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PHILIPPINE REPRODUCTIVE HEALTH The Philippines is one of a signatory country to the International Conference Plan of Action of Reproductive Health

in Cairo in 1994. To support the effective implementation of the program, the DOH issued AO 1-As. 1998 establishing the Philippine Reproductive Health which define the RH service package consisting of 10 elements that included Family Planning. In order to strengthen reproductive health AO 43,s. 1999 was issued adopting reproductive health policy to integrate RH services in all health facilities as part of basic package of health services and thus ensuring a more efficient and effective referral system from primary to tertiary, public and private facilities. In 2004, harmonization and integration of the various approaches and different efforts in relation to womens health and reproductive health, it came up with integrated Reproductive Health and Womens Health Framework with an overall goal of achieving Better Quality Life Among Filipinos. Its main objectives are: Reducing maternal mortality rate Reducing child mortality Halting and reversing spread of HIV/AIDS Increasing access to reproductive health information and services There are 10 elements very crucial on Reproductive Health. These are: Family Planning Family Planning is the foremost interventions in attaining reproductive health. It allows couples to freely decide on the number and proper spacing of births. It is one of the 10 elements selected as a response to the needs of men and women of reproductive age. The horizontal approach to the RH program ensures that the client is given health care and services in a holistic manner thus making the patient a client centered taking into consideration on particular needs. Maternal and Child Health and Nutrition Family Planning is one of the pillars of the Safe Motherhood program. The goal of attaining the optimum maternal and child health and nutrition can be achieved through the use of safe and effective family planning methods. Proper birth spacing of three to five years will give the mother ample time to regain her health and to render proper care to her newborn and other older children. The risk of pregnancy can be avoided. Thus, maternal, neonatal and infant morbidity and mortality can be reduced Prevention and Management of Reproductive Tract Infections including Sexually Transmitted Infections (STIs) and HIV/AIDS Family Planning is the central focus to prevent reproductive tract infections especially on sexually transmitted disease and HIV/AIDS. Risk assessment of RTIs is part of determining the clients eligibility for FP methods. Clients who are at risk of containing STIs may need dual protection through the use of FP methods such as

condoms that provide protection from pregnancy. Using condom, aside from being an effective means of preventing the spread of STIs. Education of people help prevent RTIs and reduce the incidence of secondary infertility due to block fallopian tubes.

Adolescent Reproductive Health (ARH) Fertility awareness, human sexually and counseling are basic services which help promote responsible sexuality among adolescents. These are very critical among the young adult to understand reproductive health. Prevention and Management of Abortion and its Complications The major causes of maternal deaths are complications from unsafe abortion as consequences of unplanned pregnancy. Preventing unwanted pregnancy through family planning reduces maternal deaths. Proper management of complications includes medical treatment and FP counseling and services. Prevention and Management of Breast and Reproductive Tract Cancers and other gynecological conditions Breast and other reproductive tract cancers are major concerns in public health. The provision of family planning services provide an opportunity for screening and detection of breast and reproductive tract cancers. Moreover, combined oral contraceptives are proven to reduce risk of ovarian and endometrial cancers. Routine cancer screening offer clients opportunity to choose various FP methods when further diagnostic work ups have to be undertaken to establish diagnosis. Education and Counseling on Sexuality and Sexual Health Mens Reproductive Health (MRH) and Involvement. Sexually education is a basic component of FP. FP counseling and providing correct information on sexuality will help reduce unwanted pregnancy. Violence Against Women and Children Domestic violence mostly occur in women and children. It is recognized now as important social and public health issue. One of the most common forms is sexual violence. This provides an opportunity to discuss and promote family planning. Prevention and Management of Infertility and Sexual Dysfunction The Framework of Reproductive Health. The concept of reproductive health in a circular presentation represents the holistic approach of all health efforts. The 10 elements are reflected in 2 outer most circles in the framework. Because of technical readiness and availability of resources, the DOH had focused in addressing the health concerns on the first 4 priority elements of the reproductive health, namely: Family Planning Maternal and Child Health and Nutrition

Prevention and Management of Reproductive Tract Infections including Sexually Transmitted Infections (STIs) and HIV/AIDS Adolescent Reproductive Health (ARH)

The other six elements are at different stages of development from policy/framework formulation to pilot implementation in selected facilities and areas. The 2 innermost circles embody that core principles and key features that the 10 elements should be built to ensure solid, responsive and effective health program directions and outcomes for Filipinos. At the core (gold, innermost circle) are gender responsive, culturally-oriented and rights based approaches, the general guiding principles that govern and design in the implantation of all reproductive health elements and other health related program and activities. Rights based recognized reproductive as a critical part of human rights Culture based recognizes the variations in health seeking behavior, service care preferences and quality perceptions of clients requiring responsive approaches in health service delivery. Gender responsive entails recognizing the differences in how women and men behave and act.

While, the second innermost circle (green) represents the 4 convergence thrusts towards health reforms that must be collectively addressed to attain better health outcomes, a more responsive health system, and equitable financing for health. This includes; Health financing which intends to secure greater and better sustained investment in health. Regulations that ensures access to quality and affordable health goods and services. Health service delivery that ensures accessibility and availability of basic and essential health care Good governance in health that will improve the performance of the health system.

I.

INTEGRATED COMMUNITY BASED NON-COMMUNICALBE PREVENTION AND CONTROL PROGRAM

DISEASE

INTRODUCTION: There are four major non-communicable diseases (also known as chronic diseases or lifestyle related diseases): cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes mellitus. The rapid rise in the prevalences of these diseases represents one of the major health challenges to global development in the coming century. This growing challenge threatens economic and social development as well as the lives and health of millions of people. In 2005, it was estimated that 35 million deaths would have occurred due to these diseases, contributing 60% of deaths worldwide. As well as a high death toll, chronic diseases also cause disability, often for decades of a persons life. The most widely used summary measure of the burden of disease is the disability adjusted life year or DALY, which combines the number of years of healthy life lost to premature death with time spent in less than full health. One DALY can be thought of as one lost healthy year of life. The projected burden of disease of these diseases is approximately half or 48% of the global burden of disease. Based on current trends, by the year 2020 these diseases are expected to account for 73 % of deaths and 60% of the disease burden. In the Philippines, increasing life expectancy, urbanization and lifestyle changes have brought about a considerable change on the health status of the country. Globalization and social change has influenced the spread of non-communicable or lifestyle/degenerative diseases by increasing exposure to risk. The life expectancy of Filipinos in 2002 has gone up to 69.6 years. The process of aging brings out myriad health problems that are degenerative by nature. Mortality statistics in 2002 showed that 7 out of 10 leading causes of deaths in the country are diseases which are lifestyle related: diseases of the heart and the vascular system, cancers, chronic obstructive pulmonary diseases, accidents, diabetes, kidney problems. Morbidity statistics in 2002 also showed that hypertension and diseases of the heart are among the top ten leading causes of illnesses in the country. The consequences of these diseases are staggering in terms of productivity losses, notwithstanding the emotional and psychological havoc it brings to those who are afflicted and their families. These diseases are linked by three major risk factors: tobacco smoking, physical inactivity and an unhealthy diet. The result of the National Nutrition and Health Survey conducted in 2003 concluded that presently 90% of Filipinos has one or more risk factors associated with chronic, non-communicable diseases. Below are the risk factors with the corresponding prevalence rates: a. Physical inactivity60.5% b. Smoking34.8%

c. d. e. f.

Hypertension..22.5%(SBP.140 or DBP.90) Hypercholesterolemia..8.5% (TC.240) Obesity4.9% (BMI.30) Diabetes..4.6%

Action to prevent these diseases should therefore focus on controlling risk factors in an integrated manner. A major strategy is health promotion across the life course and prevention of the emergence of the risk factors in the first place. Intervention at the level of family and community is essential for prevention because the causal risk factors are deeply entrenched in the social and cultural framework of the society. Addressing the major risk factors should be given the highest priority in the prevention and control of lifestyle related diseases. Promotion of healthy lifestyle then becomes an imperative. For common understanding, healthy lifestyle is operationally defined as a way of life that promotes and protects health and well-being. This would include practices that promote health such as healthy diet and nutrition, regular and adequate physical activity and leisure, avoidance of substances that can be abused such as tobacco, alcohol and other addicting substances, adequate stress management and relaxation; and practices that offer protection from health risk such as safe sex and immunization. Thus, in response to the increasing prevalence of chronic, non-communicable lifestyle related diseases, a comprehensive integrated community based non-communicable disease prevention and control program should be put in place by local government units, workplaces and various stakeholders wherever they are. Goal: Reduce the toll of morbidity, disability and premature deaths due to chronic, noncommunicable lifestyle related disease. Objectives: 1. Analyze the social, economic, political and behavioral determinants of NCD that will serve as bases for: a. Developing policy guidelines; b. Setting legislative and political directions, and c. Providing financial measures to support NCD prevention and control 2. Reduce exposure of individuals and population to major determinants of NCD while preventing emergence of preventable common risk factors. The NCD prevention and control program must focus on modification of unhealthy lifestyles and behaviors that predispose populations to NCD. To hasten this, the health sector should lobby for a health protective environment by: a. Proposing healthy public policies that encourage health-promoting settings in school, workplaces and communities b. Encouraging governments to provide protection against activities by industry and commerce that promote unhealthy products and lifestyles.

3. Strengthen health care for people with NCD through health sector reforms and cost effective interventions. In order to contribute to the improved health status of individuals and respond to the communitys basic health care needs, there must be enhanced capability to take action to address theses major NCD risk factors. Enhanced capability reiterates the value of strong community participation combined with institution-building and appropriate, cost-effective health interventions. To achieve significant reduction in morbidity and mortality from major NCDs, the following approaches should characterize the program: 1. A comprehensive Approach Focused on Primary Prevention A comprehensive long-term strategy for control of NCDs must focus on primary prevention. It must include: a. Prevention of emergence of risk factors referred to as primordial prevention; b. Specific protection form NCD by removal of the risk factors or reduction in their levels. The objectives of primary prevention can be achieved by implementing strategies aimed at reducing risk factor levels utilizing a combination of the population approach and one that is directed towards the high risk individual. Interventions aimed at primordial intervention are best achieved by influencing public policies, such as those in trade, food and pharmaceuticals, agriculture, urban development and like. The presence of large number of people who are already suffering from NCD necessitates the inclusion of secondary and tertiary prevention and curative components into the program. Secondary prevention activities are directed towards prompt diagnosis and treatment of NCD. Tertiary prevention and curative activities include rehabilitative services for stroke and CHD patients, foot care for diabetes patients, pain relief for cancer patients and other similar activities. The decision to extend the primary prevention framework and include secondary and tertiary prevention and curative activities depends much on the availability of resources. Should these activities be included in the program, they should not be done at the expense of primary prevention, which almost always happens in a cure-oriented health care delivery system. 2. Community-based Approach A community-based NCD prevention and control program recognizes people as the center of any health and development effort. The community is given the right, responsibility and capability to identify and address its own health problems and needs. Given their limitations and constraints, the program is expected to

provide a mechanism for people to participate in activities that have the potential to impact positively on health. The program provides the means to respond to their needs and the basic tools for mobilizing the people. The key ingredients to successful and sustainable community-based health initiatives are: Active community participation; Involvement of community leaders, community committees and other community groups; Strong support and guidance from local governments and technical experts; and Multi-sectoral collaboration.

3. Integrated Approach A healthy community contributes to the socio-economic development of the community. In the same manner, improved economic and social status will enable the population to attain healthy condition. It is from this perspective that an integrated NCD prevention and control program will take off. An integrated approach is viewed in the following context: NCD and its major risk factors are not to be regarded solely as health issues. Since the risk factors are rooted on the peoples way and quality of life, it becomes inherent that the NCD program be part of the overall development program of the locality. Policy decisions and appropriate legislations towards as health protective environment will be a major influencing factor in the reduction or removal of these risk factors, Interventions for NCD and its major risk factors encompass the three levels of disease prevention. Interventions aimed at primary prevention can be integrated with the health services and activities at the community level utilizing the primary health care approach while the secondary and tertiary prevention activities can be readily made available and accessible through a referral pathway. Health initiatives of private sector to develop community health services and facilities must be supported and integrated into the overall scheme of NCD prevention and control program.

Key Intervention Strategies 1. Establishing program direction and infrastructure. A community diagnosis gives good information on risk factors and prevalence of NCD, in the community. This becomes the basis for program plan and action and provides for rational resourcing. Establishing a team to manage the program is a must. 2. Changing environments. Establishing partnership and intersectoral coordinating mechanism in order to develop policies and programs that ensure health and environment neither are nor compromised by economic progress. For example, in order to encourage physical activity and exercise, make facilities like walking lanes, biking lanes, open spaces, parks, ect., accessible, walkable and attractive to people. 3. Changing lifestyle. Raising public awareness by producing and disseminating information through mass media, health campaigns, public information systems and school education. At the community level, mothers classes, barangay assemblies, positing in community bulletin boards or in places where most people frequent or converge, such as sari-sari stores or marketplaces are examples of activities that can be easily carried out. 4. Reorienting health services. Reorienting focus of health service delivery from cure to health promotion or wellness. The Roles of Public Health Nurse in NCD Prevention and Control Health Advocate Public Health Nurses promote active community participation in NCD prevention and control through advocacy work. As a health advocate, the PHN helps the people towards optimal degree of independence in decision-making and in asserting their right to a safer and better community. This involves: 1. Informing the people about the rightness of the cause. It is important to convey the problem, show how it affects people in the community and describe what possible actions to take. 2. Thoroughly discussing with the people the nature of the alternatives, their content and consequences. In this manner, needs and demands of the people are amplified and eventually become the framework for decision-making. In this exchange process, the advocate and the people strive to understand meanings in a common way and establish accuracy and reality in order to select the most effective strategy and tactic in the solution of the problem. 3. Supporting peoples right to make a choice and to act on the choice. The people must be assured that they have the right and responsibility to make decisions and that they do not have to change their decisions because of others objections.

4. Influencing public opinion. The advocate affirms the decision made by the people by getting powerful individuals or groups to listen, support and eventually, make substantial changes to solve the problem. Health Educator Health education is an essential tool to achieve community health. A health educator is concerned with promoting health as well as reducing behavior-induced disease. In noncommunicable disease prevention and control, health educations focuses on establishing or inducing changes in personal and group attitudes and behavior that promote healthier living. PHNs, as well as educators and media personnel, should conduct health education in a variety of settings. The health educator aims to: 1. Inform the people. Health education creates an awareness of health needs and problems which consequently make the people become conscious of their own responsibilities towards their own health. Misconceptions and ignorance will be corrected by disseminating scientific knowledge about causes, factors, prevention and control of non-communicable diseases. 2. Motivate the people. Telling people about health is not enough. They should be motivated to make own choices and decisions about habits and practices that are detrimental to health, such as cigarette smoking, indulgence in alcohol, physical inactivity and fat and sugar-rich diet. In order to motivate them, health education focuses on providing learning experiences on what health actions to take, how, when and under what conditions are they going to undertake them, 3. Guide people in action. Oftentimes, people need to be supported in their effort to adopt or maintain healthy practices and lifestyles. Support comes in the form of making essential health services affordable, available and accessible to them. In our society, legislative policies are also necessary to provide initial push for people to undertake measures to improve their own health status and the communities they live in. Health Care Provider The Public Health Nurse is a care provider to individuals, families and communities rendering primary, secondary and tertiary health care services in any setting including the community, school and workplace. As a care provider, emphasis of care is on health promotion and disease prevention focusing on promotion of rational diet and physical activity and cessation of smoking and alcohol drinking. In addition, action is directed towards the reduction of risk factors of non-communicable diseases. Primary prevention must be family-oriented because the family members live and eat together and the roots of chronic diseases are related to personal habits and lifestyle.

Although secondary level of care is the domain of clinical medicine, it seeks to relieve pain, arrest or cure the disease and prevent disability and death. It also prevents the development of secondary cases in the community. This is where the guidelines for clinical management of obesity, diabetes, hypertension and palliative care for cancer will come in. Disability limitation and rehabilitation does not refer to prevention of disease per se but rather to prevention of its potential consequences. The Public Health Nurse provides activities that will permit clients who have suffered from consequences of noncommunicable disease to lead a socially and economically productive life. Community Organizer As an organizer, the ultimate goal of the PHN is community health development and empowerment of the people. This is achieved by: Raising the level of awareness of the community regarding non-communicable diseases, its causes, prevention and control; Organizing and mobilizing the community in taking action for the reduction of risk factors; Influencing executive and legislative bodies to create and enforce policies that favor a healthy environment. Health Trainer The PHN provides technical assistance in the assessment of the skills of auxiliary health workers in NHD prevention and control; teaching and supervision on clinical management of non-communicable disease and other community-based services and recording, reporting and utilization of health information related to non-communicable diseases. Researcher Research is an integral part of a primary health care approach to non-communicable disease prevention and control program. It is inextricable related to community health practice since it provides the theoretical bases for developing appropriate and responsive intervention programs and strategies. Research provides valuable information especially if it is conducted using the participatory research approach. It prevents health workers from implementing irrelevant interventions. If the interventions are grounded in community needs, NCD prevention and control programs are likely to succeed. As health researcher, the PHN conducts community assessments, epidemiological studies, and intervention studies.