and
done in their community. The organizer must let them decide.
determine the root causes of these problems.

o AKA: social investigation, community study, community If the community decides to formalize the organization, it
analysis or community needs assessment, community
diagnosis must have the following characteristics:
• An organizational name and structure

This step requires a comprehensive analysis of the • A set of officers recognized by the members of the
following factors: community
1. Demographic data
• Constitution and by laws stating the vision, mission, and
2. Sociocultural data goals(VMG), rules and regulations of the organization and
3. Economic data duties and responsibilities of its officers and members
4. Environmental data
• Community may decide to seek legal recognition by registering
5. Data on health patterns (morbidity, mortality, fertility) the organization with the appropriate government agency
6. 6. Data on health resources such as Securities and Exchange Commission or the
Cooperative Development Agency.
5. Identifying Potential Leaders
• Once potential leaders are identified, they should be trained • Recognition by the LGU
and eventually become part of the community organizing team.
8. Action Phase
The following are other desirable characteristics • Known as the mobilization phase

of potential leaders: • Refers to implementation of the community’s planned projects

o They represent the target group/community.
and programs
o They possess or display leadership qualities.
o They have trust and confidence of the community. Important considerations during the mobilization
phase are as follows:
6. Core Group Formation
1. Allow the community to determine the pace and scope of
• The formation of a viable, functioning core group is the focal
project implementation.
point of community organizing.
• The community may start with simple barangay projects, such
• This requires a series of training sessions to “transfer the as Tapat Ko Linis Ko or clean and green.
technology” of community organizing, enabling the core group
to take charge of the subsequent organizing process. • As the organization gains experience and develops, it will move
toward more complex programs, like coastal resource
• An essential component of core group formation is management or a community material recovery facility
reinforcement of social consciousness of the members
particularly in terms of analyzing the root causes of the 2. The process is as important as the output.
problems. • A project may fail , but as long as the community gains
valuable experience and learns from the process, it is not a
7. Community Organization failure in itself
• On the initiative of the core group, the community conducts .
an assembly or a series of assemblies, with the goals of 3. Regular monitoring and continuing community formation
arriving at a common understanding of community concerns program are essential.
and formulating a plan of action in dealing with these
concerns.
 Community and Public Health for MLS 17

• Throughout the mobilization phase, regular meetings are • The time of exit should be mutually determined by the organizer
conducted for monitoring and continuous training for and the community during meeting for monitoring and evaluation.
community leaders.

9. Evaluation
Indications of readiness to exit by the community
• It is a systematic, critical analysis of the current state of the organizer:
organization and/or projects compared to desired or planned • Attainment of the set goals of the community organizing efforts
goals or objectives. ,

• Demonstration of the capacity of the people’s organization to lead

the community in dealing with common problems, and
• It is done periodically during mobilization (formative evaluation)
to allow revisions of strategies when needed • People empowerment as manifested by collective involvement in
decision making and community action on matters that impact their
lives
• at the end of the prescribed project period (summative
evaluation). • During the exit phase, the organizer may start exploring another
community to organize, that is, expanding to another area
.

In CO, there are 2 Major areas of evaluation: • While expanding, the organizer stays in touch with the first
• Program-based evaluation community, periodically visiting, not so much as an organizer but as
• Organizational evaluation friendly consultant.

Area of General Evaluation Parameters • Community organizing is an enabling process through which the
Evaluation community organizer becomes dispensable and the people’s
Program-Based • Where the goals and objectives of the organization takes over.
program/project achieved?
• What strategies were implemented? GOALS OF COMMUNITY ORGANIZING
What worked? What did not?
• What is the overall impact of the project
1. People’s empowerment
on the community? • People learn to overcome their powerlessness and develop
• How were the resources of the their capacity to maximize their control over the situation and
organization and community utilized? start to place the future in their own hands.
Organizational • Were the vision, mission and goals of the
organization achieved? 2. Building relatively permanent structures and
• How are the organizational policies being
people’s organizations
implemented?
• Aims to establish and sustain relatively permanent
• What is the level of participation in the
organizational structure that best serve the needs and
affairs of the community organization?
aspirations of the people
• How were the resources of the organization
utilized and managed?
• What type of interpersonal relationship is 3. Improved quality of life
shared among the members of the • Also seeks to secure short-and long-term improvements in
organization, among the leaders and the the quality of life of the people.
members of the community organization?
COMMUNITY ORGANIZING PARTICIPATORY
10. Exit and Expansion ACTION RESEARCH (COPAR)

“The best entry plan is an exit plan”

PAR
• is an approach to research that aims at promoting change
• The time required for community organizing depends on the among the participants.
diligence of the organizer and the acceptance of the community.
 Community and Public Health for MLS 18

• Member of the group being studied participate as partners • Believes in the vision of change, empowerment and
in all phases of the research, including design, data collection, development.
analysis and dissemination.
• Has a personal conviction consistent with the values and
• It was around the mid-1990s when PAR was first introduced. principles being advocated.
COPAR
• is a community development approach that allows the Points of Traditional Research COPAR
community (participatory) to systematically analyze the Compariso Approach
situation (research), plan a solution, and implement n
projects/programs (action) utilizing the process of community
Decision • Top-Down • Bottom-up
organizing
making • Expert/nurse-driven • Community-driven process
Emphasis • Much premium is • Premium is placed on the
• It is essentially a research project done by the community placed on the data and process
that leads to actions that improve conditions in the community. output
Roles • Nurse as researcher: • Community members as
The major role of the Public Health Workers In the community are • researchers: the nurse or
subjects and objects PHW is
COPAR of research, usually • a facilitator and recorder.
• to facilitate and guide the community in the critical respondents of the • Data analysis is done
assessment of the situation. research instruments. collectively
• Data analysis is done by • by the community.
• COPAR is supposed to break the practice of making the the nurse and then
people passive recipients of services merely answering presented to the
surveys and listening to the “expert’s analysis of their own community.
situation.” Methodolo • Research tools and • Research tools and
gy methodologies are methodologies
“COPAR passes the responsibility predetermined/prepa • are identified and
ckaged by the nurse- developed by the
forhealth to the people.”
organizer • community
Output • Upon completion, the • Conclusions and
Basic Qualities of a Community Organizer study is packaged, recommendations
submitted to the • are made by the
A community organizer is someone who:
agency and published. community. These
• Has exemplary professional and moral qualities. • Recommendations • will lead to agreed
are made by the community
• Possesses good communication/facilitation skills to be able
researcher based • actions/projects.
to call and lead small group discussion/trainings and
on the findings of the
community meetings. study
• Has the ability to set good leadership examples for the
community to emulate. The essence of Primary Health Care and Community
Organizing is
• Displays charismatic personality that draws people towards the development of SELF-RELIANT communities,
the organizing work and community activities. fully responsible for their health decisions. And that is
health in the “hands of the people”.
• Adopts and enjoys working with and living with all types of
communities/people.

• Can empathize with the people or community he/she is

working with.
 Community and Public Health for MLS 19

I. Comprehensive Community Diagnosis

CHAPTER 3: COMMUNITY DIAGNOSIS • Aims to obtain general information about the community with
the intent of:
COMMUNITY DIAGNOSIS ❖ determining not only prevalent health conditions and risk
• refers to the identification and quantification of health problems factors (epidemiologic approach) but also,
in a community as a whole in terms of:
❖ the socio-economic condition (socio-economic approach)
❖ mortality and morbidity, rates and ratios, and;
❖ lifestyle behaviors and attitudes that have effect on health
❖ identification of their correlates for the purpose of defining (behavioral approach)
those at risk or those in need of health care.
consists of two important parts: Elements of Comprehensive CD:
a. Collection of data about the community in order to identify A. Demographic variables
the different factors that may directly or indirectly
A.1 total population and geographical distribution and population
influence the health of the population.
density
b. Analyze and seek explanations for the occurrence of A.2 age-sex composition
health needs and problems in the community. A.3 vital indicators
A.4 patterns of migration
A.5 population projection
Community assessment
❖ “keystone” of community health process B. Socio-economic and Cultural Variables
B.1 Social indicators
• The PH worker utilizes assessment data to derive the community B.1 .1 Social indicators
health diagnoses and become the bases for developing and B.1 .2 housing conditions
implementing community health interventions and strategies B.1.3 Social classes or groupings
which completes the community diagnosis. B.2 Economic indicators
B.2.1 Poverty level income
B.2.2 Unemployment and underemployment rates
Ecologic Approach to Community Diagnosis B.2.3 Proportion of salaried and wage earners
• Recognizes the fact that the health status of the community is B.2.4 Types of industry present
a product of various interacting elements such as population, B.2.5 Occupation common in the community
physical and topographical characteristics, socio-economic and B.2.6 Communication network
cultural factors, health and basic social services and power B.2.7 Transportation system
structure within the community. B.3 Environmental indicators
B.3.1 1Physical/Geographical/Topographical characteristics
• These elements wil explain the health and illness patterns in the B.3.2 Water supply
community. B.3.3 Waste disposal
B.3.4 Air, water and land pollution
3 INDEPENDENT, INTERACTING AND CONSTANTLY B.4 Cultural factors
CHANGING CONDITIONS B.4.1 Variables that may break up the people into groups
(ethnicity, social class, language, religion, race, political
Freeman and Heinrich (1981) orientation)
B.4.2 Cultural beliefs and practices
1. The health status of the community, including the population’s level
of vulnerability. B.4.3 Concepts about health and illness
C. Health and Illness Patterns
2. Community health capability or the ability of the community to deal C.1 Leading cause of mortality
with its health problems. C.2 Leading cause of morbidity
C.3 Leading cause of infant and child mortality
3. Community action potential, or the patterns in which the C.4 Leading cause of maternal mortality
community is likely to work on its health problems. C.5 Leading cause of hospital admission
C.6 Leading cause of clinic consultation
Types of Community Diagnosis C.7 Nutritional status
D. Health Resources
I. Comprehensive Community Diagnosis D.1 Manpower resources
II. Problem-oriented Community Diagnosis D.2 Material resources
 Community and Public Health for MLS 20

E. Political and Leadership Patterns c. Interviews

E.1 Power structure in the community • face-to-face or telephone interview, individual or group
interview, structured or unstructured interview
E.2 Attitudes of the people toward authority
d. Focus group discussion
E.3 Conditions/events/issues that cause social conflict/upheavals
or that lead to social bonding or unification • qualitative research technique utilize for its value in
understanding and documenting human behavior
E.4 Practices/approaches effective in settling issues and
concerns • In the conduct of focus group discussions, make sure to set the
characteristics of the participants in terms of:
II. Problem-oriented Community Diagnosis
• responds to a particular need for a target group ❖ those characteristics that will be common to them

❖ those characteristics that will differentiate them from

COMMUNITY DIAGNOSIS: THE PROCESS each other
• The community is an active partner not a passive recipient of
care. 5. Developing the instruments.
a. Survey questionnaires / survey instruments
• The public health worker works WITH and not FOR the
community. b. Focus group discussion guide
• facilitate the direction and flow of exchange of ideas on specific
• A PHW does not operate like an external assessor of
topics or concepts among the participants
community needs, but as the facilitator working in a team
composed of community members and leaders.
c. Key informant interview guide
• gives direction to the person doing the interview using a set of
STEPS IN CONDUCTING COMMUNITY DIAGNOSIS prepared questions on a very specific subject
1. Determining the objectives.
• During the planning phase, the objectives will serve as a guide in d. Observation checklist
directing disease control and wellness promotion in the • list of data that are manifestation or indicators of health need
community. or problem

In stating the objectives, the following questions should be answered: 6. Actual data gathering.
a. What is the present health condition of the people in the a. semi-structured interviews
community?
b. analytical games
b. Why are the people in the community in such condition? What c. stories and portraits
specific problems are causing these problems? d. diagrams
e. workshop
c. What are the roots of these problems?

d. What solution will address the problems? 7. Data collation

• Put together all facts and figures to generate information about
2. Defining the study population the health status of the community

2 types of data are generated:

3. Determining the data to be collected. ❖ Numerical data
• achieved by developing a data collection plan
❖ Descriptive data
• data can be categorized as primary or secondary based on the
source of data
8. Data presentation
• Descriptive data are presented in narrative reports whereas
4. Collecting the data numerical data may be presented into table or graphs
a. Observation
• ocular survey/windshield survey Types of graphs:
a) Line graph: show data trend or change
• participant observation
b) Bar graph / Pictograph: comparisons of counts and rates
b. Records review
c) Histogram / frequency polygon: graphic presentation of
frequency
 Community and Public Health for MLS 21

d) Scattered diagram: correlation data for two variables

e) Pie chart: breakdown of a group

9. Data analysis
• the most critical stage; quantification, description and
classification of data
• Problem tree analysis approach
• causes and effects

10. Identifying the community health problems

Categories of community health problems:

Health • Described in terms of increased or decreased
status morbidity, mortality, fertility or reduced capability
problems for wellness
Health • Described in terms of lack of or absence of
resources manpower, money, materials or institutions
problems necessary to solve health problems
Health- • described in terms of social, economic,
related environmental and political factors that
problems aggravate the illness-inducing situations in the
community

11. Priority-setting
• prioritize which problems can be attended to considering available
resources, limitations, and constraints.

Criteria:
a) Nature of the condition/problem presented
b) Magnitude of the problem
c) Modifiability of the problem
d) Preventive potential
e) Social concern
 Community and Public Health for MLS 22

DEFINITION OF TERMS:
Cases
• people afflicted with a disease
EPIDEMIOLOGY Epidemic
EPIDEMIOLOGY • an unexpectedly large number of cases of disease in a
• It is the study of the distribution and determinants of health- particular population; disease occurrence in excess of normal
related states or events in specified populations, and the expectancy
application of this study to the prevention and control of Endemic
health problems. • a disease that occurs regularly in a population as a matter of
TERM EXPLANATION course; normally prevails in the community
Study Includes surveillance, observation, Hyperendemic
hypothesis testing, analytic research, and • persistent, high levels of disease occurrence
experiments Pandemic
Distribution Refers to analysis by time, places, and
• an outbreak of disease over a wide geographical area such
classes of people affected
as a continent
Determinants Include all the biological, chemical, physical,
social, cultural, economic, genetic, and Sporadic Disease
behavioral factors that influence health • few scattered cases
Health-related Refer to diseases, causes of death, Examples of a SPORADIC DISEASE, ENDEMIC DISEASE,
states or events behaviors such as the use of tobacco, HYPERENDEMIC DISEASE, PANDEMIC DISEASE, 0R
positive health states, reactions to EPIDEMICDISEASE
preventive regimens and, provision and
use of health services EPIDEMIC
Specified Include those with identifiable • 10 cases of legionellosis occurred within 3 weeks
populations characteristics such as occupational among residents of a particular neighborhood (usually
groups 0 or 1 per year)
Application to The aim of PH – to promote, protect, and
prevention and restore good health HYPERENDEMIC
control • Average annual incidence was 364 cases of
pulmonary tuberculosis per 100,000 population in one
• Makes use of concepts and methods from fields of: area, compared with national average of 134
❖ Biology casesper100,000population
❖ Sociology
❖ Demography PANDEMIC
❖ Geography • Over 20 million people worldwide died from influenza
❖ Environmental science in 1918–1919
❖ Policy analysis
❖ Statistics SPORADIC
• Single case of histoplasmosis was diagnosed in a
community

ENDEMIC
• About 60 cases of gonorrhea are usually reported in
this region per week, slightly less than the national
average
 Community and Public Health for MLS 23

PRACTICAL APPLICATIONS OF EPIDEMIOLOGY A. STUDIES OF DISEASE FREQUENCY

1. Assessment of the health status of the community or
• Measurement of frequency of disease, disability, death
community diagnosis
❖ Prevalence
2. Elucidation of the natural history of disease
❖ Incidence
3. Determination of disease causation
❖ May yield important clues to disease etiology and
4. Prevention and control of disease
development of strategies for disease prevention and
5. Monitoring and evaluation of health interventions
control
6. Provision of evidence for policy formulation
B. Studies of the disease distribution
DISEASE • Characterize who, where, or when in relation to what
DISEASE (outcome)
❖ Person: characteristics (age, sex, occupation) of the
• An abnormal condition of an organism or part, especial y
because of an infection, inherent weakness or environment individuals affected by the outcome
❖ Place: geography (residence, work, hospital) of the
stress, that impairs physiological functioning.
• Literally, the opposite of ease, when something is wrong affected individuals
❖ Time: when events (diagnosis, reporting, testing)
with a bodily function.
occurred
According to M.W. Susser
• “Descriptive epidemiology”
Disease, Illness, and Sickness • Generate hypothesis
DISEASE: C. Studies of determinants of disease
• is a physiological or psychological dysfunction • Test hypothesis
ILLNESS: • Answer why and how
• a subjective state of the person who feels aware of not • “Analytical epidemiology”
being well • Help in development of health programs, interventions, and
policies
SICKNESS:
• a state of social dysfunction, i.e. a role that the individual AREAS OF CONCERN OF EPIDEMIOLOGY
assumes when ill 1. Describing the distribution of disease in terms of sex, age,
race, geography, etc.
DISEASE AND EXPOSURE 2. Interpretation of the distribution of the disease in terms of
possible etiologic agent of causal factors.
DISEASE
✓ outcome variable (dependent variable) SCOPE OF EPIDEMIOLOGY
• A broad array of health conditions that we seek to 1. To trace the source of epidemic
understand and ultimately modify, including the: 2. Limit the spread
❖ physiologic states 3. Institute control measures
❖ mental health 4. Prevent similar occurrence in the future
❖ and the entire spectrum of human diseases
ULTIMATE CONCERN OF EPIDEMIOLOGY
EXPOSURE 1. Prevention of diseases
✓ predictor / explanatory variable (independent variable) 2. Maintenance of health
• A catch-all term for agents, interventions, conditions,
policies, and anything that might affect health PH IMPORTANCE OF EPIDEMIOLOGY
• It provides framework for different approaches for
COMPONENTS OF EPIDEMIOLOGY control measures.
A. Studies of disease frequency
B. Studies of disease distribution
C. Studies of determinants of disease
 Community and Public Health for MLS 24

ASSESSMENT OF THE HEALTH STATUS OF THE 4. Stage of Recovery, Disability or Death

COMMUNITY (Community Diagnosis) • The patient either recovers completely from the disease,
• Epidemiology is often used to describe the health status of becomes a chronic case, with, or without disability, or dies.
the population through estimation of health indicators.
Health indicators
✓ are quantitative measures that describe and summarize
various aspects of the health status of the population.
Other uses of health indicators (Turnock, 2007):
1. Determining factors that may contribute to causation and
control of diseases.
2. Identifying public health problems and needs.
3. Indicating priorities for resource allocation.
4. Monitoring implementation of health programs.
5. Evaluating outcomes of health programs.

TYPES OF HEALTH INDICATORS:

• Health status indicators (Morbidity/Mortality)
• Population indicators
• Indicators for the provision of health care DETERMINATION OF DISEASE CAUSATION
• Risk reduction indicators • Interventions that target the causes of a public health
• Social and economic indicators problem have greater chances of having positive outcomes,
• Environmental indicators hence the need to determine the etiology of the disease.
• Disability indicators • “What factors contribute to disease causation?”
• Health policy indicators • “Why does disease occur?”

STAGES IN THE NATURAL HISTORY OF DISEASE AND THE MODELS OF DISEASE CAUSATION
LEVELS OF PREVENTION A. Epidemiologic triad or triangle model
1. Stage of susceptibility (Prepathogenesis stage) HOST
• Primary level of prevention such as health education and
immunization
• The person is not yet sick but may be exposed to the
risk factors of the disease
E.g. multiple sex partners in the case of cervical cancer
2. Stage of subclinical disease
• Secondary level of prevention like Pap smear
• The person is still apparently healthy since clinical
manifestations of the disease are not yet shown, AGE ENVIRONME
although pathologic changes have already occurred. AGENT:
3. Stage of clinical disease • or microbe that causes the disease (“what”)
• Tertiary levels of prevention HOST:
• The patient now manifests recognizable signs and • or organism (human/animals) harboring the disease
symptoms (“who”)
Example: vaginal bleeding. ENVIRONMENT:
• or those external factors that cause or allow disease
transmission (“where”)
 Community and Public Health for MLS 25

❖ physical factors such as geology, climate, and physical PREVENTION, INTERVENTION, CONTROL, AND ERADICATION OF
surroundings DISEASES
(e.g., a nursing home, hospital) Prevention:
❖ biologic factors • the planning for and taking of action to forestall the onset
(insects that transmit the agent) of a disease or other health problem
❖ socioeconomic factors Intervention:
(crowding, sanitation, availability of health services) • efforts to control a disease in progress
Example: TB Control:
TUBERCULOSIS • the limiting of transmission of a communicable disease in
AGENT Mycobacterium tuberculosis a population
HOST impaired or weakened immune system; poor Eradication:
nutritional status; poor access to health care; • the complete elimination or uprooting of a disease
frequent exposure or close contact with
someone who has active tuberculosis; no BCG OUTBREAK INVESTIGATION
vaccination, for health professionals, failure
to wear proper personal protective Disease outbreak
equipment especial y mask • the occurrence of cases of disease in excess of what
ENVIRONMENT poor environmental sanitation, densely would normally be expected in a defined community,
populated area / crowding, poor ventilation geographical area or season (WHO,2012)
• an occurrence of one case of a CD is considered an
Example: RABIES outbreak provided the disease is either a previously
RABIES unknown disease, has never occurred in the area where
AGENT Rhabdovirus the lone case is observed, or has never been absent from
HOST irresponsible pet owners (unvaccinated pets; the population for a long time
unleashed pets)
ENVIRONMENT travel to a place where rabies is common or Basic Steps in an Outbreak Investigation
where there are stray dogs 1. Operationally, define what constitutes a case.
2. Based on the operational definition, identify the cases.
B. Multi-causation disease model 3. Based on the number of identified cases, verify the existence
of an outbreak.
4. Establish the descriptive epidemiologic features of the cases.
5. Record the clinical manifestations of cases.
6. Formulate a hypothesis regarding the probable etiologic agent,
the sources of infection, the MOT, and the best approach
for controlling the outbreak.
7. Test the hypothesis by collecting relevant specimens from
the patients and from the environment.
8. Implement prevention and control measures to prevent
recurrence of a similar outbreak.
9. Disseminate the findings of the investigation through media
and other forms to inform the public.
 Community and Public Health for MLS 26

EPIDEMIOLOGIST VS PHYSICIAN

Epidemiologist Clinic Physician

DIFFERENCES
Patients are whole community Patient- individual during illness
during epidemic, endemic, and
pandemic
Similarities but differ in Methodology and Technology
• Diagnose patient using • Diagnose patient using
observational stethoscope, BP
epidemiology, Natural apparatus, X-ray,
experimentation Laboratory etc.
Epidemiology, and • Treatment using
Theoretical Epidemiology medicines, surgery etc.
• Treatment- preventive
and control measures of
the community

MONITORING AND EVALUTION OF HEALTH

INTERVENTIONS
Kettner et al.,1999
Monitoring
• is an ongoing activity during the program implementation
to assess the current status of its implementation in
terms of compliance to the design of the program,
timeliness, and attainment of goals
As a result of monitoring, the project management team
is able to:
• Assess the progress of program implementation.
• Identify problems.
• Take corrective action.
• Have a tool for quality assurance and management.
• Measure achievement of program objectives.
• Lay the groundwork for program evaluation.
Evaluation
• is a process that systematically and objectively assesses
compliance to the design of the program, the
performance, the relevance and success of a project,
that is, the extent to which a project accomplishes its
goals and achieves measurable impacts.
• “Did the program work as intended?”
 Community and Public Health for MLS 27

Note:
• The most common causes of these two diseases are
atherosclerosis and hypertension.
Four Major Categories of non-communicable diseases
(NCDs) HYPERTENSION AND ATHEROSCLEROSIS
Hypertension
• Or high BP, is defined as a systolic BP≥140 mmHg or
• a diastolic BP≥90 mmHg

Atherosclerosis
❖ Cardiovascular Diseases
• is a disease of the blood vessels characterized by the
❖ Diabetes
deposition of fats and cholesterol within the walls of the
❖ Chronic Respiratory Diseases
artery (WHO,2011)
❖ Cancer
The WHO reports Note:
• NCDs to be the leading cause of mortality. Stanhope & Lancaster,2010
• Almost 63% of the total deaths were due to NCD’s and • Uncontrolled hypertension and atherosclerosis can lead to
the remaining 37%were due to CD’s (WHO,2010). heart attack, stroke, kidney damage, and a host
• In the Philippines, 75% of the total death scan be attributed complication
to NCDs, 30-50%occurred at the age below 60years
(Ulep,2012)
CONTRIBUTING FACTORS:
• A person’s genetic make-up
NON-COMMUNICABLE DISEASE
• Socioeconomic group
NONCOMMUNICABLE DISEASE • Mental health
• Diet
• It is a medical condition that is noninfectious and non-
• Overweight and obesity
transmissible.
• Inactivity
• NCDs are referred to as “chronic diseases” due to their
• Tobacco
long duration.
✓ The condition interferes with the individual’s way of • Alcohol
living a normal life brought about by different signs and • Diabetes
symptoms lasting more than 6 months. • Globalization and urbanization
• “Lifestyle-related diseases”
PREVENTION
CARDIOVASCULAR AND CEREBROVASCULAR • Focusing on risk factors for cardiovascular and
cerebrovascular disease
DISEASE
• Implementing medical screening for individuals at risk
Cardiovascular disease • Providing effective and affordable treatment to those
• “heart disease” who require it
• refer to diseases that involve the heart or blood vessels
(arteries, capillaries, veins) CANCER
• Cancer or malignant neoplasm is a group of various diseases
Cerebrovascular disease involving unregulated cell growth (Newtow,2009)
• “stroke” • The cells divide, grow uncontrollably forming malignant
• A group of brain dysfunction related to disease of the blood tumors, and invade parts of the body.
vessels supplying the brain
 Community and Public Health for MLS 28

• Substances that cause some cells to undergo genetic CHRONIC OBSTRUCTIVE Pulmonary Disease
mutations are called carcinogens. (COPD)
• It is disease of the lungs in which the airways narrow over
Risk Factors for Cancer time.
• tobacco use • It includes chronic bronchitis, chronic asthma, and
• unhealthy diet emphysema.
• insufficient physical activity • It is estimated that 7% of deaths worldwide are due to
• the harmful use of alcohol chronic respiratory diseases (WHO,2010)
• Infections • Smoking is a strong risk factor for COPD and statistics
❖ hepatitis B, hepatitis C (liver cancer) shows that 15% of cigarette smokers develop COPD.
❖ human papillomavirus (HPV; cervical cancer) • Second-hand smoke and pollution also aggravate the
❖ Helicobacter pylori (stomach cancer) problem.
• radiation
• variety of environmental and occupational exposures of DIABETES
varying importance • Diabetes is a group of metabolic disease in which an
individual has high blood sugar because the pancreas does
The majority of cancer deaths not produce enough insulin (a hormone that regulates blood
• Lung, breast, colorectal, stomach and liver cancers sugar) or the cells do not respond to the insulin produced.
• In high-income countries, the leading causes of cancer • Long term consequences include increased risk of heart
deaths are lung cancer among men and breast cancer disease, kidney disease, blindness, neural damage.
among women.
• In low-and middle-income countries cancer levels vary Symptoms of Diabetes
according to the prevailing underlying risks. In sub-Saharan • Increased frequency and amount of urination
Africa, for example, cervical cancer is the leading cause of ❖ Polyuria
cancer death among women. • Increased thirst
❖ Polydipsia
Warning signals of cancer (American Cancer Society): • Increased hunger
a. Change in bowel or bladder habits ❖ Polyphagia
b. A sore throat that does not heal • Weight loss, vision changes, and fatigue
c. Unusual bleeding or discharge
d. Thickening or lump in breast
e. Indigestion or difficulty of swallowing
f. Obvious change in a wart or mole
g. Nagging cough or hoarseness
h. Unexplained anemia
i. Sudden weight loss

WHO’s approach to cancer has five pillars:

❖ Prevention
❖ Early Detection
❖ Screening
❖ Treatment
❖ Palliative Care
 Community and Public Health for MLS 29

Prevention: • Chemicals found in cigarettes are known to cause cancer

(National Cancer Institute, 2004).
To help prevent type 2 diabetes and its complications, people
• It causes lung cancer, cancer of the mouth, pharynx,
should:
larynx, and esophagus (Laudico,2010).
• Achieve and maintain healthy body weight
• Be physically active 3. Unhealthy eating
❖ at least 30 minutes of regular, moderate-intensity
• “Obesogenic” or unhealthy eating is one of the major risk
activity on most days
factors responsible for the global increase of
• Early diagnosis can be accomplished through relatively
cardiovascular disease, cancer, diabetes, and obesity
inexpensive blood testing
worldwide (WHO,2002).
• Treatment of diabetes involves lowering blood sugar and
• Unhealthy eating has adverse metabolic effects on BP,
the levels of other known risk factors that damage blood
cholesterol, TAG, and insulin resistance (Strazzullo,2009).
vessels
• Tobacco cessation is also important to avoid complications 4. Excessive alcohol drinking
• Alcohol may cause malabsorption, inflammation of the GIT,
Control liver problems, and cancer.
Other cost saving interventions include:
• It is associated with colon and rectal cancer (Bongaerts
• Screening and treatment for retinopathy (which causes
et al., 2006)
blindness);
• Blood lipid control (to regulate cholesterol levels); 5. Viruses
• Screening for early signs of diabetes-related kidney disease • Viruses play an important role in the development of
and treatment. certain cancers (Philippine CancerSociety, 2010).
❖ HPV: cervical and vulvar cancer
RISK FACTORS FOR NONCOMMUNICABLE DISEASES ❖ Epstein- Barr virus: nasopharyngeal and anal cancer
❖ HTLV-1: non-Hodgkin lymphoma
1. Physical inactivity ❖ HB V& HCV: liver cancer
• It is defined as less than 5 times of 30 minutes of
Oncoviruses – virus escapable of causing cancer
moderate activity per week, or less than 3 times of 20
minutes of vigorous activity per week (WHO,2011).
• Physical activity is a key determinant of energy expenditure
6. Radiation
and is thus fundamental to energy balance and weight 2 most common forms:
control. ❖ UV (X-rays)
• Physical activity contributes to weight loss, glycemic control, ❖ ionizing radiation (Gamma Rays)
improved blood pressure and lipid profile, and insulin UV Radiation:
sensitivity (Kelley, 2005) • adversely affects the genes, and the cell enzymes
• The risk of getting cardiovascular disease increases by1.5 causing DNA
times for noncompliance of the minimum recommendations Ionizing Radiation:
for physical activity. • causes tissue and cell damage by breaking the DNA
molecule (Newton,2009).
2. Cigarette smoking
Solar Radiation:
• It is a primary risk factor for development of NCDs
• is the primary source of UV radiation and the major
(Gruber and Zinman, 2001).
source of skin cancer worldwide (Cadetetal., 2005).
• Smoking-related diseases like cerebrovascular disease,
COPD, and lung cancer
PREVENTION OF NCDS
• It damages the lining of blood vessels and reduces HDL
• Promote physical activity and exercise
cholesterol and oxygen in the blood (WHO, 2013).
• Promote healthy diet and nutrition
• Promote a smoke-free environment
 Community and Public Health for MLS 30

• Stress management

LAWS AFFECTING CONTROL OF NCDS

EO No. 958:
• National Healthy Lifestyle Advocacy Campaign
RA No. 1054:
• Free emergency medical and dental treatment for
employees
RANo.9211:
• Tobacco Regulation Act of 2003
RA No. 6425:
• Penalties for Violations of the Dangerous Drug Act of1
972
RA No. 9165:
• Comprehensive Dangerous Drug Actof2002
RA No. 8423:
• Traditional and Alternative MedicineActof1997
AO No. 179 s. 2004:
• Guidelines for the Implementation of the National
Prevention of Blindness Program
Department Personnel Order No. 2005-0547:
• Creation of a Program Management Committee for the
National Prevention of Blindness Program
Proclamation No. 40:
• Declaring the month of August every year as “Sight
Saving Month”
RANo.7277:
• Magna Carta for Disabled Persons
RA No. 10352:
• An act restructuring the Excise Tax on Alcohol and
Tobacco
 Community and Public Health for MLS 31

❖ Age
❖ Gender
COMMUNICABLE DISEASES ❖ socioeconomic status
• Illnesses caused by an infectious agent or its toxic products ❖ genetic makeup
that is transmitted directly or indirectly to a person, animal ❖ hygiene and behavior
or intermediary host or inanimate environment
• Can be contagious or an infectious disease 3. ENVIRONMENT
• refers to the condition in which the agent may exist,
Contagious Diseases survive or originate
• the term “contagion”, a derivative of “contact”, is a. Physical Environment: Temperature, Weather, Soil,
transmitted by direct physical contact Water and Food Sources
b. Biological Environment: Animal, Insects, Flora and other
Infectious Diseases Human Beings that acts as a reservoir or foster the
• is transmitted indirectly through: survival of the organisms
❖ contaminated food, body fluid objects c. Socioeconomic Environment: Behavior, Personality,
❖ airborne inhalation Attitudes, Cultural Characteristics of people,
❖ through vector organisms Occupation and Urbanization
• that would require a break or inoculation in the skin or
mucus membranes of individuals CHAIN OF INFECTION
Elements:
EPIDEMIOLOGIC TRIANGLE MODEL
A. Causative Agent
1. AGENT • any organism capable of producing a disease
• An organism involved in the development of a disease ❖ bacteria ❖ fungi
• An agent must be present for an infection to occur ❖ viruses ❖ protozoa
• Must be capable of infecting the Host ❖ rickettsia ❖ helminths
Include:
Bacteria TB, Pneumonia, Typhoid Fever B. Reservoir
Viruses Viral Hepatitis, Herpes Simplex, Influenza and Viral • environment or object in or on which an organism survives
Meningitis and multiplies; inanimate objects, human beings and other
Rickettsial Rocky Mountain Spotted Fever and Rickettsia pox animals
Agents
Fungi Ringworm or Tinea Capitis, Athlete’s Foot or Tinea C. PORTAL OF EXIT
Pedis • the path by which an agent leaves its reservoir;
Protozoa Malaria, Amebiasis, Giardiasis respiratory, genitourinary tract, skin and mucous
Helminths Ascariasis, Enterobiasis, Ancylostomiasis and membranes and gastrointestinal tract
Schistomiasis
Arthropods act as vectors to agent from their reservoirs to
D. MODE OF TRANSMISSION
humans (Scabies) • means by which the agent passes from the portal of exit
in the reservoir to the susceptible host; it can be
transmitted through:
2. HOST
❖ contact
• Any organism that harbors and provides nutrition for the
❖ airborne
Agent
❖ droplet
• Humans (Most often)
❖ vehicle
• Other organisms like animals ❖ vector-borne
• The ability of the host to fight the agent causing the
infection is influenced by many factors such as:
 Community and Public Health for MLS 32

• As of 2010, the DOH reported that there are 5 areas

E. PORTAL OF ENTRY
declared rabies free: Siquijor, Batanes, Camotes Island, Apo
• the path by which an agent invades a susceptible host.;
Island and Malapascua Island.
usually, this path is the same as the portal of exit
Leprosy
F. SUSCEPTIBLE HOST • Philippines has the highest prevalence among the countries
• various factors of the individual that present barriers to of Western Pacific region.
the invasion and multiplication of agents Filariasis
• endemic in the Philippines
DISEASES TARGET FOR ERADICATION
Eradication Schistosomiasis
• endemic in 12 regions in the country
• Refers to the permanent reduction to zero of the
worldwide prevalence of the disease caused by a specific
FUNCTIONS OF THE PHW IN THE CONTROL OF CD
agent
1. Report immediately to the MHO any known case of notifiable
Elimination disease
• Reduction to zero prevalence of a disease in a single 2. Refer immediately to the nearest hospital
country, continent or other limited geographical area 3. Conduct a strong health education program directed toward
• Intervention measures are still needed in elimination, since prevention of an outbreak
the disease is still present elsewhere 4. Assist in the diagnosis of the suspect based on the signs and
symptoms
International Task Force for Disease Eradication 5. Conduct epidemiologic investigations as a means of contacting
(ITFDE),1988 families’ case finding and individual as well as community
• establish to systematically review potential candidate health education
diseases for eradication and to provide leadership and
advocacy for the concept of eradication SPECIFIC COMMUNICABLE DISEASES
diseases for global eradication:
❖ smallpox ❖ lymphatic filiariasis A. Tuberculosis
❖ poliomyelitis ❖ dracunculiasis (Phtisis, Consumption Disease, Koch’s Disease)
❖ measles ❖ taeniasis
❖ rubella

diseases for global elimination:

❖ Hepatitis B ❖ Trachomatis
❖ Malaria ❖ Onchocerciasis
❖ neonatal tetanus ❖ iodine deficiency disorders
❖ rabies ❖ yaws
❖ Chagas disease,
Causative agent:
❖ Mycobacterium tuberculosis
• The WHO initiative to eradicate yaws started in 1954, ❖ Mycobacterium africanum
followed by malaria in 1955, smallpox in 1980, dracunculiasis ❖ but occasionally by M. bovis from cattle and M. canettii
and paralytic poliomyelitis in 2000 and measles in 2015.
Mode of Transmission:
Rabies • Airborne droplet through inhalation when coughing or
• the country has consistently ranked the top 10 countries sneezing
regarding human rabies death. Incubation period: 4-6 weeks
Signs and Symptoms:
 Community and Public Health for MLS 33

• Fever: low grade late afternoon, loss of appetite, easy

1. Dengue
fatigability, night sweats, dry cough, later productive with
(Hemorrhagic Fever, Break Bone or Dandy Fever, Dengue Shock
hemoptysis, chest pain
Syndrome)
Laboratory/Diagnostic Test:
1. Direct Sputum Smear Microscopy Causative Agent:
• principal diagnostic method adopted by the NTP as it ❖ Dengue Virus
provides definitive diagnosis of active TB ❖ single stranded RNA virus of 4 types (DEN-1, 2, 3, 4)
✓ A definitive diagnosis is made with the demonstration of that belong to the genus Flavivirus, family Flaviviridae
MTB using Fluorescence Acid-Fast Microscopy Staining Vector: Infected female Aedes mosquitoes
✓ Smear (+) = at least 2 (+) sputum smear results • Aedes aegypti/Yellow fever mosquito/Tiger mosquito -
✓ Smear (-) = all 3-sputum smear result as (-) principal vector predominant in urban areas
✓ The specimen out of the smear (+) results with the • Aedes albopictus/Asian Tiger mosquito - secondary vector
highest no. is the final AFB quantification. predominant in rural areas
2. Chest X-ray • Aedes polynesiensis and Aedes scutellaris- other countries

Laboratory Result MOT:

Diagnosis • Transmitted to humans through the bite of an infected
Aedes mosquito
Negative (-) No AFB seen in 100 fields
Positive (+) 1-9 AFB seen in 100 fields Incubation Period: 3-14 days, commonly 5-7 days
1+ 10-99 AFB seen in 100 fields PHASES OF ILLNESS:
2+ 1-10 AFB seen in at least 50 fields
3+ More than 10 AFB seen in at least 20
1. Febrile Phase
fields • last from 2-7 days- high grade fever, facial flushing, skin
erythema, generalized body ache, myalgia, arthralgia and
Prevention: headache
1. Bacillus Calmette-Guerin (BCG) vaccination 2. Critical Phase
2. Health Education • last from 24 to 48 hours-when the temperature drops
3. Environmental Sanitation and remains below 37.5-38°C or less usually on days 3 to 7
4. Early Diagnosis and treatment of illness
5. Respiratory Isolation • an increase in capillary permeability with increasing Hct
levels may occur
B. Mosquito-Borne Diseases
3. Recovery Phase
• usually takes place in the following 48-72 hours general
well-being improves, appetite returns, GI symptoms
subsides, and hemodynamic status become stable

MALARIA

FILARIASIS
 Community and Public Health for MLS 34

Laboratory/Diagnostic Test: 3. Biological methods - stream seeding

1. Tourniquet Test or Rumple-Leads Test 4. Zooprophylaxis - larvae eating fish
• Measures the coagulability of the blood 5. Environmental methods - cleaning and irrigating canals
• Presumptive test for dengue; used to assess bleeding 6. Screening of houses
tendencies 7. Educational methods
8. Mechanical methods - fly swats or traps
2. Capillary Refill Test or Nail Blanch Test
9. Universal precaution
• Capillary Refill
10. Screening of blood donors
✓ rate at which blood refills empty capillaries
• Measures dehydration and decreased peripheral perfusion
3. Filariasis
3. Platelet Count and Hematocrit (Hct)
(Elephantiasis, Filarioidea Infection)
• Rapid decrease in Plt count in parallel with a rising Hct is
suggestive of progress to the critical phase of dengue Causative Agent:
4. Hemagglutination-Inhibition (HI) Test ❖ Wuchereria bancrofti
❖ Brugia malayi
• Based on the ability of dengue virus Ab to inhibit
agglutination MOT:
• Bite of mosquito
Prevention: Vector:
4S in Dengue Prevention ❖ Aedes poecilus
1. Search and destroy breeding places of mosquito ❖ Culex quinquefasciatus
2. Seek immediate treatment Signs and Symptoms:
3. Say no to indiscriminate fogging • Chills, fever, myalgia, lymphangitis with gradual thickening of
4. Self-protection the skin (commonly affecting limbs and scrotum) resulting
in elephantiasis and hydrocele
2. Malaria Laboratory/ Diagnostic Test:
(Marsh Fever, Periodic Fever, King of Tropical Disease) 1. Circulating filarial antigen (CFA)- finger prick
Causative Agent: Prevention:
• Protozoa genus Plasmodium • eradication of vectors
❖ P. falciparum,
C. Sexually Transmitted Infections
❖ P. vivax
❖ P. ovale 1. Gonorrhea
❖ P. malariae (Clap, Drip, Tulo)
❖ P. knowlesi Causative Agent:
MOT: ❖ Neisseria gonorrheae
• Vector- Female Anopheles MOT:
Symptoms: •Sexual contact
• Recurrent fever preceded by chills and profuse sweating Incubation Period: 2-7 days
(triad signs), malaise Signs and Symptoms:
Laboratory/ Diagnostic Test: • Thick purulent urethral discharge
1. History of having been in a malaria endemic area: Palawan and • frequency of urination among females
Mindoro • burning urination among males/females
2. Blood Smear Diagnostic examination:
3. Rapid Diagnostic Test (RDT) 1. Culture of specimen
Prevention: 2. Gram stain
1. Mosquito control Prevention:
2. Chemical methods – insecticides 1. Crede’s prophylaxis- silver nitrate/ tetracycline
 Community and Public Health for MLS 35

2. Avoid contact with secretions MOT:

3. Practice monogamous sexual contact • Contact with secretions or excretions of mouth, skin,
vagina and feces from patients or carriers
Incubation Period: Variable
Period of Communicability:
• Presumably while lesions are present
Signs and Symptoms:
• Severe vulvular pruritus (prominent feature)
• vaginal discharge (scanty, whitish, yellow, thick to form
curds non offensive)
• sore vulva due to itching, speculum examination
✓ thick whitish plugs attached to vaginal epithelium
2. Syphilis bleeds when the plug is removed, the cervix is normal
Causative agent: Diagnosis
❖ Treponema pallidum • Microscopic demonstration of pseudohyphae or yeast cells
MOT: in infected tissues or body fluids (vaginal discharge)
•Sexual contact Prevention and Control
Incubation period: 10-90 days • Case treatment
Signs and Symptoms: • Treatment of underlying medical conditions or predisposing
a) Primary- chancre factors
b) Secondary – condylomata, alopecia, sore throat, mucous
patches of the mouth
c) Tertiary – gumma formation, cardiovascular and nervous
system involvement

Laboratory/ Diagnostic Test: 4. Human Immunodeficiency Virus Infection/

1. Darkfield illumination test
Acquired Immune Deficiency Syndrome (HIV/AIDS)
2. Venereal Disease Research Laboratory (VDRL) Test
3. Fluorescent Treponemal Antibody Test Causative Agent:
4. Rapid Plasma Reagin (RPR) Test ❖ HIV1 and 2
MOT:
Prevention: • Sexual contact
• Practice Monogamy • blood transfusion
• Sex Education • contaminated syringes, needles, nipper, blades, direct
contact of open wounds/mucous membranes with
3. Candidiasis contaminated blood, body fluids, semen and vaginal discharge
Causative Agent: Incubation Period: Varies (3-6months) to many years(810years)
❖ Candida albicans (most common cause) Signs and Symptoms:
❖ Candida tropicalis (rare cause) a. Major - Weight loss, chronic diarrhea, prolonged fever for
1 month
 Community and Public Health for MLS 36

b. Minor - Cough for 1-month, pruritic dermatitis, recurrent

herpes zoster, candidiasis and lymphadenopathy
Prevention:
1. Blood and Blood products
a. Screen blood donors
b. Observation of Universal Precaution
E. Rabies
c. Refrain from using contaminated needles and syringes
(Hydrophobia, Lyssa)
2. Sexual Transmission
a. Abstain from promiscuous sexual contact Causative Agent:
b. Be faithful to your partner and practice monogamous ❖ Rhabdovirus
sexual contact MOT:
c. Follow correct and consistent use of condom • Bite of Rabid Animal
3. Mother-to-child transmission: Source:
• For HIV+ mothers, consult with health workers to have • Saliva of infected animal or human
access to care, treatment and support to services during High Risk:
pregnancy, labor and delivery and postpartum • Handling of animals
D. Schistosomiasis Incubation Period:
(Snail Fever, Bilharziasis) • 20-90 days for humans
Causative Agent: • 1 week - 7.5 months for dogs
❖ Schistosoma japonicum Signs and Symptoms:
❖ S. mansoni A. Dog- at first withdrawn, change in mood, shows nervousness
❖ S. haematobium and apprehension, unusual salivation, paralysis starts on hind
Vector: legs spreading towards entire body, death
• Onchomelania quadrasi (snail) B. Human
MOT: 1. Incubation period
•Vehicle (water) 2. Prodromal stage- headache, pain and numbness of
• indirect (skin pores) sensation at the site of bite, depression, penile erection or
Incubation Period: 2months spontaneous ejaculation for males
3. Acute, neurologic phase
Signs and Symptoms:
a. Spastic- anxiety, confusion, insomnia
• Rush at site of inoculation
b. Dementia- intense excitement, difficulty in breathing,
• enlargement of the abdomen
swallowing, drooling, hydrophobia
• diarrhea
c. Paralytic- flaccid ascending symmetric paralysis, coma,
• body weakness
death
Laboratory/Diagnostic Test: Laboratory/ Diagnostic Test:
Direct Stool Examination
• Postmortem Direct Fluorescent Antibody Staining Test
1. COPT (Cercum Ova Precipitin Test)
2. Kato Katz Technique Prevention:
• Pre-exposure prophylactic treatment for high-risk
Prevention:
individuals
1. Proper disposal of feces and urine
2. Proper irrigation of all stagnant bodies of water
3. Prevent exposure to contaminated water
4. Eradication of breeding places of snails
5. Use of molluscicides
 Community and Public Health for MLS 37

F. Leptospirosis • inability to close eyelids (lagophthalmos)

(Canicola, Weil’s Disease) • clawing of fingers and toes
Causative Agent: • contractures
❖ Leptospira interrogans • sinking of the nose bridge
MOT: • enlargement of the breast in males (gynecomastia)
• Inoculation into broken skin, ingestion • chronic ulcers
Source of infection: Laboratory/Diagnostic Test:
•Urine and excreta of rodents • Skin Slit Test
Incubation Period: 7-13 days Prevention:
Signs and Symptoms: 1. BCG Vaccination
1. Septicemic- High remittent fever 4-7 days, myalgia/myositis, 2. Avoidance of prolonged skin to skin contact with active
particularly calf pain untreated case
2. Immune/toxic stage- jaundice 3. Good personal hygiene
3. Convalescence 4. Adequate nutrition
5. Health education
Laboratory/Diagnostic Test:
1. Blood Culture Patient Classification of Leprosy:
2. Leptospira Agglutination Test 1. Paucibacillary (PB): (-) Skin Slit Test or five or less lesions
Prevention: 2. Multibacillary (MB): (+) Skin Slit Test and more than five
lesions
• Eradication of the source

G. Leprosy
(Hansenosis, Hansen’s Disease, Leontiasis) LAWS FOR THE CONTROL OF COMMUNIABLE DISEASES
Causative Agent: 1. RA 3573
❖ Mycobacterium leprae/ Hansen’s bacillus
• Reporting of Communicable Diseases
MOT:
•Prolonged skin contact
Category I (Immediately Notifiable):
❖ Acute Flaccid Paralysis
• droplet infection
❖ Adverse Event following Immunization
Incubation Period: 5 months-5 years ❖ Anthrax
Signs and Symptoms: ❖ Human Avian Influenza
1. Early signs ❖ Measles
• reddish or white change in skin color ❖ Meningococcal disease
• loss of sensation on the skin lesion ❖ Neonatal Tetanus
• decrease/loss of sweating and hair growth over the lesion ❖ Paralytic Shellfish Poisoning
❖ Rabies
• thickened and/or painful nerves
❖ SARS
• muscle weakness
• pain or redness of the eye Category II (Weekly Notifiable):
• nasal obstruction/bleeding ❖ Acute Bloody Diarrhea
• ulcers that do not heal ❖ Acute Viral Encephalitis
❖ Bacterial Meningitis
2. Late signs
❖ Cholera, Dengue
• loss of eyebrow (madarosis)
 Community and Public Health for MLS 38

❖ Diphtheria
❖ Influenzalike Illness
❖ Leptospirosis
❖ Malaria
❖ Non-neonatal Tetanus
❖ Pertusis
❖ Typhoid
❖ Paratyphoid Fever
2. RA 4073
• An Act Liberalizing the Treatment of Leprosy
3. RA 8504
• Philippine AIDS Prevention and Control Act of 1998
4. RA 9482
• The Rabies Act of 2007
5. RA 1136
• Tuberculosis Law of1954
6. Memorandum Circular Order No. 98-155
• Pronounced the NTP as the highest priority PH program of
the LGUs
7. Presidential Proclamation No. 46 of 1992
• Reaffirming the commitment to the Universal Child and
Mother Immunization goal by launching the Polio Eradication
Project-aims to make the Philippines polio-free by 1995
8. Presidential Proclamation No. 1204 of 1998
June:
• National Dengue Awareness Month; National Dengue
Prevention and Control Program
9. AO No. 24 s 1996
• The National Tuberculosis Control Program adopted DOTS in
the management of TB