COMMUNITY
HEALTH NURSING
Sagun Lohala
NPHSHS

Course Objective
Aimed to provide
• Basic knowledge in community health nursing regarding concept of
health and spectrum of health, primary health care, community, nutrition,
epidemiology, health statistics and indicators, family planning,
immunization, pollution hazards, occupational hazards

At the end of the sessions students will be able to
• Define community
• Describe community health
• Describe community health nursing
• Define health according to WHO
• Define disease
• Define illness
• Describe spectrum of health and illness
• Identify dimensions of health

Community
• A community is commonly defined as a group of people living
together in the some geographic location and abiding by the laws
• “ The people living in a particular place or region and usually linked
by common interests”

Cont’d…
• A group of individuals and families living together in a defined
geographical area, usually comprising a village, town or city
• People living in the community may be socially and culturally similar to
one another, or they could be quite different.
• Those people have different occupations, religious values, economic
status, education, etc.

Community Health
• The term community health has replace the term public health,
preventive medicine and social medicine
• According to WHO “ Community health refers to the health status of
the members of the community, to the problems affecting their health
and to the totality of health care provided for the community

Cont’d…
• Community health is a systematic way of studying the health and
diseases present in a community and the patterns of delivery of care
both of which influence the amount and nature of disease.
• Also known as community medicine.s

Community Health Nursing
According to American Nursing Association (ANA), “community health
nursing is a synthesis of nursing and public health practice applied to
promoting and preserving the health of people. The practice is general and
comprehensive. It is not limited to particular age group or diagnosis and is
continuing, not episodic”

Concept of Health
• “Health” is perceived differently by members of the community. The
concept of health is evolved over the centuries as a concept from
individual concern to worldwide social goal and covers the whole
quality of life.

Changing Concept of Health
a) Biomedical
Concept
b) Ecological
Concept
c) Psychological
Concept
d) Holistic
Concept

Cont’d…
a) Biomedical Concept
Traditionally health is viewed as “absence of disease”, if one is free from
disease, the person was considered healthy. It is based on “germ theory of
disease”. The medical profession viewed human body as a machine, disease as a
consequence of the breakdown of the machine and one of the doctor’s task as
repair of the machine

Cont’d…
b) Ecological Concept
This concept raised because of deficiency in the biomedical concept. According
to this concept, health is viewed as a dynamic equilibrium between human being
and environment; disease as maladjustment of the human organism to
environment. The ecological concept raises two issues such as imperfect man
and imperfect environment.

Cont’d…
c) Psychological Concept
According to this concept, health is not only biomedical phenomenon but one
which is influenced by social, psychological, cultural, economic and political
factors of the people concerned. Thus health is both a biological and social
phenomenon.

Cont’d…
d) Holistic Concept
It is synthesis of all the above concepts. It describes health as a unified or
multi-dimensional process involving the well-being of whole person in
context of his environment. This approach suggests that all sectors of society
have an effect on health particularly in agriculture, animal husbandry, food,
industry, education, housing, communication and other sectors

Definition of Health
• “Health” is one of the terms which is most people find it difficult to
define although they are confident of its meaning
• Webster: The conditions of being sound in body, mind and spirit
specially freedom from physical disease or pain

Cont’d…
• The oldest definition is that health is the “absence of disease”.
• According to WHO (1947), health is defined as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity”
• In recent years, this statement has been amplified to include the ability to lead a
“socially and economically productive life”

Disease
• Webster defines disease as “ a condition in which body health is impaired,
a departure from a state of health, an alteration of the human body
interrupting the performance of vital functions”.
• According to Oxford dictionary, disease is defined as “ a condition of the
body or some part or organ of the body in which its functions are
disturbed or deranged.

Cont’d…
• From ecological concept, disease is considered as “a maladjustment of the
human organism to the environment”.
• From sociological concept, disease is considered as a social phenomenon,
occurring in all societies and defined and fought in terms of the particular
cultural forces prevalent in the society

Cont’d…
• The simplest definition is that disease is just the opposite of health i.e. any
deviation from normal functioning or state of complete physical or mental
well-being.

Optimum health
• Health is a continuum with optimum health on the one end and death on the
other side. People fall somewhere on the continuum depending on their
level of health or illness.

Illness-Wellness Continuum

Illness-Wellness Continuum
The transaction from optimum level of health to illness is gradual in nature,
where one state ends and the other begins in a matter of judgment. Health
and disease lie along a continuum and there is no single cut off point.

Cont’d…
• The lowest point in the continuum is death and the highest point
corresponds to the WHO definition of positive health.
• Thus, a person who is physically, mentally, socially and spiritually
healthy is said to be in a state of optimum health. It means people will
have access to be born healthy, grow to adulthood and live productive life

Spectrum of Disease
• Spectrum of health refers to the range of manifestations and
severities of illness associated wit ha given diseases, illness or injury.
• The term “spectrum of disease” is a graphical representation of
variations in the manifestations of disease

Spectrum of Health and Sickness

Cont’d…
• Health and disease lie along a continuum, there is no single cut-off point
• The health of an individual is not static; it is a dynamic phenomenon and
a process of continuous change
• There are degrees or "levels of health" as there are degrees or severity of
illness. As long as we are alive there is some degree of health in us.

Cont’d…
• At one end of the spectrum are subclinical infections which are not
ordinarily identified, and at the other end are fatal illness
• In the middle of the spectrum lie illnesses ranging in severity from
mild to severe.

Cont’d…
• These different manifestations are simply reflections of individual’s
different states of immunity and receptivity
• The sequence of events in the spectrum of disease can be interrupted
by early diagnosis and treatment or by preventive measures

Positive health
Positive health means perfect functioning of the body and mind. It conceptualizes
health biologically, as a state in which every cell and every organ is functioning at
optimum capacity and in perfect harmony with the rest of the body,
psychologically, as a state in which the individual feels a sense of perfect well-
being and of mastery over his environment and socially, as a state in which the
individual’s capacities for participation in the social system are optimum

Distinction between Disease, Illness and
Sickness
•Disease means “without ease” (uneasiness),
when something is wrong with bodily
function. Disease is a physiological/
psychological dysfunction.

Cont’d…
Illness means not only the presence of a
specific disease, but also to the individual’s
perception and behavior in response to the
disease, as well as the impact of the disease on
psychological environment.

Sickness
Sickness refers to a state of social dysfunction i.e. a role that the individual
assumes when ill (sickness role). Sickness is related to different
phenomenon, namely the social role a person with illness or sickness or is
given in society, in different arenas of life.

Disease Illness Sickness
A condition that
is diagnosed by
a physician or
other medical
expert.
→ (Physician)
Ill health that the
person identifies
themselves with, often
based on self reported
mental or physical
symptoms.
● It can be Acute or
Chronic
→ (Patient)
Social &
cultural
conception of a
person’s
condition.
"When it
interferes with
your life"
→ (Society)
Flu diagnosed by a
physician
Flu reported by the
patient
Missed class or
work due to Flu
(Sick leave)
Definitions: The trilogy of Disease, Illness, Sickness

Dimensions
of Health
a) Physical
Dimension
b) Mental
Dimension
c) Social
Dimension
d) Spiritual
Dimension
e)
Emotional
Dimension
f)
Vocational
Dimension
Health is
multidimensional.
WHO defines 3
specific
dimensions of
health
• Physical
• Mental and
• Social

Cont’d…
a) Physical Dimension
• Physical health relates to the anatomical, physiological, and biochemical
functioning of the human body.
• The state of physical health implies the understanding of “perfect
functioning” of the body

Cont’d…
The signs of physical health in an individual are” “ a good
complexion, a clean skin, bright eyes, well clothed, not too fat, a sweet
breath, a good appetite, sound sleep, regular activity of bowels and
bladder and smooth, easy, coordinated bodily movements.

Cont’d…
All the organs of the body are of unexceptional size and function
normally; all the special senses are intact, the resting pulse rate, blood
pressure and exercise tolerance are all within the range of
“normality” for the individual’s age and sex

Cont’d…
It conceptualizes health biologically as a state in which every cell and
every organ is functioning at optimum capacity and in perfect harmony
with the rest of the body

Cont’d…
b) Mental Dimension
• Mental health is not mere absence of mental illness.
• Good mental health is the ability to respond to the many varied
experiences of life with flexibility and a sense of purpose

Cont’d…
Mental health has been defined s “ a state of balance between the
individual and the surrounding world, a state of harmony between
oneself and others, a coexistence between the realities of the self and
that of other people and that of the environment.

Cont’d…
c) Social Dimension
• Social well-being implies harmony and integration with the individual,
between each individual and other members, society and between
individuals and the world in which they live
• It can be defined as the “quantity and quality an individual’s
interpersonal ties and the extent involvement with the community”

Cont’d…
• It includes the levels of social skills one possesses, social functioning and
the ability to oneself as a member of a larger society.
• Social health is rooted “ positive material environment” and “positive
human environment” where is concerned with the social network of the
individual

Cont’d…
d) Spiritual Dimension
• Holistic approach of health believes that the time has come to give
serious consideration to the spiritual dimension and to the role this
plays in health and disease

Cont’d…
• It refers to that part of the individual which reaches out and strives
for meaning and purpose in life.
• It is intangible “something” that transcends physiology and
psychology.
• It includes integrity, principles and ethic the purpose in life,
commitment to some higher being are belief in concepts that are not
subject to state of the any explanation

Cont’d…
e) Emotional Dimension
• The mental and emotional dimensions have been seen as one element
or as two closely related elements
• With greater numbers of research, a definite difference is emerging.

Cont’d…
• Mental health can be seen as “knowing” or “cognition” while
emotional health relates to “feeling”.
• Thus, the mental and emotional aspects of humanness may have to
be viewed as two separate dimensions of human health

Cont’d…
f) Vocational Dimension
• It is a new dimension to health
• It is a part of human existence
• When work is fully adapted to human goals, capacities and
limitations, work often plays a role in promoting both physical and
mental health.

Cont’d…
• Physical work is usually associated with an improvement in physical
capacity, while goal achievement and self-realization in work are a
source of satisfaction and enhanced self-esteem.
• The importance of this dimension is exposed when individuals
suddenly lose their jobs or faces with mandatory retirement.

Cont’d…
• For many people, the vocational dimension may be merely a source
of income.
• To others, this dimension represents the culmination of the efforts of
other dimesions as they function together to produce what the
individual considers life “success”

Determinants/ Factors of Health
• Factors which influence health lie both within the individual and
externally in the society in which he or she lives.
• A person can fall victim depending upon combination of his or her
genetic factor and the environmental factors to which he is exposed.

Determinants
of Health
1)
Biological
Factors
3)
Environment
al Factor
2) Life
style
4) Socio-
economi
c factor
5) Health
Services
6) Aging
of
populatio
n
7)
Gender
8)
Others

Cont’d…
• The health of an individual or the whole community may be
considered as the result of the interaction between those factors.

1) Biological:
•Genetic predisposition from the parents to the off-
springs
2) Behavioral and socio-cultural (Life Style)
•Cultural and behavior patterns, life long habits
developed from socialization (eg: smoking, staying
up late)

3) Environmental Factor
•Can be internal environment that is every
components in the body from the cell, tissue,
organ, system and the harmonious relationship
between the system
•Can be external environment that is every thing
outside the individual’s body which can be physical
biological, and psychological components

4) Socio-economic factor
•There is a strong impact on health. It includes race,
income, level of education, occupation, gender,
housing, and religion.
5) Health Services
•The aim of health services is to enhance health
status of population. Availability and quality of
health services can affect health of individual and
community

6) Aging population
•Rapid aging of population increases burden of
chronic disease
7) Gender
•Women's health covering nutrition, reproductive
health, the health consequences of violence,
ageing, lifestyle related conditions and the
occupational environment.
•Road traffic accidents are more prone to man

8) Others
•Information technology, health related systems like
agriculture and food
•Although technology is great, not everyone know
how to use them

Social Determinants of Health
• Social determinants are the social and economic factors that
influences people’s health.
• These are obvious in the living and working conditions that people
experience in daily life.
• For example, income, social status, education, physical environment,
social support networks, genetics, health services, etc

Cont’d…
According to WHO, social determinants of health are defined as “the
conditions in which people are born, grow, live, work and age.”

Dahlgren and Whitehead’s model of
social determinants of health

Cont’d…
• The model proposed the layer of influence on health.
• It describes the socio-ecological theory of health
• It attempts to map the relationship between the individual, their
environment, and disease

Individual Lifestyle factors: Age, sex and
hereditary factors
• The core part of the model consists of inherited attributes relating to age,
sex and hereditary factors
• It suggests that health is partly determined by individual’s lifestyle, such
as smoking, physical activity and diet that can promote or damage health
and can be modified

Social and Community Network
• The second layer on the model is social and community network.
• It draws attention to relationship with family, friends, and significant
others within the local community.

Cont’d…
• This network contributes to the health by providing help, mutual support to
members of the community in unfavorable conditions.
• Sometimes, it may not support or may also have negative effect on health. For
instance, broken family, divorce, conflict.

General socio-economic, cultural
and environmental conditions
• It is the outermost layer of the model
• It focuses on working and living conditions such as housing, health
care services, water and sanitation, education, agriculture and food
production and so on

Cont’d…
• This layer focus on broader socio-economic, cultural and environmental
forces such as economic development, shift in welfare system, political
change, social forces and structure

Importance of Social Determinants of
Health
a) It directly affects health:
For example,
• Higher income and social status are linked to better health
• Low level of education are linked with poor health, stress, etc.
• Physical environment such as safe drinking water, clean air, healthy work
places, safe houses, communities and roads all contributes to good health

Cont’d…
b) It predicts the greatest proportion of health status variance
For example,
• Poor social and economic conditions- poverty, social exclusion,
unemployment and inadequate housing contribute to health inequalities

Cont’d…
It reflects an individual’s or population group’s position in society, security,
resources, such as education, employment, housing as well as differential
levels of participation in civic society and control over life

Cont’d…
c) Social determinants of health structure health behavior:
Not only influence the overall health in positive and negative ways; it also
determines the individual’s healthy behaviors and encourages in adopting healthy
behavior
• It depends on how much an individual is aware about staying fit and adopting
healthy behaviors which helps to prolong life and stay away from disease and
disability

Cont’d…
d) Social determinants interact with each other in order to produce
healthy life. No single social determinants along can help individual obtain
health.
• For instance, cutbacks in welfare services might adversely affect people’s
access to adequate housing and thus influence their health.

Thank you !!!

Community
•A community is commonly defined as a group of
people living together in the same geographic
location and abiding by the laws.
•“ A group of individuals and families living
together in a defined geographic area, usually
comprising a village, town, or city.”

Cont’d…
•According to WHO, community is a social group
determined by geographical boundaries and/ or
common values and interests with each other. It
functions in a particular social structure and
exhibits and creates certain norms, values, and
social institutions. The individual belongs to the
broader society through his family and
community.”

Community Health
•According to WHO “ Community health refers to
the health status of the members of the
community, to the problems affecting their health
and to the totality of health care provided for the
community

Community Health Nursing
According to American Nursing Association (ANA),
“community health nursing is a synthesis of nursing
and public health practice applied to promoting and
preserving the health of people. The practice is
general and comprehensive. It is not limited to
particular age group or diagnosis and is continuing,
not episodic”

Cont’d…
An art of applying science in the context of
politics so as to reduce inequalities in health while
ensuring the best health for the greatest number.
-WHO

Goals of Community Health Nursing
1. Health promotion
2. Health maintenance
3. Prevention of illness
4. Restoration of health

Cont’d…
a) Meet the community
First goal of CHN to meet the community in order to
•Establish contact with community leaders, existing
institutions
•Obtain consent of the local leaders for a base-line
survey of the health situation for identification of
health problems and needs

Cont’d…
Various approaches for identification of community
health problems and health needs are:
•Base line survey
•Scrutining the records of PHC and sub-centre
•Specific questions regarding disease common in area
•Questions regarding birth, deaths, disability, failure to
work etc.

Cont’d…
b) Setting priorities among health problems
Four criteria used for setting priorities among health
problems:
•Frequency with which the problems occurs
•Seriousness of the problem for individuals and society
•Urgency of the problem
•Feasibility or susceptibility to control the problem
within the financial resource limitation

Cont’d…
c) Planning and problem solving
A community health nurse must decide what action
should be taken by the health team and whether the
health team will be capable of taking any action.
Planning involving questions of setting objectives,
and defining solutions to the problem

Cont’d…
d) Intervention or implementation
The community health nurse caries out activities
decided upon as being most effective, in order to
fulfill the recognized need. This phase contains all the
tasks, procedures and practices which are performed
by nurses

Cont’d…
e) Evaluation
Measurement of the extent to which the problem has
been solved or the need met. It provides “feedback”
that can lead to program more effectively

Definition of Public Health
Public Health is the field of health science that is
concerned with safeguarding and improving the
physical, mental, and social well-being of the
community as a whole

Cont’d…
Mark Salman White (1982) describes a public
health as an organized societal effort to protect,
promote, and restore the health of people and
public health nursing as focused on achieving and
maintaining public health

Public Health Nursing
A branch of nursing concerned with providing
nursing care and health guidance to individuals,
families, and other population groups in settings
such as the home, school, workplace, and other
community settings such as medical and health
centers

Cont’d…
American Public Health Association (2003)
defines public health nursing is the practice of
promoting and protecting the health of populations
using knowledge from nursing, social and public
health sciences

Goals of Public Health Nursing
1. Improve the health outcomes of all population
2. Apply clinical knowledge and expertise in
health care from an ecological standpoint
3. Acknowledge the public health problems and
the relative nature of health including cultural,
environmental, physical and social factors

Cont’d…
4. Assess the potential or actual assets, needs,
opportunities and inequities of individuals,
families and populations and translate this
assessment into action for public good
5. Focuses on advocacy, policy development and
planning which addresses issues of social justice

Population Health
Population health is defined as “the health outcomes
of a group of individuals, including the distribution
of such outcomes within the group”.
-(Kindig and Stoddart, 2003)

Components of population health
•Health outcomes
•Health determinants
•Polices

Level of Prevention

Primordial Prevention
•It is receiving of special attention in the
prevention of chronic diseases.
•It is primary prevention in its purest sense i.e.
prevention of development of risk factors in
population groups in which they have not yet
appeared

Cont’d…
•Efforts of primordial prevention are directed
towards discouraging children from adopting
harmful lifestyles as many illness in adulthood
have origins in childhood
•Main intervention in primordial prevention is
through individual and mass education

Cont’d…
•For example, many adults health problems (eg
obesity, hypertension) have their early origins in
childhood, because this is the time when
lifestyles are formed (for example, smoking,
eating patterns, physical exercise)

Primary Prevention
•It is defined as “action taken prior to the onset of
disease which removes the possibility that a disease
will ever occur”.
•Primary prevention includes holistic approach.
•It involves interventions in the pre-pathogenesis
phase of a disease or health problem or other
departure from health

Health Promotion
Health Education
Environmental
Modification
Nutritional
Intervention
Life style and
behavioral changes
Specific Protection
Immunization
Chemoprophylaxis
Use of specific Nutrients or
supplementation
Safety of drugs and foods
Control of environmental
hazards e.g. pollution

Cont’d…
•It includes measures both general health promotion
and specific protection.
•It includes the concept of “positive health”.
•Positive health is a concept that encourages
achievement and maintenance of “an acceptable
level of health that will enable every individual to
lead a socially and economically productive life.”

Cont’d…
For example:
•It is now being applied to the prevention of chronic
diseases such as coronary heart disease,
hypertension and cancer based on elimination or
modification of risk factors of disease

Secondary Prevention
•These are actions which halts the progress of a
disease at its incipient stage and prevents
complication.
•The specific interventions arse early diagnosis and
adequate treatment.

Concept of disability
•The sequence of events
leading to disability
and handicap have been
stated as:

Cont’d…
Impairment:
It is defined as “any loss or abnormality of
psychological, physiological or anatomical
structure or function” eg. Loss of foot, defective
vision, etc

Cont’d…
Disability:
It is defined as “any restriction or lack of ability to
perform an activity in the manner or within the
range considered normal for a human being”

Cont’d…
Handicap:
It is defined as “a disadvantage for a given
individual, resulting from an impairment or a
disability, that limits or prevents the fulfilment of
role that is normal for that individual”.

Cont’d…
For example:
Accident : Disease or disorder
Loss of foot : Impairment
Can’t walk : Disability
Unemployed : Handicap

Cont’d…
•It aims to arrest the disease process, restore health
by seeking out unrecognized disease and treating it
before irreversible pathological changes and reverse
communicability of infectious diseases.
•It is mainly associated with clinical medicine

Cont’d…
•Goal of secondary prevention is to cure disease at
its earliest stage or when cure is impossible, to slow
its progression as well as prevent complications
and limit disability

Tertiary Prevention
•“All the measures available to reduce or limit
impairment and disabilities, minimize suffering
caused by existing departures from good health and
to promote the patient’s adjustment to irremediable
conditions”
•All the interventions are taken in late pathogenesis

Cont’d…
•When disease process has advanced beyond its early
stages, it is still possible to accomplish prevention
by tertiary prevention because tertiary prevention
may limit disability
•When disability are more or less stabilized,
rehabilitation may play a preventable role.

Level of Intervention
1. Individual Focused
2. Community Focused
3. System Focused

Individual Focused
•It is associated with interventions for promotion of
personal health or individual health
•Means these are applied at individual level
For example
•Modification of lifestyle and behavior by an
individual for good health

Community Focused
•It is associated with interventions for promotion of
health status of a group of people or sub-groups in
the community
For example
•Health education activities, environmental
modification, population strategies, screening test,
case finding program, etc.

System Focused
•These are interventions targeted to an entire
population, state or country.
For example
•National nutrition program, national immunization
program, laws for protection against occupational
hazards, laws for control of environmental hazards,
treatment protocol for non-communicable diseases
etc.