NCM 113 Community Health Nursing 2 (Population Groups & Community as Clients) PDF

NCM 113 Community Health Nursing 2 (POPULATION GROUPS AND COMMUNITY AS CLIENTS) I. Community Health Nursing Concepts A. Introduction B. Definition C. Philosophy and Principles D. Features of CHN E. T...

NCM 113 Community Health Nursing 2 (POPULATION GROUPS AND COMMUNITY AS CLIENTS) I. Community Health Nursing Concepts A. Introduction B. Definition C. Philosophy and Principles D. Features of CHN E. Theoretical Models/Approaches 1. Social learning theory 2. Health belief model 3. Milio’s Framework for Prevention 4. Nola Pender’s Health Promotion Model 5. Transtheoretical model 6. Lawrence Green’s PRECEDE-PROCEED MODEL F. Roles and activities of Community Health Nurse F. Different Fields 1. Community health nursing 2. Public health nursing 3. Community based nursing 4. School Health Nursing 5. Occupational Health Nursing 6. Community Mental Health Nursing 7. Home health care 8. Hospice home care 9. Faith community nursing II. Concept of the Community A. Types of Communities B. Characteristics of a Healthy Community C. Components of a Community D. Factors Affecting Health of the Community 1. Characteristics of the Populations 2. Location of the Community 3. Social System within the Community E. Roles and Activities of Community Health Nurse III. Health Statistics and Epidemiology A. Tools 1. Demography Sources of Data Population Size Population Composition Population Distribution 2. Health Indicators Fertility Rates a. Crude Birth Rate b. General fertility rate Morbidity Rates a. Incidence rate b. Prevalence Rate Mortality Rates a. Crude death rate b. Specific mortality rate c. Cause of death rate d. Infant mortality rate e. Maternal mortality rate f. Proportionate mortality rate g. Swaroop’s Mortality rate h. Case fatality rate  B. Philippine Health Situation 1. Demographic Profile 2. Health Profile C. Epidemiology and the Nurse 3. Definition and Related Terms 4. Natural Life History Disease 5. Epidemiological Triangle 6. Investigations, Epidemiological Process and Investigation 7. PIDSR (Philippine Integrated Disease and Response) IV. Nursing Process in the Care of Population Groups and Community A. Community Health Assessment Tools B. Community Diagnosis 1. Types Traditional Participatory Action Research (PAR) 2. Schemes in Staffing Community Diagnosis NANDA 3. Shuster and Goppingen OMAHA System C. Planning Community Health Interventions 1. Priority Setting WHO Special Considerations 2. Formulating Goals and Objectives 3. Deciding on Community Interventions/ Action Plan MIDTERM EXAM MODULE I. COMMUNITY HEALTH NURSING CONCEPTS LEARNING OBJECTIVES ON COMPLETING THIS MODULE, YOU WILL BE ABLE TO: 1. Explain the concept, theories and principles of community health nursing practice. 2. Cite the distinguishing features of community health nursing. 3. Apply the different theoretical models and approaches to community health nursing practice. 4. Compare the different fields of community health nursing practice. The science of nursing has expanded over the years. With the advent of modern technology and the easy access to healthcare information, nurses have taken a higher plane of helping population groups achieve better health (Nies & McEwen, 2013). Community health nurses can assist in the transition of the Philippine Health Care System from a disease-oriented system to a health-oriented system (Famorca, Nies & McEwen, 2013). Nurses constitute a large group of health care workers; therefore, they can create a health care delivery system that will meet the health-oriented needs of the people. Community and public health nursing focus on all population groups whether children, adults, elderly or collectively as families in their natural environment. INTRODUCTION A Community may be defined in many different ways. One definition of community is “a social group of any size whose members reside in a specific locality, share government, and often have a common cultural and historical heritage.”  Culture, ethnicity, age, gender, sexuality all of these can be characteristics which define a community The community in which we live and work have a profound influence on our collective health and well-being. The health of a community is more than the sum of the health of its individual citizens. Community as a field of practice seeks to provide organizational structure Community can influence:  The spread of disease  Provide barriers to protect members from health hazards  Organize ways to combat outbreaks of infectious disease  Promote practices that contribute to individual and collective health Community health nurse work in every conceivable kind of community agency Their duties range from examining infants in a well-baby clinic or teaching elderly stroke victims in their homes to carrying out epidemiologic research or engage in health policy analysis and decision making. Combines all basic elements of professional clinical nursing with public health and community practice. DEFINITION Community Health Nursing  is defined as a specialized field of nursing practice that renders care to individuals, families and communities, focusing on health promotion and disease prevention through people empowerment.  Health promotion and disease prevention are the core of community health nursing.  The major goal of community health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community.  Thus, community health nursing is associated with health and the identification of populations at risk rather than with an episodic response to patient demand (Nies & McEwen, 2019). Community  Collection of people who interact with one another and share common interests and characteristics. Two types of Community 1. Geopolitical Community  Barangays,  cities,  regions,  nations  2. Phenomenological Community  Interactive groups/shared groups based on culture, values, perspective, interests, history and goals. Community Health Nursing  The synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations. Public Health Nursing  Promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences. CHN Goal  Preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. 3 BASIC CONCEPTS OF COMMUNITY AND PUBLIC HEALTH NURSING 1. The community as a client Community is a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging (Alexander et al., 2009). 2. Health as a goal Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 2010). Health is more than a state of well-being. It is a multidimensional reality that includes socioeconomic, environmental and even political factors. Health care needs to be holistic. The nurse in the community foster multidisciplinary efforts to address various core determinants of health. 3. Nursing as the vehicle or means to achieve its aims Nursing is the art and science of caring. According to Florence Nightingale (1973), nursing is a means of ensuring that people are placed in an optimum condition where nature can contribute to healing and wellness. Philosophy and Principles The health care system has been evolving from focusing on individuals in acute care settings to being more community based and population health directed. Philosophy 1. The practice of community and public health nursing is anchored on the primary of worth and dignity of man. 2. Respect for people’s inherent value regardless of their background and beliefs are edified in the universal bioethical principles. 3. Responsibility for health rests primarily on people and not on agencies or professionals. 4. The need for the attainment of independence and self-reliance in health. 5. Health is a shared responsibility and therefore requires collective efforts from all sectors. Working with communities requires active participation of the people. 6. A fundamental commitment of community and public health nurses is to adhere to the tenets of social justice. This principle speaks of promoting common good and not merely to be fair to all. 7. One hallmark of the profession is having its own code of ethics. Principles of Community and Public Health Nursing 1. Focus on the community as the unit of care. 2. Give priority to community needs. 3. Work with the community as an equal partner of the health team. 4. In selecting appropriate activities, focus on primary prevention. 5. Promote a healthful physical and psychosocial environment. 6. Reach out to all who may benefit from a specific service. 7. Promote optimum use of resources. 8. Collaborate with others working in the community. Characteristics and Features of Community and Public Health Nursing 1. Developmental 2. Multidisciplinary 3. Ecology oriented 4. Promotes social justice 5. Values consumer involvement 6. Uses prepayment mechanism 7. Focuses on preventive service 8. Offers comprehensive care A community has three features (Allender et al., 2009; Hunt, 2009) 1. People 2. Location 3. Social system Theoretical Models/Approaches a. Social Learning Theory  Social Learning Theory is based on the belief that learning takes place in a social context, that is, people learn from one another, and that learning is promoted by modeling or observing other people. It is anchored on the fat that persons are thinking beings with self- regulatory capacities, capable of making decisions and acting according to expected consequences of their behavior.  The environment affects learning, but learning outcomes depend on the learner’s individual characteristics (Bandura, 1977).  Examples: - Serving as a live model (demonstrating wound care) - Giving detailed verbal instructions (teaching how to do deep breathing exercises) - Using print or multimedia strategies in health education (infographics) The nurse facilitates learning through catching attention  through different strategies, promote retention of learning by demonstrating the step-by-step procedure, providing with occasions for the reproduction or imitation of the procedures and motivating the clients by explaining the benefits derived from the behavior (Bandura, 1977). b. Health Belief Model  The Health Belief Model (HBM) provides the basis for much of the practice of health education and health promotion today.  The HBM was developed by a group of social psychologists to explain why the public failed to participate in screening for tuberculosis (Hochbaum, 1958).  Examples: (Questions to ask) - Why do people who may have a disease reject health screening? - Why do individuals participate in screening if it may lead to the diagnosis of disease?  The HBM is used to explain behavior change and maintenance of behavior change and to guide health promotion interventions. c. Milio’s Framework for Prevention  Milio’s Framework for Prevention (1976) provides a compliment to the HBM and provides a mechanism for directing attention upstream and examining opportunities for nursing intervention at the population level.  Milio’s Proposition Summary 1. Population health deficits’ result from deprivation and/or excess of critical health resources. Example: individuals and families living in poverty have poorer health status compared with middle and upper class families 2. Behaviors of populations result from selection from limited choices; these arise from actual and perceived options available as well as beliefs and expectations resulting from socialization, education, and experience. Example: positive and negative lifestyle choices are strongly dependent on culture, socioeconomic status and educational level. 3. Organizational decisions and policies dictate many of the options available to individuals and populations and influence choices. Example: health insurance coverage and availability 4. Individual choices related to health promotion or health damaging behaviors are influenced by efforts to maximize valued resources. Example: Choices and behavior of individuals such as use of illegal drugs 5. Alteration in patterns of behavior resulting from decision making of a significant number of people in a population can result in social change.  Example: Some behaviors such as tobacco use have become difficult to maintain in many settings or situations in response to organizational and public policy mandates. 6. Without concurrent availability of alternative health-promoting options for investment of personal resources, health education will be largely ineffective in changing behavior patterns. Example: Addressing persistent health problems (hypertension etc.) d. Nola Pender’s Health Promotion Model Health Promotion Model (HPM) explores many biopsychosocial factors that influence individuals to pursue health promotion activities. Health Promotion Model Variables 1. Individual characteristics and experiences 2. Prior related behavior 3. Personal factors 4. Behavior-specific cognitions and affect 5. Perceived benefits of action 6. Perceived barriers to action 7. Perceived self-efficacy 8. Activity-related affect 9. Interpersonal influences 10. Situational influences 11. Commitment to a plan of action 12. Immediate competing dem e. Transtheoretical Model The Transtheoretical Model (TTM) combines several theories of intervention, thus the name transtheoretical. Stages of Change 1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance Decisional Balance 1. Pros-The benefits of behavior change 2. Cons-The costs of behavior change Change is difficult, even for the most motivated individuals. People resist change for many reasons. Change may: - Be unpleasant - Require giving up pleasure - Be painful - Be stressful  - Jeopardize social relationships - Not seem important any more - Require change in self-image f. Lawrence Green’s PRECEDE-PROCEED MODEL  The PRECEDE-PROCEED Model provides a model for community assessment, health education planning and evaluation.  PRECEDE which stands for: P redisposing, R einforcing and E nabling C onstructs in E ducational D iagnosis and E valuation is used for community diagnosis.  PROCEED an acronym for: P olicy, R egulatory and O rganizational C onstructs in E ducational and E nvironmental D evelopment. Predisposing factors refers to people’s characteristics that motivate them towards health-related behavior. Enabling factors refers to conditions in people and the environment that facilitate or impede health related behavior. Reinforcing factors refers to feedback given by support persons or groups resulting from the performance of the health-related behavior. Different Fields 1. Community Health Nursing  It is the synthesis of nursing practice and public health practice applied to promoting and preserving the health of the populations  CHN is considered to be a broader and more general specialty area that encompasses subspecialties that include public health nursing, school nursing, occupational health nursing and other developing fields of practice such as home health, hospice care and independent nurse practice. 2. Public Health Nursing  Public Health Nursing has frequently been described as the synthesis of public health and nursing practice.  It includes technical nursing, interpersonal, analytical and organizational skills that are applied to problems of health as they affect the community. 3. Community Based Nursing  Community based nursing is the application of the nursing process in caring for individuals, families and groups where they live, work or go to school as they move through the health care system. 4. School Health Nursing  School health nursing aims to promote the health of school personnel and students that could hinder learning or performance. According to World Health Organization (WHO, 1997), “to learn effectively, children need good health.”  School Health Services:  Comprehensive School Health Education (Grades K-12)  Physical Education and Activity  Nutrition Services  School Health Services  School Counseling, Psychological and Social Services  Health and Safe School Environment  Student, Family and Community Involvement in Schools  Health Promotion for School Staff 5. Occupational Health Nursing  Occupational health nursing aimed at assisting workers in all occupations to cope with actual and potential stresses in relation to their work and work environment. 6. Community Mental Health Nursing  Community Mental Health Nurses are specialized nurses who provide wholistic nursing services for people with mental health issues, in a community setting such as caring and confidential supports for the clients, using the recovery model for care.  The services may include: o Treatment Planning o Medication Management o Assessment o Counseling o Family Support o Education o Group Support o Facilitate services with visiting psychiatrists 7. Home Health Care  Home health care helps in providing nursing care to the individuals and families in their own place of residence mainly to minimize the effects of illness and disability. 8. Hospice Home Care  Hospice home care specifically renders to terminally ill, intended to provide comfort to improve quality of life provide support to the patient and family. 9. Faith community nursing  Faith community nursing or parish nursing is the practice of art and science and nursing combine with spiritual care. Module II. Concept of the Community Learning Objectives On completing this module, you will be able to: 1. Define the key concepts of community. 2. Enumerate the different types of communities. 3. Describe the characteristics of a healthy community and its components. 4. Identify the factors affecting health of the community. 5. Demonstrate understanding on the roles and activities of community health nurse. In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interest or characteristics form the basis for a sense of unity or belonging” (Allender et al., 2009). “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may exhibit a commitment with one another and may shade a geographic boundary” (Lundy & Janes, 2009) “a group of people who share common interests, who interact with each other, and who function in collectively within a defined social structure to address common concerns” (Clark, 2008); and “a locality-based entity, composed of systems of formal organizations reflecting society’s institutions, informal groups and aggregates” (Shuster & Goeppinger, 2008). Maurer and Smith (2009) further addressed the concept of community and identified four defining attributes: (1) people, (2) place, (3) interaction, and (4) common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as group or collection of locality-based individuals, interacting in social units and sharing common interests, characteristics, values, and /or goals. Types of Communities (Maurer & Smith, 2009) 1. Geo-political communities  Geopolitical communities are most traditionally recognized or imagined when considering the term community.  Geopolitical communities are defined or formed by both natural and man-made boundaries and include barangays, municipalities, cities, provinces, regions, and nations. Other commonly recognized geopolitical communities are congressional districts and neighborhoods. Geopolitical communities may also be called territorial communities.  2. Phenomenological communities  Phenomenological communities, in the other hand, refer to relational, interactive groups, in which the place or setting is more abstract, and people share a group perspective or identity based in culture, values, history, interests, and goals.  Examples if phenomenological communities include schools, colleges, and universities; churches, and mosques; and various groups or organizations.  These communities may also be described as functional communities.  A community of solution is a type of phenomenological community and is a collection of people who form a group specifically to address a common need or concern.  The Gawad Kalinga, whose members aim to alleviate poverty by community development, and a group of indigenous people who lobby against environmental degradation of their ancestral land are examples.  These groups or social units work together to realize a level of potential “health” and to address identified actual and potential health threats and health needs.  Depending on the situation, needs and practice parameters, community health nursing interventions may be directed toward a community (e., residents of a small town), a population (e., all elders in a rural region), or an aggregate (e., pregnant teens within a school district). Characteristics of a Healthy Community (Hunt, 1997; Duhl, 2002) 1. Shared sense of being a community based on history and values. 2. General feeling of empowerment and control over matters that affects the community as whole. 3. Existing structures that allow subgroups within the community to participate in decision making in community matters. 4. Ability to cope with change, solve problems, and manage conflicts within the community through acceptable means. 5. Open channels of communication and cooperation among the members of the community. 6. Equitable and efficient use of community resources within the view towards sustaining natural sources. A healthy community is, in fact, the context of health promotion defined in the Ottawa Charter (WHO, 1986) as “the process of enabling people to increase control over and to improve their health. ” A healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources that enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.  It aims to: a. Achieve a good quality of life b. Create a health-supportive environment c. Provide basic sanitation and hygiene needs d. Supply access to health care Components of a Community  A community can be described as a complex whole resulting from the combination of the environment, people health, quality of life, and economics.  The functionality of a community depends solely on these key elements.  Thus, the components of the community are as follows: a. the environment, b. the people, c. the economy, d. the culture, e. health, and f. the quality of life. Factors Affecting Health of the Community 1. Characteristics of the Populations 2. Location of the Community 3. Social System within the Community Determinants of Health and Disease  The health status of a community is associated with several factors: 1. Health care 2. Access 3. Economic conditions 4. Social 5. Environmental issues 6. Cultural practices Roles and Activities of Community Health Nurse  The complex nature of the health needs of communities calls for a holistic response from public health nurses.  This in effect demands not only collaborative interventions but at the same time the nurse working with communities is expected to demonstrate competencies demanded by different settings and situations of his/her clientele.  The Philippine Professional Regulatory Board of Nursing (NNCCS, 2012) expects beginning professional nurses to be able to perform three roles: that of health care provider, manager-leader, and researcher.  But a community and public health nurse takes on additional roles, owing to the realities of changing times and age. Healthcare Provider.  Caring is the essence of nursing and has been widely accepted in all settings. The use of the nursing process applied in the natural environment of the client pertains to this role.  Examples include the occupational health nurse conducting a physical examination of an employee, a school nurse providing first-aid to student who sustained a cut, and a nurse taking the history of a pageant woman in the village clinic. Health Educator.  Communicating information to help patients make an informed choice regarding their health is a key activity in public health works. It is hoped that awareness will impact people’s behavior to achieve health in their own hands. Instructing patients how to take their prescribed medicine or sharing information about the benefits of healthy lifestyle illustrates this role. Program Implementer.  Nurses working under local government units deliver healthcare to the grassroots.  This also requires that programs initiated by the national government thru the Philippine Department of Health (DOH) are executed at all levels.  This includes immunization which offers protection against infectious disease.  The nurse works with the rural health midwife in conducting routine vaccination in communities to achieve herd immunity and contribute to the over-all goal of reducing child mortality.  Likewise, submitting reports per standards of documentation on targets reached and missed is part of this role of the nurse in community/public health. Community Organizer.  Working with people in communities and providing them ownership of their healthcare needs and to act collectively on their issues is best captured by this role of the nurse in public health. Manager/Leader.  Community and public health work deal with competing claims specifically on utilization of limited resources.  Hence, the nurse employs principles of management to maximize resources effectively and efficiently.  Budgeting, inventories, scheduling and staffing, conducting training sessions are likewise included under this role. Researcher/Epidemiologist.  The nurse is regarded as the health monitor of the community.  Together with the rural health midwife, they keep track of illnesses encountered in their areas of jurisdiction and submits reports to health authorities as required by law. In the event of an outbreak, community/public health nurses work with other professionals and agencies in conducting investigation to identify etiology of epidemic and ultimately identify potential solutions to halt the progress of the problem.  Apart from collecting actual data for research, the nurse utilizes research findings to provide evidence to convince decision-makers to enact policies for health. Client Advocate.  The community/public health nurse takes a proactive stance in ensuring that the right to health of the population he/she works with is realized and protected.  To do this, he/she engages stakeholders in clamoring and lobbying for policies that impact health of communities.  The nurse in the field also initiates organizing activities to form coalitions and linkages to foster awareness of people to various health-related issues. Module III. Health Statistics and Epidemiology Learning Objectives On completing this module, you will be able to: 1. Define epidemiology and explain the components of its definition. 2. Elucidate the practical applications of epidemiology. 3. Calculate epidemiologic measures that are used for assessing the health status of the community. Although the beginnings of epidemiology might have been during the time of Hippocrates when he explicated that disease could be associated with climate and the physical environment, it is still a young science that developed rapidly only after Snow’s investigation of the cholera epidemic in London in 1854. Epidemiology originated from the Greek words, epi, meaning “upon”, demos, meaning “people”, and logos, meaning “study”. Epidemiology is the study of the distribution and determinants of health- related states or events in specified populations an the application of this study to the prevention and control of health problems. This includes Practical applications of epidemiology are: a. Assessment of the health status of the community or community diagnosis b. Elucidation of the natural history of disease c. Determination of disease causation d. Prevention and control of disease e. Monitoring and evaluation of health interventions f. Provision of evidence for policy formulation Community assessment is an essential process for understanding the community, identifying its needs or weaknesses and assets or strengths that is useful to achieve healthy communities. It is a fundamental step that supports the actions of the community health nurse in planning and implementing interventions in the community. A community health assessment is otherwise termed as community health needs assessment.  The data that need to be collected depend on the objectives of community assessment. In general, the nurses need to collect data on the three features of a community: people, place and social system. The community data base for Planned Approach to Community Health (PATCH), a community health planning model based on Green’s PRECEDE model includes quantitative and qualitative data. 1. Community Profile: demographic, educational, economic data 2. Morbidity and mortality data 3. Behavioral data 4. Opinion data from common leaders A. Tools 1. DEMOGRAPHY - Is the science which deals with the study of the human population size, composition and distribution in space. Sources of Data 1. Primary data  original data collected for a specific purpose by a researcher.  Example: Data collected when there is a suspected Cholera outbreak in a community, which could include getting water sample from their water source and interviewing people about their symptoms. 2. Secondary data  Data already collected by other individuals and/ or institutions for some specific purpose.  Example: Population census, birth, and death certificates, disease registries, patients’ medical records, health insurance claims, health surveys, etc.  Vital Statistics  is the study of the characteristics of human populations. It comprises a number of important events in human life including birth, death, fetal death, marriage, divorce, annulment, judicial separation, adoption, legitimation and recognition.  Individual records  birth, death, marriage/divorce  Population records  it serves as key demographic variables in the analysis of population size, growth and geographic distribution.  Population indicators  includes population growth indicators (crude birth rate, general fertility rate, total fertility rate and annual growth rate) and other population dynamics (migration) that can affect the age-sex structure of the population.  Population Size 1. Natural increase 2. Rate of natural increase Population Composition 1. Sex composition 2. Age composition 3. Age and sex composition Population Distribution 1. Urban-Rural distribution 2. Crowding index 3. Population density 2. HEALTH INDICATORS  Fertility Rates 1. Crude Birth Rate (CBR) - measures how fast people are added to the population through births. CBR=total number of live births for a given area and time period/total population at the midpoint of the time period x 1000 2. General Fertility Rate (GFR) – the number of live births per 1,000 women aged 15-49 in a given year GFR=number of registered live births in a year/midyear population of women 15-49 years of age x 1000  Morbidity Rates 1. Incidence Rate (IR) describes the occurrence of new cases of a disease or condition in a community over a given period relative to the size of the population at risk for that disease or conditions during that same period. IR=number of new cases of disease developing from a period of time/ population at risk of developing the disease X F 2. Prevalence Rate (PR) is the number of all cases of a specific disease or condition in a population at a given point in time relative to the population at the same point in time. PR=number of existing cases in population at a particular point in time/ population at the same specified point in time x F  Mortality Rates 1. Crude Death Rate (CDR) represents the total or overall death rate in a given population.  CDR=number of deaths for a given area and time period/ size of population at risk of dying, usually taken as the estimated population at the midpoint of the calendar year x 1000 2. Specific Death Rate represents a subset of the population or with particular classes of deaths SDR= number of deaths in a specified group/ midyear population of the same specified group x 1000 3. Cause of Death Rate gives the rate of dying due to specific causes. Cause of Death Rate = number of deaths from a specified cause / midyear population x 1000 4. Infant Mortality Rate (IMR) is the number of deaths per 1,000 live births of children under one year of age. IMR= deaths under 1 year of age/ number of live births x 1000 5. Maternal Mortality Rate (MMR) refers to deaths due to complications from pregnancy or childbirth. MMR= number of deaths due to pregnancy, delivery and puerperium / number of live births x 1000 6. Proportionate Mortality Ratio describes the proportion of deaths in a specified population over a period of time attributable to different causes. PMR= number of deaths from a particular cause / total deaths x100 7. Swaroop's index is the proportion of deaths aged 50 years and above. The higher the Swaroop's index of a population, the greater the proportion of the deaths who were able to reach the age of at least 50 years, i.e., more people grew old before they died. Swaroop’s Rate=numbers of death among those 50 yrs. and over/ total deaths x 100 8. Case Fatality Rate also called case fatality risk or case fatality ratio. It is the proportion of people who die from a specified disease among all individuals diagnosed with the disease over a certain period. Case Fatality Rate typically is used as a measure of disease severity and is often used for prognosis (predicting disease course or outcome), where comparatively high rates are indicative of relatively poor outcomes. It also can be used to evaluate the effect of new treatments, with measures decreasing as treatments improve. Case fatality rates are not constant; they can vary between populations and over time, depending on the interplay between the causative agent of disease, the host, and the environment as well as available treatments and quality of patient care. CFR= numbers of death from a specified cause/number of cases of the same disease x 100 B. Philippine Health Situation (worldometers/demographics/philippines- demographics/) 1. Demographic Profile  A nation’s health care delivery system has a tremendous impact not only on the health of its people but also on their development, including their socioeconomic status. Nations go through a struggle to overcome multiple forces in efforts to advance the nation’s health within the context of their financial and political situations.  Anderson and MCFarlane (2011) emphasized the role of the following factors in shaping 21st century health that further influence health care delivery system: 1. Health care reforms 2. Demographics 3. Globalization; 4. Poverty and growing disparities; 5. Social disintegration.  The current population of the Philippines is 111,448,385 as of Thursday, October 14, 2021, based on Worldometer elaboration of the latest United Nations data.  The Philippines 2020 population is estimated at 109,581,078 people at mid year according to UN data.  The Philippines population is equivalent to 1% of the total world population.  The Philippines ranks number 13 in the list of countries (and dependencies) by population.  The population density in the Philippines is 368 per Km 2 (952 people per Mi2).  The total land area is 298,170 Km2 (115,124 sq. miles)  47 % of the population is urban (52,008,603 people in 2020)  The median age in the Philippines is 25 years. Fertility in the Philippines  A Total Fertility Rate (TFR) is the average number of children per woman needed for each generation to exactly replace itself without needing international immigration.  2.6 – Live Births per Woman, 2020 Life Expectancy in the Philippines BOTH SEXES 71 years (life expectancy at birth, both sexes combined) FEMALES 75 years (Life expectancy at birth, females) MALES 67 years (Life expectancy at birth, males) Infant Mortality Rate and Deaths of Children under 5 Years Old in the Philippines INFANT MORTALITY 17.5 (Infant deaths per 1,000 live births) DEATHS UNDER AGE 5 24.8 (per 1,000 live births) Philippines Urban Population  Currently, 47 % of the population of the Philippines is urban (50,971, people in 2019) Population Density  The 2019 population density in the Philippines is 363 people per Km 2 ( people per mi 2 ), calculated on a total land area of 298,170 Km2 (115,124 sq. miles). 2. Health Profile Causes of Morbidity and Mortality 10 Leading Causes of Morbidity in the Philippines, 2010 ( DOH, 2010) 1. Acute Respiratory Infection 2. Acute Lower Respiratory Tract Infection and Pneumonia 3. Bronchitis/Bronchiolitis Frequency refers to the number of health events, such as the number of cases of COVID 19 or Dengue in a population. Pattern refers to the occurrence of health conditions or disease by time, place and person. Time patterns maybe annual, seasonal, weekly, daily, hourly or any other breakdown of time that may influence health condition or disease. Place patterns include geographic variation, such as urban/rural differences and location such as schools or workplace. Epidemiologic methods are used to study both communicable and non- communicable diseases and other health-related states or events. Epidemiologic methods and tools are important for accurate community assessment and diagnosis and in planning and evaluating effective community interventions. Types of Health Indicators and their Examples 1. Morbidity - prevalence, incidence 2. Mortality- crude and specific death rate, maternal mortality, infant mortality, neonatal mortality 3. Population – Age-sex structure of the population, population density, migration 4. Indicators of the provision of healthcare- access to health program 5. Risk reduction indicators- Cases consulting a health provider 6. Social and economic indicators-level and distribution of economic wealth, types and levels of employment 7. Environmental -potability of drinking water 8. Disability – chronic mobility limitations 9. Health policy- allocation of manpower History of Disease  In studying the course and outcome of diseases, epidemiology gives a picture of the natural history of diseases in individuals and groups.  It describes the subclinical changes to signs and symptoms of the clinical disease until its resolution to either recovery to death. The moment the pathogen enters a susceptible host is referred to as exposure.  The pathogen will invade the target organ or tissue and multiply there.  The human body will start its immune system response at which stage there is already an acknowledged infection whether the patient is symptomatic or asymptomatic.  This period between exposure and infection is called latent period since the pathogen is present in a latent stage without clinical symptoms or signs of infection in the host.  The period between exposure and onset of clinical symptoms is called incubation period.  The host may become infectious at any moment of the infection. Infectious period is defined as the time during which time the host can infect another susceptible host; whereas noninfectious period is the period when the host’s ability to transmit the disease to other hosts ceases. Level of Disease Occurrence (CDC, 2020) 1. Sporadic refers to a disease that occurs infrequently and irregularly. 2. Endemic refers to the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area. 3. Hyperendemic refers to persistent, high levels of disease occurrence. 4. Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. 5. Outbreak carries the same definition of epidemic but is often used for a more limited geographic area. 6. Cluster refers to an aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even though the expected number may not be known. 7. Pandemic refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people. Triangle  In understanding diseases or poor health outcomes, it is also important to understand the risk factors or any attribute, characteristics or exposure of an individual that increases the likelihood of developing a disease or health condition.  There are three models of disease causation: 1. Epidemiological triad 2. Iceberg principle 3. Web of causation Epidemiological triad  is the traditional model for infectious diseases, consisting of susceptible host, an external agent and an environment that brings the host and agent together.  In this model, disease results from the interaction between the susceptible host and the agent in an environment that supports transmission of the agent from a source to that of the host (CDC, 2012). Iceberg principle  shows the disease situation where the problem is subclinical, unreported or hidden from view. Only the tip of the iceberg is known, eg, resulting deaths from suicides or reported cases of AIDS. The public health goal is to find out through screening and early detection those who are exposed or affected so that proper interventions can be done. Web of causation  shows the relationship between different multiple factors that contribute to the cause of a disease. This model proposes that diseases are caused by the interaction between genetic factors and environmental factors. Personal behaviors also affect this interaction and interventions can be done through health promotion. Epidemiological Process and Investigation Screening and Surveillance  are important in identifying risk factors and monitoring health and disease conditions in the population. Evidence from surveillance studies is often used to develop screening programs, prevention and treatment policies. Screening is the active search or process of detection for disease or disorders among apparently healthy people. The primary aim of screening is to identify risk factors