Community Health Midterm PDF

 Strengthen the community resources.  Prevent and control communicable and non-communicable diseases.  Provide specialized services.  Conduct research.  Principles of Community Health Nursing: It should be planned based on the needs of the community. It is based on identifie...

 Strengthen the community resources.  Prevent and control communicable and non-communicable diseases.  Provide specialized services.  Conduct research.  Principles of Community Health Nursing: It should be planned based on the needs of the community. It is based on identified needs and functions. Integration of Health education, guidance and supervision with community health nursing services. Health services should be realistic in terms of available resources. Community is the focus which is the unit of health care services. Professional relationship with etiquette and dignity Community participation is the integral part of the community health services. Individual and family members participation in decision making. Health services must be continuous. Proper records and reports are essential. Proper evaluation of health services Health services must be available to all without any difference. * Factors influences on community health nursing's development: 1- Advanced technology: Advanced technology has contributed in many way to shape the practice of CHNg. E.g. technologic innovation has greatly improved health care, nutrition & life style. 2- Progress in causal thinking: Causal thinking is relating disease or illness to its cause. Progress in the study of causality, particularly in epidemiology, has significantly 5 affected the nature of CHNg. E.g the germ theory of disease causation, was the first real break through in control of communicable disease. 2- Changes in education: Changes is nursing education have had an important influence on community health nursing practice. The wealth of information relevant to CHNg practice means that nursing students have more content to participate in CHNg. For the learner, education has led to more responsibility. 4- Changing role of women: Changing role of women has profoundly affected CHNg. The women's right's movement made considerable progress, women's achieve to right to vote and gained a greater economic independence by moving into labor force. Women's movement has contributed to CHNg' gains in assuming leadership roles. 5- Consumer movement and changing demographics: Consumers become more aggressive in demanding quality services and goals and they need to participate in descisions that affected them. Changing demographics such as immigration, number of births or deaths affect CHNg planning and programming. 6- Economic forces: Economic have affected community health nursing practice. E.g unemployment, the rising costs of living and health care costs. 6 Characteristics of CHNg: 1- It is a specialty field of nursing: The two characteristics of any specialized nursing practice are (1) specialized knowledge and skills (2) focus on particular set of people. These two characteristics are true for community health nursing. 2- Combines public health with nursing: Community health nursing is grounded in both public health science and nursing science, which makes the nature of its practice unique. 3- Population focused: CHNg have essential feature that is population focused means that it is concerned with the health study of population groups and their environment. 4- Emphasizes prevention Health promotion & wellness: - Including services for mother, infant and school programs. 5- Promotes client responsibility and self care: CHNg can encourage individuals participation rather than permitting a dependency. 6- Uses aggregate measurements and analysis: The need to examine data after collection for the entire population under study before making intervention decision is fundamental to CHNg. E.g analysis of Health state and environmental factors. 7- Uses principles of organizational theory: The community health nurses carefully assess group and community needs, establish priorities and plan, implement and evaluate services, they are using the organizational principles. 1 8- Involves inter professional collaboration – plan with physician, social worker physical therapist and teacher team work of health. * Function of community health nursing: Community health nurses work as partners within a team of professionals in public health and other disciplines to improve the health of population. T he various roles and settings for practice including three primary functions of public health: 1- Assessment: Refers to measuring and monitoring the health status and needs of designated community or population. It is a continuous process of collecting data and information about health, diseases, injuries, air and water quality, food safety and available resources. 2- Policy development: Is the formation of a guide for action that determines present and future decisions affecting the public's health which is builds on data from the assessment function. It provides leadership and administration for the development of health policy and planning. 3- Assurance: Is the process of translation established policies into services. This function ensure that population based services are provided, whether by public health agencies or private sources. It also monitors the quality of and access to those services. 8 * Components of community Health practices:  Community Health practices: It is part of the larger public health effort that is concerned with preserving and promoting the health of specific populations and communities. Community health practice incorporates six basic elements: 1- Promotion of Health:  It includes all efforts that seek to move people closer to optimal well- being or higher level of wellness.  It is the combination of educational and environmental supports for action and condition of living conducive to health. 2- Prevention of Health problems: Means anticipating or discovering problems as early as possible to minimize possible disability and impairment, through the three levels of prevention. Primary prevention: Measures taken to keep illness or injuries from occurring, ex local health departments helps control and prevent communicable disease by providing regular immunization programs. Secondary prevention: Involves efforts to detect and treat existing health problems attempts to discover a health problem at a point when intervention may lead to its control or eradication. Tertiary prevention: Attempts to reduce the extent and severity of a health problem to its lowest possible level to minimize disability and restore or preserve function. 9  3- Treatment of disorders: It focuses on the illness end of continuum and is the remedial aspects of community health practice. This is practiced by: 1. Direct service to people with health problems; E.g. home visit for elderly peoples, chronic illness, etc. 2. Indirect service; e.g. assisting people with health problem to obtain treatment and referral. 3. Development of program to correct unhealthy condition; e.g. alcoholism, drug abuse, etc. 4- Rehabiliation: In community health the need to reduce disability and restore function applies equally to families, groups, individuals and community. 5- Evaluation: Is the process by which the practice is analyzed, judged according to established goals and standards. 6- Research: Is a systematic investigation to discover facts affection affecting community health and community health practice, solve problems and explore improved methods of Health services. Settings (scopes of CHNg): The types of places in which community health nurses practice are increasingly varied including a growing number of non-traditional settings and partnership with non-health groups. 41 The various settings can be grouped into six categories: 1- Homes. 2- Schools. 3- Ambulatory service setting example M.C.H, family planning centers. 4- Occupational health settings. 5- Residential institutions example. Camping for poliomyelitis hospices care. 6- The community at large. * Roles of Community Health Nurses: Community health nurse assume a varity of roles while conduction practice, these roles are: 1- Clinician role: The most familiar community health nurse role is that of the clinician or provider of care. The clinician role in community health means that the nurse ensures health services are provided, not just to individuals and families but also to groups and population. The clinician role emphasis on holism, health promotion, and skill expansion. * Holistic practice: A holistic approach means considering the broad range of interacting needs that affect the collective health of the client as a larger system. E.g. considering relationships, age, education developmental needs, peer influence, environment. * Focus on wellness: Community health nursing identify people who are interested in achieving a higher level of health and work with them to accomplish that goal, they also identify groups and population that may be vulnerable to 44 certain health threat and design preventive and promotive Health programs. * Expanded skills: The community health nurse uses different skills, e.g physical care skills, observation, listening, communication and counseling. There are also other stronger skills as collaborative skills, use epidemiology and biostatistics community organization, research program evaluation. 2- Educator role: It is widely recognized that health teaching is a part of good nursing practice and one of the major functions of a community health nurse. The educator role is especially useful in promoting the public‘s health for at least two reasons: 1- has the potential for finding greater receptivity and providing higher yield results. 2- Is significant because wider audience can be reached. The emphases throughout the health teaching process continue to be placed on illness prevention and health promotion. 3- Advocate role : The issue of clients‘ rights is important in health care today. Every patient or client has the right to receive just equal and humane treatment. However, our present health care system is often characterized by fragmented and depersonalized services The community health nurse often must act as advocate for clients pleading the cause or acting on behalf of the client group. There are times when health care clients need someone to explain what services to expect and which services they ought to receive 42 List characteristic of community health nursing Discuses component of community health practices Research is a systematic investigation to discover facts affecting community health and community health practice. (true or false) 43  Communicable Diseases Objectives: At the end of this lecture the students will be able to: - Define the communicable diseases - Explain the different terminology related to communicable diseases - Mention the predisposing factors of infection. - Discuss the chain of infection. - List the most communicable diseases and explain the cause, mode of transmission and signs of each one. - Discuss the role of community health nurse in preventing &controlling communicable diseases. 44 Out lines: - Introduction - Definition of communicable diseases - Terminology and definitions: - Causes of diseases - Chain of infection - Most common communicable diseases: Common Foodborne Diseases Common Droplet Infections: Common Blood Borne diseases Sexual Transmitted Diseases Zoonotic Diseases - The role of Community health nurse in preventing and controlling of communicable diseases according three levels of prevention 45  Communicable diseases Introduction: Communicable diseases spread from one person to another or from an animal to a person. The spread often happens via airborne viruses or bacteria, but also through blood or other bodily fluid. The terms infectious and contagious are also used to describe communicable disease. In this section, learn about coordinated efforts to combat a few of the most serious communicable diseases. Communicable disease; any disease transmitted from one person or animal to another directly, by contact with excreta or other discharges from the body;indirectly, by mea ns of substances or inanimate objects, such as contaminated drinking glas ses, toys, or water; or by means of vectors,such as flies, mosquitoes, ticks, or other insects. Communicable diseases may be caused by bacteria, chla mydia, fungi, parasites,rickettsiae, and viruses. To control a communicabl e disease, it is important to identify the organism, prevent its spread to the environment, protect others against contamination, and treat the infected person. Many communicable diseases, by law, must be reportedto the loc al health department. Also called contagious disease. Definition of communicable disease: Communicable disease: An illness due to specific infectious agent or its toxic product, capable of being directly or indirectly transmitted from man to man. A disease that is transmitted through direct contact with an infected individual or indirectly through a vector. Also called contagious disease. Communicable disease is one that can transmit from one person to another and caused by infectious agent that is transmitted from a source or reservoir to susceptible host. 46 Different terminology: Infection: the entry and development or multiplication of infectious agent in the body of man. An infection doesn't always cause illness. Infectious disease: is one that caused by infectious agent. Zoonoses: An infectious disease that is transmissible under normal conditions from animals to humans. Outbreak: this word used when the epidemic occurs in small confined area. e.g., School, camps, hotel or prison, though confined to the use of infectious diseases. Endemic (En = in, demos = people): It refers to a disease that exists permanently in a particular region or population. e.g., Malaria is a constant worry in parts of Africa. Epidemic (Epi = upon, demos = people): It refers to the occurrence of a disease in the community or region in excess number of cases more than expected. OR An outbreak of disease that attacks many peoples at about the same time and may spread through one or several communities. Pandemic: When an epidemic spreads throughout the world. e.g., Influenza pandemic in year 1917, H1N1 in 2009. Host: person/ animal that affords subsistence to an infectious agent under natural condition. Case: a person having the particular disease, health disorder, or condition under investigation. Carrier: Person/ animal that harbors a specific infectious agent in the absence of discernible clinical disease and serves as potential source of infection. Incubation period: it is defined as the time interval between invasion of the body by an infectious agent and appearance of the first sign and symptoms of the disease 41 Family roles: Roles are expectations of behavior, obligations, and rights that are associated with a given position in a family or social groups. Social and cultural factors that influence role fulfillment include rates of social change, contradictions, modifications, and alternatives in prevailing role definitions. Also, social class, race, ethnicity, and age have significant implications for role conception and performance e.g among the poor population in society, a married woman with a husband present usually has few rights but has demanding domestic and economic obligations to the family. The upper – class wife usually has great freedom and serves as the manger for employed assistants who provide domestic services family adult roles. 1- Child socialization. 2- Child care. 3- Provider role. 4- Housekeeper role. 5- Kinship role. 6- Sexual. 7- Therapeutic role. Assisting family members to cope with problems as providing emotional support. 8- Recreational role. Family functions: All families have certain functions that are performed to maintain the integrity of the family unit and to meet the family unit's needs, the individual family members' needs, and society's expectations. These functions are: 1-Biological 1. Reproduction and child-bearing 82  2. Rearing of the child 3. Nutrition of the family members 4. Production of health of family members at all ages 5. Recreational for family and its members 2-Psychological 1. Emotional security of the members 2. Sense of identity 3. Maturation of personality 4. Psychological protection 5. Ability to make relationship outside the family 3-Socio-culture 1. The transfer of values related to behaviors, tradition, language, and morals 2. Socialization of children 3. The formulation of behaviors for all stage in development and adult life 4-Economic 1. Acquision of resources to fulfill other functions 2. Distribution of resources expenditure, savings 3. Economic buffering of members of family 5-Educational 1. Preparation for adult role 2. Fulfillment of adult role Factors Influencing Family Health The state of health or well-being of a family at any given time or a family's capacity to reach a state of family health is determined by the interaction of many factors both outside and inside the family. These factors which together make up the families' total environment may be set out as follows: a) Environmental factors 83  1. Climate, water supply, air. 2. The biological environment, animals and all living things. 3. Man-made physical environment-character of buildings, noise, space, sewage disposal, etc. b) Family factors influencing physical or mental health 1. Family structure and type as number, age, relationship and family type. 2. Biological characteristics of each member's as genetic, prenatal, nutritional, physical and mental health. 3. Cultural patterns, family dynamics and roles, coping and behaviors patterns. 4. Social class or status, value systems; religious belief; occupation of wage earners, skills, social habits. 5. Economic status. C) Factors Affecting Family Coping Pattern: Factors in addition to age that may affect family and social relationships include cultural beliefs, economic status, lifestyle, previous life experience, and external stressors such as illness of a family member. 1-Culture, values and beliefs: Cultural traditions have an impact on the family as it functions. Components of a socio –cultural dimension include ethnic patterns, language, food customs, patterns of communication, role expectations, health care beliefs, childbearing practices, availability of extended family support and religious beliefs and practices. The nurse may encounter much variation in family structure and function among different cultures, each of these variations can have an affect on the person's health status. For example, the extended family is valued, and childbearing is a group endeavor. The extended family is essential as a support system to help families cope when stressors such as illness occur. 84 2-Economic resources A clear economic influence on family and social relationships can be observed as people with marginal incomes struggle to survive. Economic constraints often create problems in maintaining a family's lifestyle after divorce or a change in employment, or with a change from two wage- earners to one. Resentment toward society or toward other members of the family for forcing a below – standard lifestyle may arise. Functioning in single – parent families will be difficult when they have limited support, without psychological and economic resources. 3-Lifestyle: The mobility of families can affect relationships as parents move from job to job and children move from school to school. Support people and friendships change. Lack of extended family support systems due to geographic distance can increase the strain on parents after relocation. The need to have two incomes has created the "latch-key" practice in childbearing, in which children are responsible for their own care and supervision after school. The family's lifestly in terms of rest and relaxation, nutrition, smoking drug and alcohol use, and exercise influences the health status of all the members and the choices the children will make as they become adults. 4-Previous life experience: Previous life experience greatly affects a family's functioning. Children learn about relationships almost exclusively from their parents and early family life. They will carry beliefs to their own future families about how to form relationships, how to make decisions and solve problem, what are accepted roles for men and women, how to raise children, how to use resources, and how to show affection. 5-Coping and stress tolerance: 85  Any stress on the entire family or an individual member greatly affects functioning. Acute or chronic illness of a member may alter roles and relationships within the family. For example, in a family with a seriously ill father, the mother may become the primary economic provider and a child may provide care and nurturing for the father in the home setting. Other stresses, such loss of a family member, involvement in a natural or man made disaster, or an accident, also alter family functioning. Some families have the ability to grow as the result of a crisis, where as other experience dysfunction; some families live with constant stress and others experience little change or stress. Health Tasks of the Family The tasks of the family include the following: 1. Recognizing interruptions of health development: The family monitors illness or failure to thrive and this recognition will facilitate healthful development. 2. Making decisions for seeking health care: Usually the family is the first to recognize any deviation from normal health and when necessary family members must take decision about utilizing health care system. 3. Dealing with health crisis: Crisis is inevitable in any family. Severe illness, death, child bearing and hospitalization are crisis situations and affect the heath of the family. 4. Providing nursing care to sick or dependent members of the family: Care of sick in the hospital or at home is done by the family members with the help of the health team. 5. Maintaining healthy home environment: Home should be clean, safe from hazards like fire, accidents, falls, etc. The place for play and recreational activities should provide emotional and social environment conducive to development. Family dynamics: 86  Family dynamics reflect and influence the physical, mental and spiritual health of the individuals in a family. Family dynamics mean that how to keep family's relationship peaceful and harmonious – even through troubled times. Family health assessment: 1- Family demographics. 2- Physical environment data. 3- Psychological and spiritual environment. 4- Family structure and roles. 5- Family function. 6- Family values and beliefs. 7- Family communication patterns. 8- Family decision making pattern. 9- Family problem solving patterns. 10- Family coping patterns. 11- Family health behavior. 12- Family social & cultural pattern. Guidelines for family health assessment: 1- Focus on the family as a total unit. 2-Ask goal – directed questions. 3- Collect data overtime. 4- Combine quantitative & qualitative data. Role of the nurse in family care: 1- Collection of a family nursing database (general or focused). Data collection is focused on both identification of problem areas and strengths of the family. 81  Often this and the following step diagnostic reasoning become integrated so that assessment and analysis of the data collected occurs concurrently. Nurses make inferences and draw conclusions about the data they collect, which in turn directs more data collection or defines the problem areas. 2- Diagnostic reasoning and generation of specific family nursing diagnosis. In this step, nurses make clinical judgments about which problems can be solved by nursing intervention, which problem need to be referred to other professionals, and areas of concern to which the family is successfully adapting on its own without intervention. The problems that require nursing intervention area specifically stated as family nursing diagnoses. The family nursing diagnosis provides direction for the collaboration of the nurse and the family in designing a plan of action. 3- Collection of nursing and medical data and generation of data supported nursing prognosis for each family nursing diagnosis. The nursing prognosis is a nursing judgment, based on the holistic view of the family and its members, predicts the probability of the family's ability to respond to the current situation. The predictive or statement, outlines the most successful course of action on which to focus the intervention. 4-Treatment planning based on family nursing diagnosis and prognosis, plus additional data on daily living and family resources and deficiencies, that influences planned nursing actions. The nurse and family work in a partnership to design and contract for a plan of action based on identified family strengths. The goal of the plan of action is to have the family successfully manage its health care concerns. 5- Implementation of family –negotiated plans of action. The specific family and nursing interventions are carried out by the identified family member or provider to achieve the goals upon which hey all agreed. 6-Evaluation of family / family members responses to plans of action, effects of family diagnosis, prognosis, and previous treatment. The evaluation phase is 88  based on the family outcomes, not on the effectiveness of the interventions. Modification of family nursing diagnosis and plans occurs as necessary based on an ongoing evaluation. 7-Termination of the nurse- family partnership included in the plan of action and implemented based on the evaluation. More detailed discussion of the family nursing process that demonstrated how to implement the process is presented in the following sections. - The data in family record include: - a-Family travels - b- Family feeding practice. - c-Referral services - E-Immunization against major infectious disease. - List characteristic of healthy family - Discuses role of the nurse in family care 89  COMMUNICATION AND EDUCATION Learning objectives: By the end of this lecture, the student will be able to:  Define health education.  Define learning process.  State the objectives of health education.  Describe the principles of health education program.  Recognize process of health education program.  Apply advanced communication skills appropriate to each age group.  List methods of health education.  List barriers facing health education.  Identify role of the nurse as health educator.  State qualities of CH. Nursing & health educator. N.B.: H.E means health education. 91 Out line: - Introduction. - Definition of health education. - Objectives of health education. - Scope of health education. - Principles of health education. - Definition of learning process. - Factors affect learning process. - General principle of learning. - The process of health education program. - Methods of health education. - Barriers facing health education. - Core of communication skills. - Role of the nurse as health educator. - Qualities of C.H. Nurse & health education. 94 Introduction: Education in health care today, both patient and nursing staff, student, education is a topic of utmost interest in every setting in which nurses practice. The need for community health nurses to teach others will continue to increase in this era of health care reform. Nurses are considered information brokers educators who can make significant difference in how patients and families cope with their illness, how the public benefits from education directed at prevention of disease and promotion of health and how staff nurses gain competency and confidence in practice through continuing education activities. All nursing care is directed toward, promoting, maintaining, and restoring health, preventing illness, and assisting people to adapt to the residual effects of illness. These nursing activities are accomplished through health education or patient teaching. Definition of health education: - Health education is the science of teaching people the essentials of healthy living and impressing the given knowledge so that attitudes and practice becomes part of their personality and habits. This will lead to protection and promotion of their own health. - Or Health educations the sum of experience, which influence knowledge, attitudes and practice to health. Objectives of Health education: 1- To inform people abut promotion of health and prevention of disease. 2- To motivate the public to follow sound health behavior and show active participation to solve health problems and verity health needs of the community. 92  3- To change faulty traditional beliefs, practices and behavior related to health. 4- To promote the development & proper use of health services. 5- Reduce undesired risks of diseases and illnesses. These objectives can be reduce the morbidity and mortality and disability also cost of health care can be reduced. Scope of health education: H.E. is not limited to situations in which actual instruction is given. It results from a wide variety of experiences in homes, clinics educational institutions and schools, community & industry. 1- In Homes: Community health nurse meets her teaching opportunities in a variety of situations e.g. the hygiene habits, family attitude towards health, prevention & management of illness and environmental sanitation or home sanitation. 2- In clinics: The nurse can use demonstration & group teaching with patients who have similar problem. 3- In educational institutions & school: Health record & attendance records help the nurse to assess the health problems & learning needs of individuals & various students. The school nurse may take part in the develop of curriculum for health teaching. Also she can help in service training programmers for teachers. 4- In the community: The nurse is participate in community activities that influence health behavior. 93  attend schools and spend about half of their day for a period of 9 years.  School students are considered a vulnerable group. They are growing exposed physiological, mental and emotional stress at home or school.  Some children attend school with different health problems, could be early discovered and treated.  School students are very active& curious so liable to accidents.  Health status of students is a strong determinant of their school environment.  Students are affected by school environment.  School years are the best opportunity for health education.  We can reach parents through their children. Needs of school age children: 1- Nutritional needs: School student need 2400 calories/ day. It should be well balanced diet containing all nutrients and vitamins, minerals as well as adequate fluid intake. 2- Protection from infection: Booster immunization, healthfully school environment, daily observation of all pupils for early detection of any disease or problem, and screening for infectious diseases as skin diseases, scabies, and ringworm 3-Sanitary environment (home, school): through; - Avoid noise and noisy place around the school. - School building must be wide with sufficient play area. - Good ventilation in classrooms. - Safe water supply and natural and artificial light. - Clean baths and insect control. 36  3- Exercise: - There should be a wide safe play area. - School schedule should include physical training lessons. - Teach children the body mechanism while sitting, reading. 4- Rest, sleep: - The school child needs adequate periods of rest and sleep. 5- Adequate health services: - Either school health insurance, governmental health services. 6- Psycho social needs: - As: security, safety, peer group interaction. 7- Health education: - The children must understand the meaning of health and create health consciousness which reflect on their health behaviors. Health problems of school age children: 1- School problems which are divided to: a. School phobia: - All organic cause must be ruled out before school phobia. The most common complaints are abdominal pain, vomiting, headache, regression, nausea, diarrhea, panic attacks b. Learning difficulties: - The learning difficulties are represented in variety of specific learning disabilities in children. These difficulties are in reading, writing, and understanding. 2- Behavioral problems: - Children sometimes employ aggressive, negative or disobedient behavior in an attempt to feel important and control others. The forms of aggression are: - lying, stealing, cheating. 3- Sexual problems Child is interested in birth and conception information and questions. 31 4- Nutritional problems that may be Overfeeding (Obesity) or Underfeeding (Anemia). Deficiency diseases: Anemia and vitamin A deficiency 5- Communicable diseases e.g., Diphtheria, Typhoid Fever, and Hepatitis A Virus. 6- Dental problems. 7- Skeletal problems e.g., Bone fractures, Scoliosis. 8- Accidents: the school age child may faces many forms of accidents such as: road traffic accident, drowning, electric shock, fall, poisoning, head injury, eye trauma/injury and foreign body entry in the eye, burns and scalds, body injuries/trauma, and dog bites/wounds. 9- Infections e.g., Respiratory infections are the most frequent occurring illness in childhood. Strepto cocal infection (Tonsillitis), some food- borne infections (Ascariasis), Eye infection (Conjunctivitis) & Skin infections (Ring worm of the scalp). Urinary tract infection 10-Tobacco and drugs abuse School Health Program The school health program is defined as the procedures to protect and promote the health of pupils and school personnel from all aspects physical, mental, social, and emotional health.  A comprehensive, coordinated school health program helps each child achieve and maintain an optimal health condition so that maximal physical, emotional and intellectual growth can occur. 38 Objectives: The main objective of school health program is: Prevention of illness as well as the promotion of health and well-being of the students through: - Early detection and care of students with health problems - Development of healthy attitudes and healthy behaviors by students - Ensure a healthy environment for children at school - Prevention of communicable diseases at school Components of school health program: The program includes three phases, they are not separate and each effect on the others. They are: School living environment School health services Health education 1- School living environment: The importance of sanitary school environment on effective learning and providing comfort and educational facilities is also emphasized. Poor sanitation has its impact on health and health teaching as well. 1-School Living Environment School living environment physical Social & environment emotional environment 39 Physical environment: *Components of school physical environment: 1. Building 2. Class room 3. Water supply 4. Lavatories 5. Bath and douches 6. Sewage disposal 7. Insect control 8. Food sanitation 1. Building: It requires a special building design while residential buildings are not satisfactory Site: Must be sufficiently away from source of noise, heavy traffic and pollution, it should be in proper location to provide safety. Size: It should be sufficiently wide and with suitable playground. 2. Class room: size: Usually 6x8 or 5 x 7 m students: Number of students should not exceed 30 to 40 students. Ventilation: The windows are arranged in both side walls to allow cross ventilation. Light: Natural lighting should be available as well as artificial lighting 41 Desks and seats: It should be properly designed for the body of the students. Unsuitable desks and seats may cause discomfort, deformities and optical errors. 3. Water supply: Piped water supply in urban and underground water in a rural areas or areas with no public water supply. 4. Lavatories: Provided with soap and should be placed near the water closets for hand washing. 6. Bath and douches: It could be available for personnel cleanliness. 7. Sewage and refuse disposal: Refuse should be collected daily. Small baskets should be distributed in the class room and playground to collect paper and waste materials. Sanitary system of sewage disposal should be used. 8. Insect control: The school environment should be free from any breading places, application of insecticides usually used when necessary. 9. Food sanitation: Special consideration is given to the canteen and avoiding the food handlers scattered around the school. B-Social & emotional environment - Good relationship between students and teachers and parents. - Good relationship between children themselves. 44  - The school day and homework are properly arranged to prevent fatigue. - Social activities are available along the school times. - Opportunities for developing talents and skills. 2-School health services: Definition: Are those services which provided in school for the welfare of children. Aims of school health services: - To enhance overall health. - Early detection of disorders. - Appropriate treatment. - Prevention and control of communicable disease. - Healthy environment. Provision of health services to the children and young students in following forms fall under this category: School health services include:  Appraisal services  Preventive services  Curative services  Dental services 42  1- Appraisal services Health appraisal means the organized activity carried out to assess the health status of the students from the physical, mental, social and emotional condition. Health appraisal includes the following: a. History b. Observation c. Screening d. Laboratory test e. Comprehensive medical examination f- Special survey a. History: History should be taken from preschool health records, or from parents through questionnaire or interview about: Past history of diseases: measles, chicken box. allergy, accidents, surgical operation, immunization. Family history: - communicable diseases: T.B -Hereditary diseases: DM., epilepsy  Social habits and behaviors: smoking b. Observation: Health observation done by teachers and health visitors. The teachers can observe only the changes in the appearance of the child behavior and compare it with the other children. Many manifestations of illness could be discovered from the daily observation such as: 43  - Loss of interest and easy fatigability. - Eye problems as error of refraction. - Behavioral problems as aggression, lack of confidence. - Manifestations of diseases: pallor, episodes of bronchial asthma. c. Screening: The health visitors and the teachers are responsible for these tests. Some of these tests done yearly as height, weight and visual acuity, hearing and speech defects. Collaboration between health visitors and education sectors is crucial for this component of school health program. d. Laboratory test: Urine analysis: for albumin, sugar, and Schistosoma. Stool analysis: for parasites as ascaris. Blood analysis: Hemoglobin for anemia. X- ray: on the chest. e. Comprehensive medical examination: This is conducted by physician and dentists. The physician used all the previous screening and laboratory tests. In Egypt, examination is done on entry in each new grade of each education. f. Special surveys: This should be done periodically to detect any health problems. 2- Preventive services Preventive services includes the following: A. Prevention and control of communicable diseases B. Early detection and correction of non-communicable disease : C. Early identification and education of children with special 44  disabilities. D. Emergency care and first aid services. A-Prevention and control of communicable diseases *Most common infectious diseases in school children are: Respiratory diseases. Diseases spread through droplet infections measles, German measles, chicken box, common cold. etc. Parasitic diseases Eye diseases (trachoma, conjunctivitis). Skin diseases (scabies, ring worm and impetigo.etc). Food and milk born infection as diarrheal diseases as dysentery and amebic dysentery, enteritis, food poisoning and hepatitis. *Measures for prevention 1- Healthful environment 2- Immunization: * Booster doses of DT in 1 st and 4 th year of primary school Booster doses of meningitis in 1 styear of primary school, 1 st * year of preparatory school and 1 st year of secondary school. 45 3- Daily observation of the students for early detection of any disease. 4- Providing education about health issues and promoting healthy living habits. 5- Referral if necessary. 6- identifying children with communicable diseases and excluding them from school: Hepatitis A 21 days Whooping cough 18 days Mumps 14 days Measles 14 days Chicken pox 14 days German measles 7 days COVID 19 14 days 7- Readmission to school after sickness, the child should be examined by the nurse before readmission to school. 8- Care of contacts, once the child is isolated for communicable diseases, his home contacts and class mates should be put under supervision. 9- Care of absence; it is important to know the cause of absence among the students especially during epidemics. 10- Food handlers in school should be examined yearly and treated. B- Early detection and correction of non-communicable diseases Early detection of non- communicable diseases as the nutritional problems, eye defects, speech defects, dental problems, deficiency 46 diseases, hearing problems, emotional and behavioral problems. A- Early identification and education of children with special disabilities Disabling conditions include mental retardation, speech impairment, visual impairment, learning, physical disabilities, emotional disturbance and deaf- blindness. Such impairment needs medical, social, and educational care. Most specialists prefer education of handicapped children in the ordinary school with other children. B- Emergency care and first aid services It is care for urgently diseased or injured students and staff members. First aid is skilled application of accepted principle treatment on the occurrence of an accident or in case of sudden illness. The most common medical emergencies are: appendicitis, gastroenteritis, renal colic, epileptic fits, fainting, and accident. It is the responsibility of school centers for main concerns; 1- Prevent injuries from happing in school 2- Provide safety education 3- Provide basic first aid care for child, school staff with an illness or injury. 4- Emergencies requiring transport and more extensive treatment at a hospital. 5- Develop a plan for handling emergencies. This implies the following: - Preparing a suitable room for emergency care with proper supplies and equipment. - Performing training programs for students, teachers in first 41  aid procedures and how to handle emergency situations. - Prevent injuries from happening in school. - Immediate care and referral. - Notify parents and authorities. 3-Curative services School health program provides curative services to school students. This service is provided in: - School clinics provided by general practitioners and school nurses. - A number of affiliated hospitals or services (students' health insurance hospital). - Medication administration and monitoring. In Egypt: The health services done through health insurance services, where there is a health unit for each 3000 students; the activities are done by doctor and nurse. In case of a discovered case with specific diseases, it is referred to students' hospital with specialist, (as in case of further investigation or operation). The medication is given free for chronically ill children, and with low fees for the other cases. 4-Dental services: Dental disease begins in childhood. Three basic forms of activity should be included in a school dental health program:  Dental health education.  Prevention measures.  Referral with follow through procedures in cases of discovered dental problems 48 Health education is the process of providing learning experience for the purpose of influencing knowledge, attitude and changing behavior into a healthful one. Health education is essential component of any school health program. It can be done through; - Conducting health conferences with teachers about students' health problems. - Assist in services education training for teachers. - Interpret and use of the available community resources. - Contributing to the health of the family through discussion on home visits. - Participate in class discussion in occasions such as immunization, comprehensive medical examination and injuries. Health education should include items as: - Personal and dental hygiene. - Nutrition. - Pollution. - Accident prevention. - Prevention of infection. - Disasters preparedness in the school, crisis interventions. - First aids. - Anti-drugs and anti-tobacco education - Sports and Physical education - Environment education - Common health problems. 49  School health nursing Role of the nurse in school health program The school nurse is responsible for providing a broad range of services, including the following component of a coordinated school health program: A- Healthful school environment: 1- Physical environment: - Ensure that there is a high standard of environmental sanitation. - Daily round in the classes to be sure there is a good ventilation and good lighting. - Daily round in the bath room to ensure adequate water supply and proper sewage disposal. - Write a report on the building in a special book and present it to the administrator and the physician. - Be alert to the environmental deficiencies and hazards and make suggestions to the maintenance department. 2- Nonphysical environment: - The nurse must involve teachers and parents in children's problems. - Listen to students and their problems. - Give support and advice to any student need it. - Promote good student- teacher- parent relationship. B- School health services: 1- Screening: - Taking history (personal, family, medical, etc.) 51 - Observing signs of sickness and deviation from normal. (scoliosis) - Preparing students for screening tests and laboratory investigations. - Screen vision, hearing and measure weight and height. - Help in laboratory investigations. - Assist in comprehensive medical examination. - Interpret the findings to the teachers and parents. - Conduct special surveys to detect any health problems. 2- Follow up and counseling for the children deviated from normal. 3- Prevention and control of communicable diseases: - Provide immunization. - Daily observation of students for early case finding, referral and isolation. - Prevention and control of outbreaks of infection. - Provide health teaching about period of isolation. - Care of contacts. - Care of absence. - Ensure healthful school environment. - Be sure that the food handlers in the school pass through physical examination and have a health certificate. 4- Early case finding and referral of non- communicable diseases and parasitic diseases. 5- Emergency care and first aid: - Carry out first aid measures for injured and if necessary transfer them to hospital or clinics. - Ensure enough first aid equipment and supplies in the 54  school. - Arrange for in services training program for teachers and students. 6- Care of exceptional children: - Identify exceptional children and arrange for referral, follow up. - Help them to accommodate with their defects. 7- Health services for school personnel according to their needs. 8- Record keeping and documentation. 9- Curative services: - Identify students in need for medical treatment or special care. - Referral treatment for any discovered diseases. - Provide medication for chronically ill children. - Keep complete health records. - Interpret the findings for teachers, physician and parents. C- School health education: - The nurse can participate in the parents counsel and stimulate the interest and cooperation of parents in the school health program. - Conduct health conferences with teachers about students' health. - Emphasize utilization of community's resources and guides parents in selecting suitable agencies for assistance of their children. - Give health education to sick children about how to prevent reinfection. 52 References: Nies, M., and McEwen, M.( 2022).Community/Public Health Nursing E Book.Community/Public Health Nursing. E-Book. Elsevier Health Sciences. P. 672-689 Guzys, D., Brown, R., Halcomb, E., and Whitehead, D. (2020). An Introduction to Community and Primary Health Care.Cambridge University Press. P.362 -School health services include appraisal services, Preventive services and screening services (true or false) -The teachers can observe only the changes in the appearance of the child behavior and compare it with the other children (true or false) 53  PRIMARY HEALTH CARE Objectives:  General objectives: By the end of this lecture, the student will able to acquire knowledge, attitude and practice related to primary health care.  Specific objectives: the student will be able to:  Define primary health care.  Recognize primary health care strategies.  List principles of primary health care.  List elements of primary health care.  Determine sectors which support primary health care.  Discuss role of the community health nurse in primary health care. Outlines:  Definition of primary health care.  Primary health care strategies.  Principles of primary health care.  Elements of primary health care.  Sectors which support primary health care.  Role of the community health nurse in PHC 54  Introduction: PHC is fundamental to community health and is an essential part of the MOH strategy to achieve ―health for all. " PHC emphasize preventive Health care at its three levels: primary, secondary and tertiary. As a primary approach to improving the health of the population, the community health nurse must play a fundamental role in the provision of PHC services.- order to make progress toward achieving health for all. Definition of Primary Health Care (PHC) Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every state of their development in the spirit of self- reliance and self- Determination. PHC strategies & approaches: Strategy1: Expansion of services and Ensuring efficiency: The services are to be made, accessible to the citizens within easy reach of one hour travel. By establishing fully equipped health centers both , in rural and urban areas taking care of the underserved population to extend ,services to all the population. efficiency of services would be improved by providing continuity of care with equity in coverage, providing well defined infrastructure for rendering each PHC service component and by improving the skills of the personnel through continued education. 55  Strategy2 : Developing Better Relations with the community: a- Developing rapport with the community:- by involving the community leader in every health centers, committee e.g. Imams school teacher...etc. the committee! to be well informed about PHC approach and its role defined. b-Out-Reach Activities By:  Defining priority areas which need such services Introducing out -reach programs in health education which Is planned, documented and implemented by involving the community.  Initiating communicable disease control activities in the community including immunization. Strategy 3: weaning the people Towards comprehensive Health care:- The people would be oriented to accept health centers as the place for opting comprehensive, health-services rather than more dispensing outlets through: a- Service approach: by providing all the services in the PHC approach (Promotive, preventive, curative). b-Educative approach: by educating the people regarding the necessity of opting for comprehensive health care. c-Legislative approach: by introducing appropriate legislation as in case of compulsory immunization of children as a prerequisite to obtain birth certificate Strategy 4: Integration of preventive and Curative services: Integrating existing health offices, MCH centers and dispensaries, to function as one unit. Coordinating national disease control programs through PHC committees at the regional level. 56 Strategy5: Promotion of Health Awareness: Having a well-defined educational program for PHC development at the central ministry level and by utilizing existing government mass media like radio and television network. Strategy 6: Coordination with secondary care: Secondary care facilities like local hospitals are to be motivated and involved for strengthening PHC development by: - Involving the clinicians and other technical personnel in continued education programs for improving the skills of PHC personnel. - Establishing system for two way referral for all the types of consultation Required. Strategy7: Coordination with academic institutions for PHC development: Orientation of future national health manpower in the concepts and practices of PHC by introducing them in the curricula of the concerned educational institutions is essential for the viability of PHC system. principles to help communities link community health and social services with their educational system is The principles encompass community participation, early assessment of community needs, integration of health services. Community participation: Social awareness and community self- reliance are the key factors in human development and the people have both the right and duty to participate in the process for the improvement and maintenance of "health, this enables them to become agents of their own development instead of passive receiving of development aids. The scope of involvement is unlimited (involving in all sphere of PHC activity for planning, implementations and evaluation). 51 References: Nies, M., and McEwen, M.( 2022).Community/Public Health Nursing E Book.Community/Public Health Nursing. E-Book. Elsevier Health Sciences. P. 672-689 Guzys, D., Brown, R., Halcomb, E., and Whitehead, D. (2020). An Introduction to Community and Primary Health Care.Cambridge University Press. P.362 -School health services include appraisal services, Preventive services and screening services (true or false) -The teachers can observe only the changes in the appearance of the child behavior and compare it with the other children (true or false) 53  PRIMARY HEALTH CARE Objectives:  General objectives: By the end of this lecture, the student will able to acquire knowledge, attitude and practice related to primary health care.  Specific objectives: the student will be able to:  Define primary health care.  Recognize primary health care strategies.  List principles of primary health care.  List elements of primary health care.  Determine sectors which support primary health care.  Discuss role of the community health nurse in primary health care. Outlines:  Definition of primary health care.  Primary health care strategies.  Principles of primary health care.  Elements of primary health care.  Sectors which support primary health care.  Role of the community health nurse in PHC 54  Introduction: PHC is fundamental to community health and is an essential part of the MOH strategy to achieve ―health for all. " PHC emphasize preventive Health care at its three levels: primary, secondary and tertiary. As a primary approach to improving the health of the population, the community health nurse must play a fundamental role in the provision of PHC services.- order to make progress toward achieving health for all. Definition of Primary Health Care (PHC) Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every state of their development in the spirit of self- reliance and self- Determination. PHC strategies & approaches: Strategy1: Expansion of services and Ensuring efficiency: The services are to be made, accessible to the citizens within easy reach of one hour travel. By establishing fully equipped health centers both , in rural and urban areas taking care of the underserved population to extend ,services to all the population. efficiency of services would be improved by providing continuity of care with equity in coverage, providing well defined infrastructure for rendering each PHC service component and by improving the skills of the personnel through continued education. 55  Strategy2 : Developing Better Relations with the community: a- Developing rapport with the community:- by involving the community leader in every health centers, committee e.g. Imams school teacher...etc. the committee! to be well informed about PHC approach and its role defined. b-Out-Reach Activities By:  Defining priority areas which need such services Introducing out -reach programs in health education which Is planned, documented and implemented by involving the community.  Initiating communicable disease control activities in the community including immunization. Strategy 3: weaning the people Towards comprehensive Health care:- The people would be oriented to accept health centers as the place for opting comprehensive, health-services rather than more dispensing outlets through: a- Service approach: by providing all the services in the PHC approach (Promotive, preventive, curative). b-Educative approach: by educating the people regarding the necessity of opting for comprehensive health care. c-Legislative approach: by introducing appropriate legislation as in case of compulsory immunization of children as a prerequisite to obtain birth certificate Strategy 4: Integration of preventive and Curative services: Integrating existing health offices, MCH centers and dispensaries, to function as one unit. Coordinating national disease control programs through PHC committees at the regional level. 56 Strategy5: Promotion of Health Awareness: Having a well-defined educational program for PHC development at the central ministry level and by utilizing existing government mass media like radio and television network. Strategy 6: Coordination with secondary care: Secondary care facilities like local hospitals are to be motivated and involved for strengthening PHC development by: - Involving the clinicians and other technical personnel in continued education programs for improving the skills of PHC personnel. - Establishing system for two way referral for all the types of consultation Required. Strategy7: Coordination with academic institutions for PHC development: Orientation of future national health manpower in the concepts and practices of PHC by introducing them in the curricula of the concerned educational institutions is essential for the viability of PHC system. principles to help communities link community health and social services with their educational system is The principles encompass community participation, early assessment of community needs, integration of health services. Community participation: Social awareness and community self- reliance are the key factors in human development and the people have both the right and duty to participate in the process for the improvement and maintenance of "health, this enables them to become agents of their own development instead of passive receiving of development aids. The scope of involvement is unlimited (involving in all sphere of PHC activity for planning, implementations and evaluation). 51 Inter-sectoral coordination : Health cannot be attained by the health sector alone primary health care requires the support of other sectors. The development efforts of each sector is complimentary to others. e.g. the role of municipalities in environment improvement, ministry of agriculture of potable water, provision of food and control of brucellosis, minister of education in school health, mass-media in providing health programs and valid information on health and ministry of industry in establishing industries related to health. Team approach: PHC services are implemented through a team of health personnel which is composed of: Physicians , Dentists, Nurses, Nurse mid-wives, Sanitarians, Laboratory Technicians , Food inspectors, Social Worker ,Community workers , Health Records Technician (Clerks) , Pharmacists. Principles of primary health care: 1-Equity in distribution and accessibility: Equity: Means services to all and more services to the needy and vulnerable. Continuing to provide essential health care for all the population irrespective of social, economic and cultural preferences. Extended care is to be provided to the "high risk" groups in the community either within the health centers, or in the hospitals and also provide services to homes and working places. Accessibility: Implies that continuing and organized supply of care that is geographically, financially, culturally and functionally within easy reach of the whole community, it has often been expressed in terms of a numerical ratio between services and the population. 58  Ex, The number of hospital beds per unit of population or number of doctors and nurses per unit of population or the number of people for whom a health center has been established and the availability of transportation. 2-Appropriate technology:  Primary health care requires development, adaptation and application of appropriate technology that the people can use and afford. e.g. materials, methods and technologies are required not only for diagnostic and therapeutic maneuvers but also for disease control and health promotion.  The simplicity of the technology is always desirable e.g. breast feeding in spacing, weighing for growth maintaining.  Appropriateness means scientifically sound and also acceptable to those who apply it and to those for who it is used. The person who is going to apply is trained health professional. In PHC practice, technology may have to be applied by the individual, family or community. 3-Multi-sectoral approach. 4-community participation. 5-Emphasizes on promotive and preventive services more than curative ones.  PHC services applied mainly to maintain maximum level of health through promotive measures as socioeconomic development, health education, genetic counseling and increase people awareness toward health maintenance.  Also PHC applied to prevent occurrence of disease by immunization and chemoprophylaxis and environmental sanitation. 59 6-Essential drug : list receded for implementation *Instruments in PHC delivery: 1-Management of common non-complicated health problems. 2-Tretment of childhood illness e.g. through integrated management of childhood illness as diarrhea and fever. 3- Control of infectious diseases outbreaks and epidemics. 4-First aid, emergency and life-saving services. 5-Management of chronic non-communicable diseases (Diabetes and hypertension). 6-Controlof endemic priority diseases: TB, and hepatitis). 7- Conduction of minor surgery. 8-Basic Lab work , ultra sound. 9-Referral of needy cases and follow up. Family records : The data in the family record include: 1-Family composition and size 2- Social configurations and relations 3-Family members demographic characteristics (e.g. age, sex, education, occupation). 4- Domestic environment characteristics (water supply, sanitary disposal, number of rooms, electricity). 5- Individuals' health status and disease registry. 6- Provided health care and timing. 7- Referral services and follow up Role. 61  PHC Elements: 1- Education concerning health problems and the methods of preventing and controlling them. 2- Promotion of food supply and proper nutrition. 3- Adequate, safe water supply and basic sanitation. 4- Maternal and child health care, including family planning. 5- Immunization against major infectious diseases. 6- Preventing and control of local endemic diseases. 7-Appropriate treatment of common diseases and injuries. 8-Provision of essential basic house hold drugs for the community. 1-Education for the identification and prevention/ control of Health problems.  In the developing countries emphasis still needs to be placed on malnutrition, diarrhea, acute respiratory tract infections and the killer diseases of poverty, measles, malaria, tuberculosis and cholera. More recently aids, and childhood disabilities have also become major health problems in many of these countries.  WHO (1998) stated that health education activities focused mainly on information giving related to problems of each community for health promotion and elaborated that further inter-sectoral approach to promote and protect the health.  Greater emphasis was given to the development of cities, schools, villages, hospitals and work places to decentralize the health 64 education from national institutions. 2-Promotion of food supply and proper nutrition: IT IS related to promotion of activities that can improve food supply at the family level through. 1-correction of faulty feeding practices in infants and young children. 2-Treatment and prevention of prevalent nutritional diseases as anemia and vitamin A deficiency. 3-Promotion of better nutrition for pregnant and lactating women. 4-One fifth of the population of developing countries doesn't have access to enough food to meet basic needs. 5-Anemia due to iron deficiency was the most common nutritional deficiency worldwide. 6-Vitamin A deficiency is decreasing worldwide. 7-Food borne diseases continue to be a major health concern in both developed and developing countries 3- Adequate safe water supply and basic sanitation: - A safe water supply and clean disposal of wastes are also essential to the health and well-being of any community. - Lack safe water supply and sanitation contributes to diarrheal disease and intestinal worm infections which together make up to 10% of total disease in developing countries and also leads to cholera. 62  4. Maternal and child health care including family planning: - It aims at promoting and protecting the health of children and women in child bearing age. So that all children have possibility for healthy growth and development and the women in reproductive life will be with a state of health. - In developed countries, 97% of women make at least one antenatal visit, 90% make at least one post-partum visit, 99% deliver with a skilled attendant. ( WHO 1997). - In developing countries 65% of women make at least one antenatal. visit, 53% give birth with a skilled attendant but only 30% make at least one postpartum care visit with rate as low as 5% in some regions in rural areas in Africa and south Asia. Due to distance and lack of transport of poor interaction with providers. child health are related to social, economic and health status of the mother. Most infant morbidity and mortality can be prevented through adequate safe water supply and sanitation, good nutrition, good immunization, promotion of breast feeding and also prevent diseases as: Pneumonia that kills 3-5 million young children each year, diarrhea diseases kill 2.2 Million young children each year, and problems of malnutrition as iodine deficiency that resulted in mental retardation, defective speech, and hearing and also prevent iron deficiency anemia. 5-Immunization against major infectious diseases: - Millions of children die each year throughout the world from childhood diseases ( measles, tuberculosis, diphtheria, tetanus, whooping cough and polio). - WHO reported that 80 percent of the world's children had been immunized against six diseases. It estimated that three million child death each year can be prevented as a result of this a achievement. 6-preventing and control of local endemic disease: This means prevention of disease transmission through health education, early detection of the disease and control the spread of the disease. 63 7- Appropriate treatment of common diseases and injuries: - it means total comprehensive management of diseases for which the people usually seeks treatment as hypertension and diabetes. - The knowledge about common diseases is to be acquired through an active and continuous process in the course of community survey. - It also means providing comprehensive care to the injuries, that range from minor injuries as ( cuts and abrasions) that are totally managed in health centers and major injuries as ( traffic accident, poisonous ) that requires life support and resuscitation. 8- Provision of Essential Drugs: In 1978 lack of drugs for Public sector especially for PHC, was identified a ssignificant problem from the national level to the hospital to the patient, many countries lacked drugs in sufficient quantities. So that this element was integrated in PHC.  Reasons for slow progress:  Insufficient political commitment  Failure to achieve equity in access to all PHC components  The continuing low status of women  Slow socio- economic development  Difficulty in achieving inter sectoral action for Health  Unbalanced distribution of resources  Widespread inequity of health promotion efforts  Weak health information systems and lack of baseline data  Pollution, poor food safety, and lack of water supply and sanitation 64  Rapid demographic and epidemiological changes  Inappropriate use and allocation of resources for high cost technology  Natural and manmade disasters Sector which support primary health care: 1- Agricultural sector: it can cure production of food for family consumption which improves the national status. 2- Water sector: plentiful supplies of clean water help to decrease morbidity and mortality in the proper use and maintenance of water, sanitary facilities is important. 3- Wastes sector: safe disposal of wastes and execrate has significant influence on health. 4- Housing: - It needs to be proof against insects' rodents that carry disease. - It should be cleaned. - Education is important for ensuring the proper maintenance of houses and the area surrounding them. 5- Educational sectors: it helps people to understand their own health, problem and predict possible solution to them parent and teacher can take some responsibility for primary health care with school and community as sanitation program, courses on nutrition and first aid. 6- The mass media: can play an educational role by providing valid information on health and ways of training it and by detection the benefit to and the pattern of income consumption, and stability of family income all are directly related to the health of family. Health education in maternal /child health clinic settings about - Importance of prenatal care. -Breast feeding and proper nutrition. 65 -Immunization. - Sanitary home environment. -Child care prevention of diarrhea and communicable disease. -Weaning. -Periodic follow up. -Early detection and proper treatment. -Accident prevention. -Family planning services. Preconceptional Care : It is a care of female before conception. It is continued care from birth, through stages of growth and development, and until the time of conception and pregnancy, so as to prepare the female for normal child bearing and delivery in the future. Components of Preconceptional Care: Health promotion and prevention of health hazards specially those of particular risk to pregnancy. Regular health appraisal for early case detection and management, and prevention of squeal or complications. Health education of young girls e.g. determinants and requirement of health, family health, family planning….. Premarital care (for both partners). Premarital Care : It includes: Premarital counseling Premarital immunization Premarital examination: 66  History taking Genetic counseling Systemic medical examination Investigations Antenatal care: 1-Assessment of the antenatal client:  Comprehensive medical and reproductive health history.  Comprehensive family history.  History of current pregnancy.  Psychosocial assessment (by social worker if possible).  Nutrition assessment (by nutritionist if possible).  Comprehensive physical examination (weight – height – vital signs and general examination). II-Care provision include counseling and health education: a-Initial prenatal visit:  take assessment.  Biochemical evaluation:  Complete blood count -Blood type and Rh.  Examination:  Primary (weight – height – blood pressure).  General examinations. 61 b-Subsequent visits:  Assessment each visit:  Vital signs.  Weight.  Urine analysis for glucose, albumin and ketones.  Fungal height.  Fetal movement.  Leopold's maneuvers to evaluate, fetal lie / presentation.  Assess presence or absence of edema.  Continuing prenatal care:  Examinations- immunization – health education and referral services when necessary.  Number of visits:  Every 4 weeks until 6 months.  Every 2 weeks through 7-8 months.  Every week until birth. c-Health education and counseling:  Prenatal education should focus not only on appositive labor and birth experience but, more importantly on lying the ground work for a successful pregnancy outcome as family experience. Prenatal education topics: 1-First trimester: -Smoking cessation -Alcohol avoidance. 68 -Work and rest patterns -Illicit drug avoidance. -Physiologic changes of pregnancy -Emotional changes of pregnancy -Healthy life style -Screening, diagnostic tests. -Nipple assessment, breast feeding -Nutrition promotion. 2-Second trimester : as first trimester with added: 1-Exercise. 2-Family roles. 3-Third trimester: as first trimester: -Post-partumself-care. -Post-partum emotional change. -New born care. -Child birth education. Post-partum care: I-Assessment of the post-partum mother:  Assess blood pressure and pulse.  Assess the uterine fundus for tone and position.  Assess the amount of lochia on perineal pad and under buttocks.  Assess the condition of the perineum.  Assess the condition of episiotomy. II-Care provision including counseling and health education: -Physical care: -Post-partum examination (vital signs – uterine size and lochia). 69 -Exercises : these are necessary to bring the stretched abdominal and pelvic muscles back to normal as quickly as possible. Psychological care: -The mother feels insecurity for her new born child prenatal care should help to eliminate these feeling by daily care for her baby. Family planning: -To motivate mothers early to adopt a suitable method for spacing between pregnancies. Health education : about: -Personal hygiene- baby care- nutrition – breast care- breast feeding – birth spacing – weaning and immunization. Family planning services: -Methods used to control fertility and prevent conception are called contraceptives. -The forms of contraception are placed in three broad categories: i-Hormonal. ii-Barrier. iii-Permanent sterilization I-Hormonal contraceptives: 1-Oral contraceptives combined. (Estrogen – progestin).  Dosage is one pill each day.  The effectiveness is 96.8% Advantages: -Decreased menstrual blood loss. -Decreased increase of dysmenorrheal. 11 -Decreased increase of ovarian cancer, breast disease. -Decreased increase of ectopic pregnancy. Disadvantages: -Cause breast tenderness, weight gain, nausea. -Contraindicated for women with history of thromboembolic disorders, cerebrovascular or coronary artery disease. 2-Oral contraceptives (progestin – only):  Dosage is one pill each day.  The effectiveness rate is 95%. Advantages: -Lactation is not impaired by this formulation. -Less likely to cause cardiovascular complication, headaches or hypertension. Disadvantages: -Irregular bleeding, amenorrhea. -Functional ovarian cysts can occur. II-Barrier methods: -Devices must be used at the time of sexual act. *Condoms:-Is a latex or synthetic sheath placed over the erect penis before coitus / side effect from condoms resulting in itching, skin irritation. Spermicides: spermicides are inserted in the vagina and work by killing the sperm. -Formulated as jellies, creams, foams and suppositories. -Side effects: skin irritation. 14 -The advantage of spermicides are over the counter availability and low cost. Advantage of barrier methods: -Decreased cost and protection from ST Ds. III-Permanent sterilization: (Post-partum tube ligation / vasectomy) -The effectiveness rate is 99.5%. -Advantage : no need for additional contraception. IV-Intrauterine Devices (IUD): -Is inserted into the uterine cavity. Where it caused a sterile inflammatory response. -The mechanism of action of IUD prevents the sperm form reaching the egg. Advantages: -Use for breast – feeding women, long term and continues use requiring minimal effort. Disadvantages: -Contraindicated for women with a history of pelvic inflammatory disease. CHILD HEALTH Infant and child priorities (UNICEF) : 1. Reduction of infant and under 5 mortality rate 2. Reduction of moderate and severe malnutrition 3. Universal access to safe drinking water 4. Access to all couples to information and services to prevent pregnancies that are too early, too closely spaced, too late or too many. 5. Reduction of low birth weight babies 12  6. Elimination of iodine deficiency 7. Elimination of vitamin A deficiency 8. Encouragement of women to breast feed their children exclusively 9. Growth promotion and monitoring 10. Eradication of poliomyelitis 11. Elimination of neonatal tetanus 12. Reduction of measles death 13. Maintenance of a high level of immunization coverage. 14. Reduction of deaths due to diarrheal diseases 15. Reduction of deaths due to ARIs 16. Increased acquisition of knowledge, skills and values required for better living by all families. What can be done to improve child health? *Child Health Service (Program) The MCH center provides child care that starts before birth and continues throughout childhood. Functions of MCH centers for child care: Maternal care (prenatal and natal) Neonatal care Adequate nutrition of infants and children Health appraisal (assessment) Prevention and control of communicable diseases including immunization. 13  Clinical (curative services) Social services. The Integrated Management of Childhood Illness (IMCI) IMCI is a broad strategy to improve child health outcomes developed by WHO and UNICEF. IMCI encompasses interventions at home, in the community and in the health system. The aims are to reduce childhood deaths, illnesses, and disability and to improve children's growth and development, with a particular focus on the poorest and most disadvantaged children. IMCI has three main components: Improve family and community practices related to child health and nutrition; Improve the health system for effective management of childhood illness; Improve health workers' skills. Centers and units providing primary health care: Rural: rural health centers (in big villages) and units (in small villages). Urban: urban health centers, MCH centers, school health centers and units, industrial health-centers and units, and health office. Health team of primary health care: The team is a group of different personal who work together in cooperation and harmony, to provide-consumers with health services. The team is made of:  Medical personnel: one or more physicians, and may be dentist in some centers.  Paramedical personnel: nurses, nurse midwives, health visitors, and technicians. 14   Health – related personnel: social workers, sanitarians and food inspectors. Resources of primary health care:  Manpower (personnel of health team).  Equipment, drugs, and first aid and emergency requirements.  Budget (financial resource). Role of the community health nurse in PHC:  Primary Prevention : CH nurse apply activities that promote optimum health and prevent illness as: 1- Provide health education for individuals to promote their health e.g. proper nutritional habits and hygiene, 2- Increase people awareness and positive approach toward health as right. 3- Help people to accept primary responsibility for maintaining his health and to make sound decision about their health. 4-Provide Genetic counseling programs. 5-Increase level of resistance against health problems. 6-Active participation in immunization programs. 7- Increase people knowledge about importance of environmental sanitation. Food sanitation: Good health habits e.g. cleanness of hand by running water and soap. Proper washing of food eaten e.g. vegetables. 15  Control of the. insects especially cockroockers and flies. Ice in certain area especially not places and contaminated. Examine the food handlers as follows.  X- ray chest for T.B  Vidal test for typhoid carriers.  Stool analysis.  Skin examination for staph infection,  Throat swab for diphtheria.  Secondary Prevention: CH nurse perform activities to reduce prevalence of disease and limit disability by: - Participate with health team in assessment, early case finding and diagnosis and provision of prompt treatment. Provide information about care centers and referral for individuals according to their needs. - Provide health education for individuals based on their diagnosis and needs. - Teach patient the necessary adaptation in the activities of daily living that will support recovery. - Help patient to participate in programs of activity according to their illness to limit disability.  Tertiary prevention: CH Nurse work to prevent or minimize disablement through - Identify type and severity of disability. - Determine that goals should be aimed for. 16 - Make realistic rehabilitative plan. - Determine which members of health care team are most appropriate involved in rehabilitation. - Investigate social and family circumstance in order to determine whether further support is required. - Apply rehabilitation plan. - Then assess patient's ability to carry out every day activities of living and working. CH Nurse should apply the management process through all levels of prevention by making: - Assessment and prioritizing of community problems and needs. - Community diagnosis. - Planning for nursing intervention. Evaluation-of intervention followed by reassessment in order to improve PHC intervention. 11  References Guzys, D. Brown, R., and Halcomb, E. (2020): An Introduction to Community and Primary Health Care introduces students to the theory, skills and professional roles in community settings. Available at https://cutt.us/FicIe. Accessed on 28/10/2021. Bishai, D. and Schleiff, M. (2020) :Achieving Health for All: Primary Health Care in Action. Available at: https://cutt.us/Ivp2m. Accessed on 20/10/2021. - Primary health care is complementary nursing care (true or false) - Secondary prevention in primary health care includes: a- Health promotion b- Genetic counseling c- Help patients to participate in programs. d- Active participation in immunization program - Primary prevention consists of measures which prevent occurring of disability such as 1. Early identification of impairment 2. Treating and monitoring conditions 3. Stress management 4. Provision of PHC services, prenatal and postnatal care - Sectors which support primary health care include: a- Inequity of health promotion b- The mass media c- Profession of essential drugs d- Distribution of resources 18  THE FAMILY AS ACLIENT Learning Objectives: By the end of this lecture the students will be able to:  Define family and family health  Identify characteristics of healthy family.  Identify the advantages of family care  List types of family  Discuss family role  Enumerate factors influencing family health  Discuss factors affecting family coping pattern:  Identify health tasks of the family  Mention family dynamics in the community  Apply family assessment to fulfill needs of the family.  Apply communication skills appropriate to each age group.  Demonstrate nursing care plan, implement action, and evaluation. Related to individual, family to services, community resources, and other sources of support relevant to their specific needs. 19 Introduction The family, as the basic unit of the community, represents all age groups. The family also reflects the culture values, and health status of a community. Therefore, this topic will provide the graduate nurse with a family- focused perspective rather than a focus on the individual. Provide the community with nurse graduates who are equipped with the knowledge, skills and attitudes needed to provide nursing care to families with members of various age groups and with a variety of needs. Definitions 1-Family: Refers to two or more individuals who depend on one another for emotional, physical, and financial support. A family is a social system composed of two or more people living together who may be related by blood, marriage, or adoption, or who stay together by mutual agreement. Family members usually share living arrangements, obligations, goals, the continuity of generations, and a sense of belonging and affection. 2- Family Health: Is the continuing ability to meet defined function in interaction with other social, political, economic and health systems. Characteristics of healthy families: 1-There is a facilitative process of interactions among family members. 2-They enhance individual member development. 3-Their relationships are structured effectively. 4-They actively attempt to cope with the problem. 5-They have a healthy home environment. 81 6-They establish regular links with broader a community. Advantages of Family Care  Knowledge of the family background makes it easy to understand health care needs of each member of the family.  All family members can assist in preparing a plan to provide health care to a member who requires special health care services.  Family based care provides the opportunity to give health care to an individual member as pre-determined schedule.  It is economical as it saves time, money and resources of health services.  Overlapping of services and deficient services can be avoided.  It helps the family to be self-reliant in meeting the needs of its members, and in improving health, welfare and nutrition of the family. Types of family: 1-Nuclear: A father and a mother with a child (ren). 2-Extended: three generations living together including married brother and sister, grandparents, aunts, uncles, and cousins'. 3-Single – parent families: consists of an adult female or male and children. 4-Dyad: Husband and wife alone without children. 5-Blended: A combination of two families with children from one or both families and children from the newly married couple. 6-Single adult living alone: common occurrence for the never married, divorced or widowed. 7-Compound: one man with several spouses. 8-Step-families: is composed of two adults, at least one of whom has remarried following divorce or death of a spouse step families can include children. 84 Family roles: Roles are expectations of behavior, obligations, and rights that are associated with a given position in a family or social groups. Social and cultural factors that influence role fulfillment include rates of social change, contradictions, modifications, and alternatives in prevailing role definitions. Also, social class, race, ethnicity, and age have significant implications for role conception and performance e.g among the poor population in society, a married woman with a husband present usually has few rights but has demanding domestic and economic obligations to the family. The upper – class wife usually has great freedom and serves as the manger for employed assistants who provide domestic services family adult roles. 1- Child socialization. 2- Child care. 3- Provider role. 4- Housekeeper role. 5- Kinship role. 6- Sexual. 7- Therapeutic role. Assisting family members to cope with problems as providing emotional support. 8- Recreational role. Family functions: All families have certain functions that are performed to maintain the integrity of the family unit and to meet the family unit's needs, the individual family members' needs, and society's expectations. These functions are: 1-Biological 1. Reproduction and child-bearing 82 Aim of environmental health:  Reducing the risk (chance) of getting diseases and injuries from the environment  Promoting good health. Scope of environmental health: - A good water supply - The correct disposal of (getting rid of) liquid and solid waste - A healthy food supply - Pest control - Personal hygiene - A healthy house - Air hygiene and prevention of atmospheric pollution. - Elimination of other hazards e.g. noise, radiation. Environmental health team The presence of inter disciplinary team work enhance the ability to make progress in environmental health. This team includes variety of medical and community expertise (e.g) nurses, occupational physician, safety specialists, epidemiologist, psychologist, sanitarians, chemists, biologists, climatologists, also voluntary personnel accepts as member of the team. Environmental risk problem in home, in a workplace and in the community (1) Environmental risk in home: While we would like to think of our homes as safe and healthy havens, they may have hidden risks that we can often easily reduce or eliminate. These risks may be associated with the building itself, such as formaldehyde, which is commonly used to bind wood chips in 448 pressboard, or with lead-based paint, commonly found in housing stock build before the 1950s and sometimes found in houses built before 1978, when lead-based paint was banned from use in house paint. Indoor air pollution The air we breathe indoors, whether at home, or at workplace, may represent a bigger threat to human health than outdoor air pollution. Common Sources of Home Pollution:  Tobacco smoke is very hazardous through passive smoking leading to heart attack, stokes, lung cancer.  Deteriorating building materials and furnishing e.g. asbestos, certain wood, wet or damp carpentry.  Combustion of fossil fuel  Household cleaning products, solvents, and pesticides.  Biologic including legionnaire pneumonia. (2)Environmental risk at work: The words ‗risk‘ and ‗hazard‘ are often used interchangeably. The six main categories of hazards are: Biological. Biological hazards include viruses, bacteria, insects, animals, etc., that can cause adverse health impacts. For example, blood and other bodily fluids, harmful plants, sewage, dust and insects. Chemical. Chemical hazards are hazardous substances that can cause harm. These hazards can result in both health and physical impacts, such as skin irritation, respiratory system irritation, blindness, corrosion and explosions. 449  Physical. Physical hazards are environmental factors that can harm an employee without necessarily touching them, including heights, noise, radiation and pressure. Safety. These are hazards that create unsafe working conditions. For example, exposed wires or a damaged carpet might result in a tripping hazard. These are sometimes included under the category of physical hazards. Ergonomic. Ergonomic hazards are a result of physical factors that can result in musculoskeletal injuries. For example, a poor workstation setup in an office, poor posture and manual handling.