These are community health notes for first years

1. PROGRAM:
UNIT: INTRODUCTION TO COMMUNITY HEALTH
BY
FELISTUS KIMANZI
KITUI CAMPUS
MODULE COMPETENCE
By the end of this unit the learner should be able to practice community health nursing
COURSE CONTENT
 History of Community Health Nursing
 Functions of County Health Management Team
 Functions of Ministry Of Health
 Concept of Community Health Nursing
 Principles of Community Health Nursing
 Structure of the ministry of health
 Functions and roles of FBO,NGO,CHMT,CDC
 Health care delivery system
 Integrated health services
 Concept of rural health service
 Members of health Centre team their roles and function
Specific objectives
By the end of the lesson the student will be able to:
 Define the commonly used terminologies in CHN
 Describe the history of CHN
 Describe the concepts and principles of CHN
 Describe the structure of MOH
 Describe health care delivery system
 Describe the policies, guidelines and standards of CHN
 Describe integrated health services
Common terminologies used in CHN

2.  Community- is a group of people(small or large group) living in a certain geographical
area and working together for a common goal. They share the same resources such as
water, climatic and geographical conditions, health services, administration and
leadership, interests, functions, values and social amenities, as well as disadvantages
such as shortage, risks and dangers.
 Community health- is the science and art of promoting health and preventing
diseases through organised community participation OR Refers to the healthy status of
the member of the community to solve the problems affecting their health and to the
totality of a health care provided for the community
 Community Health Nursing- synthesis of nursing and public health practice applied
to promoting and preserving the health of populations.
 Concept- category or class of objects or phenomena that represents either an abstract
version of the real world e.g an idea
 Principles- the foundations for rules
INTRODUCTION
Community health is concerned with the promotion of health and prevention of diseases
through close community participation. The greatest human possession is health and a
healthy community is a productive community. Currently the natural diseases equal to man-
made diseases or life style diseases like obesity, hypertension, diabetes, cancer, accidents etc.
In our health facilities, 70% of the cases seen are due to communicable diseases which are
preventable at community level through simple practices.As a clinician/nurse we need to
focus on preserving health, promoting health and preventing illness for all the people in the
community so that we can improve their health, prolong their life span and reduce
workload/disease burden.
The concept of CHN
Health is a highly individual perception, meaning and descriptions of health vary considerably.
Each individual person is different and unique.
Each has a mixture of some characteristics, some of which they share with others.
Factors that influence individual’s definition of health: developmental status, social and cultural
influences, previous experiences, expectations of self, perception of self.

3. The community has been described as one of the most fruitful areas for improving the health of
the people.
The social, the cultural and the physical aspects of the community have a major influence on an
individual’s health status
NB: Social environment- social problems and social support are directly related to physical and
mental illness
Physical environment- physical problems like air, water and soil pollution lead to various
diseases in human beings
Cultural environment- food patterns and lifestyles have major implications on health.
The hallmark of understanding CHN is:
 Increase the average span of human life
 Decrease the mortality rate(esp.IMR& MMR)
 Decrease morbidity rate
 Increase the physical, mental and social wel-being of individual
 Increasing the pace of adjustment of the individual to his environment
 Providing total health care to enrich quality of life
The goals of CHN
 Health promotion
 Health maintenance
 Prevention of illness
 Restoration of health
NB; elements of community health practice
Health promotion
 Health maintenance
 Prevention of illness
 Restoration of health
 Rehabilitation
 Research
 Evaluation
History of community health nursing
Community health nursing is the product of centuries of responsiveness and growth. Its practice was
adapted to accommodate the needs of a changing society, yet it has always maintained its initial goal

4. of improved community health. Community health nursing development has been influenced by
changes in nursing, public health and society that is traced through several stages. In tracing the
development of public health nursing, now it is clear that leadership role has been evident
throughout its history. Nurses in this specialty have provided leadership in: planning and developing
programs; shaping policy; administration; and the application of research to the community health.
Four general stages mark the development of public health or community health nursing.
• The early home care stage
• The district nursing stage
• The public health nursing stage
• The community health nursing stage
Early Home Care Stage (Before Mid 1800s) For many centuries female family members and friends
attended the sick at home. The focus of this care was to reduce suffering and promote healing
(Kalish and Kalish, 1986). The early roots of home care nursing began with religious and charitable
groups. In England the Elizabethan poor law written in 1600, provided medical and nursing care to
the poor and disabled. In Paris, St. Vincent DePaul started the sisters of charity in 1617, an
organization composed of laywomen dedicated to serving the poor and the needy. In its emphasis on
preparing nurses and supervising care as well as determine causes and solutions for clients' problems
their work laid a foundation for modern community health nursing (Bullough and Bullough, 1978).
The set back of these services were:
• Social approval following the reformation caused a decline in the number of religious orders with
subsequent curtailing of nursing care for the sick and poor.
• High maternal mortality rates prompted efforts to better prepare midwives and medical students.
• Industrial revolution created additional problems; among them were epidemics, high infant
mortality, occupational diseases, injuries and increasing mental illness both in Europe and America.
This stage was in the midst of these deplorable conditions and response to them that Florence
Nightingale (1820 - 1910) began her work. Much of the foundation for modern community health
nursing practice was laid through Florence Nightingale's remarkable accomplishments.
Nightingale’s concern for population at risk as well as her vision and successful efforts at health
reform provided a model for community health nursing today
District Nursing (Mid 1800s to 1900)
The next stage in the development of community health nursing was the formal organization of
visiting nursing (Phoebe, 58AD) or district nursing. Although district nurses primarily care for the
sick, they also thought cleanliness and wholesome living to their patients, even in that early period.

5. Nightingale referred to them as “health nurse”. This early emphasis on prevention and health nursing
became one of the distinguishing features of district nursing and later of public health nursing as a
specialty.
The work of district nurses focused almost exclusively on the care of individuals. District nurses
recorded temperatures and pulse rates and gave simple treatments to the sick poor under the
immediate direction of a physician. They also instructed family members in personal hygiene, diet
and healthful living habits and the care of the sick. Problems of district nursing: Increased number of
immigrants Increased crowded city slums Inadequate sanitation practices Unsafe and unhealthy
working conditions Nevertheless, nursing educational programs at that time did not truly prepare
district nurses to cope with their patients, multiple health, and social problems.
Public Health Nursing Training (1900-1970)
By the turn of the century, district nursing had broadened its focus to include the health and welfare
of the general public, not just the poor. This new emphasis was part of a broader consciousness
about public health. Specialized programs such as infant welfare that brought health care and health
teaching to the public and gave nurses an opportunity for more independent work, and helped to
improve nursing education (Bullough and Bullough 1978, p. 143). Lillian D. Wald’s (1867-1940)
contributions to public health nursing were enormous. Her driving commitment was to serve needy
populations. Wald’s emphasis on illness prevention and health promotion through health teaching
and nursing intervention as well as her use of epidemiological methodology established these actions
as hallmarks of public health nursing practice .The public health nursing stage was characterized by
service to the public with the family targeted as a primary unit of care.
Community Health Nursing (1970 to present)
The emergence of the term community health nursing heralded a new era while public health nurses
continued their work in public health by the late 1960s and early 1970s. Many other nurses, not
necessarily practicing public health, were based in the community. Their practice settings included
community based clinics, doctor’s office, work sites, schools, etc, to provide a label that
encompassed all nurses in the community. The confusion was laid in distinguishing between public
health nursing and community health nursing. The terms were being used interchangeably and yet,
had different meanings for many in the field in 1984 the division of nursing convened a consensus
conference on the essentials of Public Health Nursing practice and education in Washington DC
(1985). This group concluded that community health nursing was the broader term referring to all
nurses practicing in the community regardless of their educational preparation. Public health nursing,
viewed as a part of community health nursing, was described as generalist practice for nurses
prepared with basic public health content at the baccalaureate level and a specialized practice for
nurses prepared in the public health at the masters level or beyond.The debate over these areas of
confusion continued through the 1980’s with some issues unresolved even today. Public health
nursing continues to mean the synthesis of nursing and public health sciences applied to promoting

6. and protecting the health of populations. Community health nursing is used synonymously with
public health nursing and refers to specialized population focused nursing practice which applies
public health sciences as well as nursing services.
Principles of community health nursing
 Community health nursing services should be planned according to the needs of the
community.
 community health nurse should be qualified either as certificate, diploma or graduate or post
graduate in nursing
 Community health nurse(CHN) should not accept any gift or bribes from the patient and their
relatives
 CHN should follow the policy of the agency,where she/he appointed
 CHN should not belong to political group.
 There should be proper facilities andjob conditions
 CHN should function/serve as important member of health team.
 CHN should maintain professional relationship with all the leaders of the community
 CHN should follow ethics while working in the community
 CHN should keep continuous contact with the individual, family, community
 CHN should respect people’s culture and guide the community accordingly
Function of Community Health Nursing
 Home visiting
 Running child welfare clinic
 Running family planning clinic or assisting
 Assist in running ANC andPNC
 Conducts school health services
 Carries out or assist the PHN in inspection of day care centres
 Collection of information or data from the community
 Health education
 Record keeping
The structure of Ministry of Health

7. Functions of MOH
 Planning (for the delivery of health care services)
 Maintaining effective health information systems

8.  Manpower training, recruitment and development
 Promotive and preventive services
 Curative services
 Health care financing
 Registration and licensing of health facilities
 Health care policy development
 Health care quality assurance
The Ministry of Health operates at four main levels, which are based on our country's administrative
setup.
The four levels are:
i. National (Central)
ii. Provincial
iii. District (County)
iv. Community (Peripheral
CHMT
The MOH does not work in isolation. They have a team of health professionals who form the County
Health Management Team (CHMT).
The CHMT is charged with the responsibility of monitoring and supervising all health care services
in the County. Most of the members of the CHMT are found at the County hospital. The other key
members of the CHMT are found at the
County administrative headquarters
The members of the CHMT include:
 The County Medical Officer of Health (Chairman)
 The County Public Health Nurse
 The County Registered clinical Officer
 The County Public Health Officer
 The County Public Health Education Officer
 The County Health Administrative Officer
 The County Health Information Officer
 The County Pharmacist
The CHMT has other co-opted members who include:
 County HIV/AIDS/STD Coordinator
 County Physiotherapist
 County Disease Surveillance Officer

9.  County Nutritionist
 County Laboratory Technologist
 County Orthopaedician
Functions of CHMT
 Formulating relevant health objectives for the County in keeping with the national health
policies
 Training and deployment of staff to health facilities/ promotes capacity building/ CME.
 Planning and coordinating health activities for optimal utilisation of County resources.
 Supervising all health care activities and services within the County.
 Collecting and analysing data on community health needs and assessing
health coverage.
 Monitoring, evaluation and supporting the rural health staff and community health workers.
 Licensing health facilities/clinics.
 Measures effectiveness and efficiency of programs on ground
Functions of SCPHN
 The County Public Health Nurse (CPHN), also known as the County Community
Health Nurse, is an important member of the CHMT and he/she is supervised by the
CMOH.
 The main duties and responsibilities of the CPHN are:
 Planning, organising and supervising all community health activities in the County.
 Deploying nursing staff to community/rural health facilities.
 Conducting staff update courses.
 Collecting health information and compiling reports about community health
services.
 Planning and coordinating health campaigns.
 Procurement, storage and distribution of EPI vaccines.
 Implementing health development projects for the County development committee.
Functions of Community Health Nurse
ROLES FUNCTIONS
Manager
Organising and managing health care programs, being a team leader for
supervising community health nursing activities.
Implementer Implementing community health action/programs in collaboration with t
stakeholders in community health. Creating community awareness and i

10. their health. Developing the community’s ability to assess their health st
resources. Sharing knowledge and skills with the community on how to
their health and to prevent illness.
Advocator
Advise the health care providers, planners and other agencies on the
needs/problems of the community.
Advisor Sharing technical health information with individual families and comm
Health educator
Teaching individuals and families how to prevent disease and improve
their health.
Assessor/Identifier
Assessing the health status of the community. Identifying existing and p
health needs/problems and resources in the community.
Planner
Planning for health action with the other health team members and
community members.
Evaluator Evaluating the performance and the outcome of community health activi
Researcher
Carrying out surveys, studies and research to identify problems related to
your work.
Trainer
Training other community health workers, both designated and voluntary
community-based health workers.
Other functions
Care giver/service provider
Case finder
Coordinator
Collaborator
Counselor
Consultant
Epidemiologist
Good observer
Team leader

11. Health promoter
Role model
Policy and standards
Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health
care goals within a society. An explicit health policy can achieve several things: it defines a vision
for the future which in turn helps to establish targets and points of reference for the short and
medium term plans
Policy- agreed plan of action ( in this context the key stake holders of MOH makes and implements
the policy in conjunction with political party).
Standard- is a level of quality that is universally accepted.
NB: policies and standards are set according to the specific practice e.g we have breast feeding
policy, Kenya health policy, cost sharing policy, universal standard precautions on IPC reproductive
health policy etc
Goal- attaining the highest possible health standards in a manner responsible to the population needs
Aims- to achieve this goal through supporting provision of equitable, affordable and quality health
and related services at the highest attainable standards to all Kenyans
This policy gives Kenyans direction to ensure significant improvement in overall status of health in
line with vision 2030 and constitution
The policy based on three pillars; political, economic and social
The adoption of the vision 2030 by Kenya came after a successful implementation of the economic
recovery strategy (ERS) for wealth and employment creation. This increased GDP from 0.6% in
2002 to 6.1% in 2006.
Economic pillar: aim to improve prosperity of all Kenyan through economic development
programme in all regions of Kenya and to achieve a GDP growth rate of 10% per annum beginning
2012.
Social pillar: Seeks to build a just and cohesive social equity in a clean and secure environment.
Political pillar: aim to realize a democratic political system founded on issue based politics that
respects the rule of law and protects the right and freedom of every individual in kenyan society.

12. Health care system
Is a multitude of services rendered to individual, families or communities by agents of health
services or professions for the purpose of promoting, maintaining, monitoring or restoring health.
The term “Health care delivery system” is often used todescribe the way in which health care is
furnished to thepeopleCharacteristic of health care system
 Appropriateness
 Accessibility
 Affordability
 Feasibility
 Availability
 Adequacy
 Comprehensiveness
. Classification of health care delivery system is by acuity of the client’s illnesses and level of
specialization of the professionals.
� Primary care level
� Secondary care level
� Tertiary care level
Primary care level: is the usual entry point for clients of thehealth care delivery system. It is
oriented towards thepromotion and maintenance of health, the prevention ofdisease, the management
of common episodic disease and the monitoring of stable or chronic conditions. Primary
careordinarily occurs, in ambulatory settings. The client or thefamily manages treatment with health
professionals providingdiagnostic expertise and guidance.
Secondary care level: It involves the provision of specializedmedical services by physician or a
hospital on a referral by theprimary care provider.A patient has developed a recognizable sign and
symptomsthat are either definitively diagnosed or require furtherdiagnosis. It is oriented towards
clients with more severeacute illnesses or chronic illnesses that are exacerbated. If hospitalization
occurs it is usually in a community (county)hospital. Most individuals who enter this level of care
arereferred by primary care worker, although some are self-referred.The physicians who provide
secondary care areusually specialists and general practitioners.
Tertiary care level: It is a level of care that is specialized andhighly technical in diagnosing and
treating complicated orunusually health problems.Patients requiring this level often present in
extensive andcomplicated pathological conditions. It is the most complexlevel of care. The illness
may be life-threatening, and the careordinarily takes place in a major hospital affiliated by a
medicalschool. Clients are referred by workers from primary orsecondary settings. The health

13. professionals, including physicians and nurses tend to be highly specialized, and theyfocus on their
area of specialization in the delivery of care.The other classification of health care delivery system
is:
Preventive: is aimed at stopping the disease process before itstarts or preventing further
deterioration of a condition thatalready exists.
Curative: is aimed at restoring the client's health.
Rehabilitative: is aimed at lessening the pain and discomfortof illness and helping clients live with
disease and disability.Some nurse theorists have conceptualized the nursing role asbeing focused on
sustaining care and preventing disease.However, the work role of nurse practitioners and home
healthcare nurses would probably span all three of theseorientations. The nurse must understand and
remember thatthe preventive services are also popularly categorized asprimary, secondary, and
tertiary preventive health care.
Levels of prevention
Primary prevention: refers to the prevention of an illnessbefore it has a chance to occur.
Aims: Health promotion and Protection against illness
Primary preventive measures apply before a diseasemanifests with sign and symptoms.
Examples:
 Eating well balanced diet
 Regular exercise program
 Maintaining weight
 No smoking
 Moderation of alcohol
 Information on
 Alcohol
 Substance
 Nutritional counseling
 Environmental control
 Safe water Supply
 Good food hygiene
 Safe waste management
 Vector and animal reservoir control
 Good living and working condition
 Stress management

14. Secondary prevention: includes the early detection of actualor potential health hazards. This allows
for prompt interventionand possibly a cure of a disease or condition. It is directedforwards health
maintenance for patients experiencing health problems.
Secondary prevention has two sub-levels
a. early detection (diagnosis) of disease
b. prompt treatmente.g. hypertension screen and acute care.
Secondary prevention increases awareness of:
 breast self – examination
 testicular self-examination
 mammography
 pap smear
 BP screening
 Blood glucose screening
 Teaching breast self - examination
 Antibiotic treatment of streptococcal pharyngitis
 aimed at preventing rheumatic fever
 “Caution” of cancer
Tertiary Prevention: is aimed at avoiding further deteriorationof an already existing problem.
Rehabilitative efforts aresometimes tertiary preventive measures. It deals withrehabilitation and
return of client to a status of maximumfunction within the limit posed by the disease or disability
andpreventing further decline in health. This level of preventionoccurs after a disease caused
extensive damage.
Examples -Rehabilitation after stroke, Smoking cessation program for clients withemphysema.
During the NHSSP II the MOH proposed the rationalization of service delivery through six KEPH
levels and life cycle cohort
The specified six levels of health care system:
Levels inclusions Population covered
Level 1 Community 5,000
Level 2 Dispensary 10,000

15. Level 3 Health centre, nursing
homes
25,000 – 30,000
Level 4 County , Sub County 100,000
Level 5 Provincial 1,000,000
Level 6 National > 1,000,000
Levels of service delivery under KEPH
Levels of health care delivery in the Kenya Essential Package for Health (KEPH)
6 Tertiary hospitals
5 Secondary hospitals
4 Primary hospitals
6-Tertiary
5- secondary
4 -primary
3 -H/C,NH, MAT
2- Dispensary/clinics
1- Community, HH, Village and
individual

16. 3 Health centres, maternities, nursing homes
2 Dispensaries/clinics
INTERFACE
1 Community: Villages/Households/Families/Individuals
The KEPH defines the six life cycle cohorts as;
i. Pregnancy and newborn up to 2 weeks
ii. Early child hood -2 weeks to 5 years
iii. Late child hood – 6-12 years
iv. Adolescent – 13-24 years
v. Adult – 25-59years
vi. elderly - > 60years
NB: Each cohort has specific activities/health messages, minimum kit and human resource
Key messages for each cohort below
i. Pregnancy and new born up to 2 weeks
Information Education Communication (IEC) on early recognition of danger signs: referral; birth
preparedness health promotions
ii. Early child hood -2 weeks to 5 years
Behavior Change Communication (BCC) to promote key household care practices in
prevention, care of the sick child at home, service seeking and compliance, promoting growth and
development.
iii. Late child hood age:6 yrs-12yrs
School enrolment, attendance and support behavior formation, and hygiene.
iv. Adolescent – 13-24 years
BCC; Peer education and information; Supply of preventive commodities, Referral
services
v. Adult – 25-59years
BCC and IEC, Home Care, Treatment Compliance (TB, ART) Supply of preventive
commodities, Referral services Promotion of gender and health rights
vi. Elderly - > 60years
IEC and BCC to reduce harmful practices; regular medical checkups, Referral services

17. Integrated health services
Integrated healthcare system involves all levels in the healthcare service delivery and
organization, engaging both managements in National and County levels.
Offering many health activities under one roof/umbrella. For example in MCH the following
activities are offered
Major component of MCH services
 Provision of quality ANC, delivery care,
 PNC, and FP services
 Prevention of STIs/HIV/AIDS
 Immunization
 Growth monitoring
 Well baby clinic
 Sick baby clinic
 Nutrition Rehabilitation Clinic
 Nutrition counseling and healtheducation
 School health education
 Adolescent health services
The usual services provided for children at these clinics are:
 Vaccinations
 Nutrition evaluation and advice
 Treatment of minor illness
 Referral for more difficult problem
Rural health
School health services:
 Screening and examination of school children and food vendors
 Immunization and micronutrient supplementation
 Health education on current public health issues
 Management of minor ailments and injuries
 Introduction of life skills and moral values including reproductive health
 Maintenance of a hygienic school environment
 School deworming
 Referrals
Health Centres

18. Health centres are staffed by midwives or nurses, clinical officers, and occasionally by doctors.
They pro-vide a wider range of services, such as basic curative and preventive services for adults
and children, as well as reproductive health services. They also provide minor surgical services such
as incision and drain-age. They augment their service coverage with outreach services, and refer
severe and complicated condi-tions to the appropriate level, such as the district hospital.