Study Guide 1 – Fundamental Concepts of Community Health Nursing

Topic Outline
1. Definition
2. Philosophy and Principles
3. Features of Community Health Nursing
4. Theoretical Models/ Approaches
a. Health Belief Model (HBM)
b. Millio’s Framework for Prevention
c. Nola Pender’s Health Promotion
d. Lawrence Green’s PRECEDE-PROCEED MODEL
5. Different Fields
a. School Health Nursing
b. Occupational Health Nursing
c. Community Mental Health Nursing

Learning Objectives
After studying this module, you will be able to:
 State the basic concepts and principles of community health nursing practice.
 Apply the essential concepts related to community health nursing practice.
 Describe the different theories and their application to community health nursing practice
 Explain how theory-based practice achieve the goals of community health nursing by protecting
and promoting the health of the public.
 Explain how the use of theoretical models provides varying perspectives on a community health
assessment
 Compare the different fields of community health nursing practice

Introduction
Community health nursing is one of the broadest fields of nursing in terms of setting or place of
practice. As a field of specialty in nursing, it is an old, established one, antedating by several decades
the shift in orientation of the other health professions in the community. In community health nursing,
nurses enter the environment in which people live and practice within the environment, in addition to
the one-to-one or single-family approach to health care, the community health nurse think in terms of
populations, aggregates at risk within these populations, including families at risk, are identified so
that preventive measures and resources can be targeted for them. Likewise the community health
nurse have committed to help the client take responsibility for his or her own well-being and
wholeness, through genuine interest and caring. Furthermore the important characteristics of
community health nursing practice are autonomy, continuity of care, collaboration, interactivity,
accountability and intimacy with reality of client’s situations. As community health nurses makes its
unique contribution by ensuring an equitable distribution of health care, a basic standard of living that
supports the health and well-being of all people and a healthful physical environment.

Activating Prior Knowledge

Do a quick search on the internet about the concepts of community health nursing practice in
the Philippines. From the readings what realizations can you conclude of the CHN practice in the
Philippines? Share your sights in 3-5 sentences.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
1
 Discussion of Key Concepts COMMUNITY HEALTH NURSING CONCEPTS

Definition
According to the Department of Health, community health nursing is a unique blend of nursing
and public health nursing practice woven into a human service that properly developed and applied
has a tremendous impact on human well-being. Its responsibilities expand to the care and supervision
of individuals and families in their homes, in places of work, in schools, and clinics. Community health
nursing (CHN) as a distinct field of nursing has been aptly described as any of the following:
• A field of nursing that is a blend of synthesis of nursing practice with the public health
using primary health care as the tool in the delivery of health services.
• A learned practice discipline with the ultimate goal of contributing as individuals and in
collaboration with others to the promotion of the client’s optimum level of functioning thru teaching
and delivery of care. (Jacobson, 1969)
• A service rendered by a professional nurse to individuals, families, communities and
population groups in health centers, clinics, schools, and the workplace in order to promote health,
prevent illness, provide care for the sick at their respective homes, provide effective rehabilitation.
(Freeman, 1970)
• The utilization of the nursing process in the different level of clientele- individuals,
families, population groups and communities concerned with the promotion of health, prevention of
disease and disability and rehabilitation (Maglaya et. al)

Goal and Objective of CHN

The goal of CHN is to assist the individual, family and community in attaining the highest level of holistic
health which attained through multidisciplinary effort and to promote reciprocally supportive relationship
between people and their physical and social environment.
The ultimate objective of care is achieving the highest possible level of community health by developing
and enhancing the capabilities of individuals, families and various population groups and the community
as a whole to take care of their own health and effectively cope with health problems.

Philosophy of CHN
The philosophy of CHN is based on the worth and dignity of men (Shetland, 1958). The
philosophy of care of based on the belief that care directed to the individual, the family, and the group
contributes to the healthcare of the population as a whole.
A philosophy is defined as ä system of beliefs that provide a basis for guides and action”. A philosophy
provides the direction and describes the what’s, and the why’s and the how’s of activities within a
profession.

Concepts and Principles of CHN

1. Family – the family is the unit of care and the community is the patient in CHN, and there are
four levels of clientele – the individual, the family, the population group, and the community.
2. Partnership – the community health nurse works with, or not for, the individual patient,
family, group or community as active partners the different phases of care. In CHN the client is
considered as an active partner, not a passive recipient of care.
3. Change – CHN practice is affected by developments in health technology, in particular and
changes in society in general.
4. Healthcare delivery system – CHN is part of health care system and of the larger human
services system. The CHN shares with other members of the health team and other sectors in
the community the responsibility of delivering health care services using a multidisciplinary
approach as the driving force in the efficient, effective and equitable delivery and utilization of
the services.
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
2
Features of CHN
1. Population or aggregate-focused – the hallmark of CHN. The whole community
is the patient/client.
2. Greatest good for the greatest number – is the emphasis of CHN where the
nurse first looks at the health needs and problems of the community rather than focusing solely on
the needs of the individuals or families.
3. Utilizes the nursing process – using the problem solving method
4. Promotive-preventive by nature – the priority of CHN
5. Uses a variety of instruments – CHN makes use of tools for measuring and analyzing community
health problems like vital statistics. Community map is also a very useful tool. Interview, schedule.
Survey forms and questionnaires may also be used.
6. Requires management skills – CHN applies the principles of management especially during the
organization of the nursing service in the local health agency and in activities that require the
effective management of a certain program or health service.

Theoretical Approaches/Model
Disease management in the community is challenging as illnesses are interwoven with social,
economic, genetic and environmental risks in ways that are difficult to understand and more difficult to
change. In the face of these challenges, how can nurses succeed in their goal to improve public health?
Theories or parts of theoretical frameworks to guide practice best achieves the goal of improving
nursing practice- including that of public health.
A theory is like a map of a territory as opposed to an aerial photograph. The map does not give the
full terrain (i.e., the full picture); instead it picks out those parts that are important for its given purpose
-Barnum, 1998

Health Belief Model

Provides the basis for much of the practice of health education and health promotion. Was
developed by a group of social psychologists to explain why the public failed to participate in screening
for tuberculosis.

The Health Belief Model is a theoretical model that can be used to guide health promotion and
disease prevention programs. It is used to explain and predict individual changes in health behaviors.
It is one of the most widely used models for understanding health behaviors

Key elements of the Health Belief Model focus on individual beliefs about health conditions,
which predict individual health-related behaviors. The model defines the key factors that influence
health behaviors as an individual's perceived threat to sickness or disease (perceived susceptibility),
belief of consequence (perceived severity), potential positive benefits of action (perceived benefits),
perceived barriers to action, exposure to factors that prompt action (cues to action), and confidence in
ability to succeed (self-efficacy). The above elements or constructs are presented in Table 1.1

According to Kurt Lewin “Behavior is based on current dynamics confronting an individual rather than
prior experiences “.

Table 1.1 Key Concepts and Definition of Health Belief Model (HBM)

Concept Definition Application

Perceived Susceptibility One’s opinion of chances of Define population
getting a condition (s) at risk, risk
levels; personalize
risk based on a
person’s features
or behavior;
heighten perceived
susceptibility if too
low.
Perceived Severity One’s opinion of how Specify
serious a condition is and consequences of
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
3
 what its consequences are the risk and the
condition
Perceived Benefits One’s belief in the efficacy Define action to
of the advised action to take; how, where,
reduce risk or seriousness when; clarify the
of impact positive effects to
be expected.
Perceived Barriers One’s opinion of the Identify the reduce
tangible and psychological barriers through
coasts of the advised action reassurance,
incentives,
assistance
Cues to Action Strategies to activate Provide how-to-
“readiness” information,
promote
awareness,
reminders
Self-Efficacy Confidence in one’s ability Provide training,
to take action guidance in
performing action

Limitations of the model:

 It places the burden of action exclusively on the client.

 It assumes that only those clients who have distorted or negative perceptions of the specified
disease or recommended health action will fail to act.
 It focuses the nurse's energies on interventions designed to modify the client's distorted
perceptions, without acknowledging the health professional's responsibility to reduce or alter
health care barriers other than patients’ perspectives

Despite this limitation, HBM is used by the nurse to determine client’s misperceptions that serve as
barriers to appreciate health action. The nurse must be conscious, however, of possible barriers other
than client’s misperceptions causing inaction or inappropriate health action.

Milio’s Framework for Prevention

Nancy Milio a nurse and leader in public health policy and public health education developed a
framework for prevention that includes concepts of community-oriented, population focused care.
(1976,1981). The basic treatise is that behavioral patterns of populations and individuals who make up
populations are a result of habitual selection from limited choices. She challenged the common notion
that a main determinant for unhealthful behavioral choice is lack of knowledge. Governmental and
institutional policies, she said set the range of options for personal choice making. It neglected the role
of community health nursing, examining the determinants of community health and attempting to
influence those determinants through public policy.

This framework provides a complement to the Health Belief Model and provides a mechanism
for directing attention “upstream.” It provides for the inclusion of economic, political, and
environmental health determinants; therefore, the nurse is given broader range in the diagnosis and
interpretation of health problems. Propositions proposed by Milio are listed in Table 1.2

Milio’s framework provides inclusion of economic, political and environmental health determinants,
therefore the nurse is given broader range in the diagnosis and interpretation of health problems.
Lifestyles are pattern of choices made from available alternatives according to people’s socioeconomic
circumstances and how easily they are able to choose some over others (Milio, 1981). It encourages
the nurse to understand health behaviors in the context of their societal milieu.

Table 1.2 Application of Milio’s framework in public health nursing (Milio, 1976)

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
4
 Milio’s proposition summary Population health examples
Population health results from deprivation Individuals and families living in
and/or excess of critical health resources. poverty have poorer health status
compared with middle-and upper-class
individuals and families.
Behaviors of populations result from selection Positive and negative lifestyle choices
from limited choices; these arise from actual (e.g smoking, alcohol use, safe sex
and perceived options available as well as practices, regular exercise,
beliefs and expectations resulting from diet/nutrition, seatbelt use) are
socialization, education and experience. strongly dependent on culture.
Socioeconomic status and educational
level.
Organizational decisions and policies (both Health insurance coverage and
governmental and non-governmental) dictate availability are largely determined and
many of the options available to individuals financed by the government through
and populations and influence choices. Philhealth and private insurance (out
of pocket expense by patients or
provided by employers) the source
and funding of insurance influences
health provider choices and services.
Individual choices related to health promotion Choices and behaviors of individuals
or health damaging behaviors is influenced by are strongly influenced by desires,
efforts to maximize valued resources. values and beliefs. For example, the
use of illegal drugs by adolescents is
often dependent on peer pressure and
the need for acceptance, love and
belonging.
Alteration in patterns of behavior resulting Some behaviors such as tobacco use
from decision making of a significant number have become difficult to maintain in
of people in a population can result in social many settings or situations in
change. response to organizational and public
policy mandates.
Without concurrent availability of alternative Addressing persistent health problems
health-promoting options for investment of (e.g. hypertension) is hindered
personal resources, health education will be because most people are very aware
largely ineffective in changing behavior of what causes the problem, but are
patterns. reluctant to make lifestyle changes to
prevent or reverse the condition.
Often, “new” information (e.g. a new
diet) or resources (e.g. a new
medication) can assist in attracting
attention and directing positive
behavior changes.

Pender’s Health Promotion

Explores the many biopsychosocial factors that influence individuals to pursue health promotion
activities. Contains seven variables related to health behaviors, as well as individual characteristics that
may influence a behavioral outcome. HPM does not include threat as a motivator, as threat may not be
a motivating factor for clients in all age groups. The model focuses on the following three areas:
•Individual characteristics and experiences (prior related behavior and personal factors).
•Behavior-specific cognitions and affect (perceived benefits of action, perceived barriers to action,
perceived self-efficacy, activity-related affect, interpersonal influences, and situational influences).
•Behavioral outcomes (commitment to a plan of action, immediate competing demands and preferences,
and health-promoting behavior).The HPM is depicted in Figure 1.3.

Seven Variables of Pender’s Health Promotion Model

1. Prior related behaviors influence subsequent behavior through perceived self-efficacy, benefits
barriers, and affects related to that activity. Habit is also a strong indicator of future behavior.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
5
 2. Personal factors are categorized as biological, psychological and socio-cultural. These
factors are predictive of a given behavior and shaped by the nature of the target behavior
being considered.
 Personal biological factors. Include variables such as age gender body mass index pubertal
status, aerobic capacity, strength, agility, or balance.
 Personal psychological factors. Include variables such as self-esteem, self-
motivation, personal competence, perceived health status, and definition of health.
 Personal socio-cultural factors. Include variables such as race, ethnicity,
acculturation, education, and socioeconomic status.

3. Behavior specific cognition and affect considered to be very significant in behavior

motivation. They are a “core” for intervention because they may be modified through nursing actions.
Assessment of the effectiveness of interventions is accomplished by measuring the change in these
variables.
 Perceived benefits of action - Anticipated positive outcomes that will occur from health behavior.
 Perceived barriers to action - Anticipated, imagined or real blocks and personal costs of understanding
a given behavior.
 Perceived self-efficacy - Judgment of personal capability to organize and execute a health-promoting
behavior. Perceived self-efficacy influences perceived barriers to action so higher efficacy results in
lowered perceptions of barriers to the performance of the behavior.

4. Activity-related affect may be a subjective positive or negative feeling that occurs before, during and
following behavior based on the stimulus properties of the behavior itself. Activity-related affect
influences perceived self-efficacy, which means the more positive the subjective feeling, the
greater the feeling of efficacy. In turn, increased feelings of efficacy can generate a further
positive affect.
 Interpersonal influences are cognition concerning behaviors, beliefs, or attitudes of the others.
Interpersonal influences include norms (expectations of significant others), social support
(instrumental and emotional encouragement) and modeling (vicarious learning through observing
others engaged in a particular behavior). Primary sources of interpersonal influences are families,
peers, and healthcare providers.
 Situational influences are personal perceptions and cognitions of any given situation or context
that can facilitate or impede behavior. Include perceptions of options available, demand
characteristics and aesthetic features of the environment in which given health promoting is
proposed to take place. Situational influences may have direct or indirect influences on health
behavior.

5. Commitment to a plan of action is the concept of intention and identification of a planned strategy
leads to the implementation of health behavior.

6. Immediate competing demands and preferences are those alternative behaviors over which
individuals have low control because there are environmental contingencies such as work or
family care responsibilities. Competing preferences are alternative behaviors over which
individuals exert.
relatively high control, such as choice of ice cream or apple for a snack.

7. Health-promoting behavior is an endpoint or action outcome that is directed toward attaining

positive health outcomes such as optimal wellbeing, personal fulfillment, and productive living.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
6
Figure 1.3 The Health Promotion Model

Precede-Proceed Model
Developed by Dr. Lawrence W. Green and colleagues. Provides a model for community
assessment, health education planning and evaluation.
PRECEDE: stands for Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and
Evaluation. A model for community diagnosis.
PROCEED: stands for Policy, Regulatory, and Organizational Constructs in Educational and Environmental
Development. A model for implementing and evaluating health programs based on PRECEDE. The
process is shown in Figure 1.4 (Green and Ottoson, 1999). In this model predisposing factors refer to
people’s characteristics that motivate them towards health-related behavior. Enabling factors refer to
conditions in people and the environment that facilitate or impede health-related behavior. Reinforcing
factors refer to feedback given by support persons or groups resulting from the performance of the
health-related behavior.   
PRECEDE consists of five steps or phases (see Figure 1.4). Phase one involves determining the
quality of life or social problems and needs of a given population. Phase two consists of identifying the
health determinants of these problems and needs. Phase three involves analyzing the behavioral and
environmental determinants of the health problems. In phase four, the factors that predispose to,
reinforce, and enable the behaviors and lifestyles are identified. Phase five involves ascertaining which
health promotion, health education and/or policy-related interventions would best be suited to
encouraging the desired changes in the behaviors or environments and in the factors that support those
behaviors and environments.
PROCEED is composed of four additional phases. In phase six, the interventions identified in
phase five are implemented. Phase seven entails process evaluation of those interventions. Phase eight
involves evaluating the impact of the interventions on the factors supporting behavior, and on behavior
itself. The ninth and last phase comprises outcome evaluation—that is, determining the ultimate effects
of the interventions on the health and quality of life of the population.
In actual practice, PRECEDE and PROCEED function in a continuous cycle. Information gathered in
PRECEDE guides the development of program goals and objectives in the implementation phase of
PROCEED. This same information also provides the criteria against which the success of the program is
measured in the evaluation phase of PROCEED. In turn, the data gathered in the implementation and
evaluation phases of PROCEED clarify the relationships examined in PRECEDE between the health or
quality-of-life outcomes, the behaviors and environments that influence them, and the
factors that lead to the desired behavioral and environmental changes. These data also
All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
7
suggest how programs may be modified to more closely reach their goals and targets.
Figure 1.4 The PRECEDE-PROCEED Framework for health education planning and
evaluation begins at the end of the causal chain (bottom left) with the social diagnosis.
Subsequent steps corresponds to the causal relationship among factors linking health education to
ultimate health and social goals.

Figure 1.4 Precede-proceed Framework

Different Fields of CHN

1. School Health Nursing – the application of nursing theories and principles in the care of the school population. It has
three components (a) school health services, (b) health instructions, (c) health monitoring. The aim
of the school nursing is to promote the health of the school children and prevent health problems
that would hinder the learning process and performance of their developmental task. Health is
considered an important requisite for education.
2. Occupational Health Nursing – the application of nursing principles and procedures in conserving the
health of workers in all occupations. It aims to assist the workers in all occupations
to cope with actual and potential stresses in relation to their work environment. The
focus of occupational health nursing is on the promotion, protection, and
restoration of workers health within the context of a safe and healthy work environment.
3. Community Mental Health Nursing – is a specialized nursing concerned with the treatment and nursing
care of people of all ages who are suffering from mental illness and its effects in the community. It has four
components (a) stress management, (b) drugs and alcohol abuse rehabilitation, (c) treatment and
rehabilitation of mentally-ill patients, (d) special project for vulnerable groups. The focus of community
health nursing is on mental health promotion. There is no need to identify the disease as it aims to increase
mental wellness of people.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
8
 Activity: Critical Thinking
Apply HBM and Pender’s HPM in the following situation: Amy 30 years old,
married, now in the third month of her second pregnancy, came to the health
center for prenatal consultation. For her first pregnancy she availed of the services of a traditional
birth attendant (TBA) aka hilot that ended in a stillbirth in the 8th month gestation. Working full time in
a garment factory, she claims that she hardly has the time for regular prenatal visits. However she
says that she and her husband want a healthy baby, which is the reason why for her “ëarly”
consultation.

Summary
Knowledge and skills enable community health nurses to work in a diverse community settings
ranging from the isolated rural area to the crowded urban ghetto. To meet the health needs of the
population, the community health nurse must work with many individuals and groups within the
community. The community health nurse must develop sensitivity to these groups and respect the
community and its established method of problem management. This will enable the nurse to become
more proficient in helping the community improve overall health.
Nursing and health service literature often focus on health care access issues. Access to care is associated with economic,
social, and political factors, and depending on individual and population needs. It can be a primary determinant of health
status and survival. Structural variables, such as educational status, gender, and income, may be highly predictive of health
status. These types of factors, which are strongly grounded in the sociopolitical and economic milieu. Identify risk factors
for poor health and opportunities for community-based interventions.

Likewise nurses in this practice area must have access to theoretical perspectives that address the social, political, and
environmental determinants of community health. The integration of population-based theory with practice gives nurses
the means to favorable impact the health of the global community.

Readings and References

American Nurse Association (ANA). Public Health nursing scope and standards of practice.
American Nurses Publishing: Silver Spring, MD
American Public Health Association., 1996. Ad hoc committee on public health nursing; the
definition and role of public health nursing practice in the delivery of health care. The Association:
Washington, DC.
Allender J.N; Spradely B.W. Community Health Nursing Concepts and practice. (8th edn)
2001.Lippincott,342-45.
Stanhope M; Lancaster J. Community Health Nursing Promoting health of Aggregates, Families
and individuals.(4th edn) 2001.Mosby,265-80.
Famorca, Zenaida U. Nursing care of the community.

Interactive Link
http://currentnursing.com/nursing_theory/theories_community_health_nursing.html
https://www.ruralhealthinfo.org/toolkits/health-promotion/2/theories-and-models/health-belief
https://www.slideshare.net/brissomathewarackal/theories-applied-in-community-health-nursing
https://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/precede-
proceed-model
https://nurseslabs.com/nola-pender-health-promotion-model/
https://www.slideserve.com/cyma/precede-proceed-framework
https://www.google.com/search?q=precede-proceed+model&sxsrf=ALeKk01D4C

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
9