S6: Fundamental of Nursing

Key Unit Competence:

Apply the principles and components of health promotion to prevent diseases and 

promote health of communities.

Introductory activity 6

1) What do you think as actions to be done in order to optimize the health of 
people in each of the sections of the image above?
2) Read this page: https://www.who.int/news-room/fact-sheets/detail/

primary-health-care and think about why Primary Health care is necessary.

6.1. Primary Health Care Overview

6.1.1. Concept of primary health care

Self-assessment 6.1.1 

Using library books or Internet, read on Primary Health Care and try to explain 
the following concepts:
1) Primary health care

2) Objectives of the primary health care

Primary Health Care “is essential health care made universally accessible to 
individuals and families in the community by means acceptable to them, through 
their full participation and at a cost that the community and country can afford. It 
forms an integral part both of the country’s health system of which it is the nucleus 
and of the overall social and economic development of the community”.
Primary health care is essential (promotive, preventive, curative, rehabilitative, and 
supportive) care that focuses on preventing illness and promoting health. It is both 
a philosophy of health care and an approach to providing health care services.
Primary health care is what happens when someone who is ill (or who thinks 
he or she is ill or who wants to avoid getting ill) consults a health professional 
in a community setting for advice, tests, treatment or referral to specialist care. 
Such care should be holistic, balanced, personalized, rigorous and equitable, and 
delivered by reflexive practitioners who recognize their own limitations and draw 
appropriately on the strengths of others.
Types of primary health care
• Selective PHC -Health promotion initiatives aimed at certain groups or 
specific issues 
• Comprehensive PHC -Health promotion initiatives aimed at the health and 
wellness for the whole community 
• Primary care -Initial decisions on managing a health issue e.g. general 
practice decisions about managing chronic conditions
a. Primary care and primary nursing 
Primary health care should not be confused with primary care or primary nursing. 
Primary care is provider driven and is the entry point to the health care system. 
Primary nursing is a system of delivering nursing services whereby a nurse is 
responsible for planning the 24-hour care of a specific patient. Both these concepts 

are illness-oriented concepts

b. Objectives of the primary health care
The objectives of the primary health care are: to increase the programs and services 
that affect the healthy growth and development of children and youth; to boost 
participation of the community with government and community sectors to improve 
the health of their community; To develop community satisfaction with the primary 
health care system; to support and advocate for healthy public policy within all 
sectors and levels of government; to support and encourage the implementation 
of provincial public health policies and direction; to provide reasonable and timely 
access to primary health care services; to apply the standards of accountability in 
professional practice; to establish, within available resources, primary health care 
teams and networks ; and to support the provision of comprehensive, integrated, 
and evidence-based primary health care services.
c. Role of the Nurse in primary health care
The goal of nursing is to improve the health of clients through partnerships with 
clients, other health care providers, related community agencies, and government. 
Nursing practice involves a variety of roles, including direct care provider, educator, 
administrator, consultant, policy adviser, and researcher.
• Care giver: The caregiver role has traditionally included those activities that 
assist the client physically and psychologically while preserving the client’s 
dignity. The required nursing actions may involve full care for the completely 
dependent client, partial care for the partially dependent client, and 
supportive–educative care to assist clients in attaining their highest possible 
level of health and wellness.
• Communicator: Communication is integral to all nursing roles. Nurses 
communicate with clients and their support people, other health care 
professionals, and people in the community. The quality of a nurse’s 
communication is an important factor in nursing care. The nurse must be able 
to communicate clearly and accurately so that a client’s health care needs 
are met.
• Educator: As a health teacher, the nurse helps clients learn about health and 
the health care procedures they need to perform to restore or maintain health
• Client Advocate: A client advocate acts to protect the client. In this role, 
the nurse may represent the client’s needs and wishes to other health care 
professionals, such as relaying the client’s request for information to a 
member of the health care team. 
• Counsellor: Counselling is the process of helping a client recognize and 
cope with stressful psychological or social problems, develop improved 
interpersonal relationships, and promote personal growth. It involves providing 

emotional, intellectual, and psychological support.

In contrast to the psychotherapist, who counsels individuals with identified 
problems, the nurse counsels primarily healthy individuals who are 
experiencing normal adjustment difficulties.
• Change Agent: The nurse acts as a change agent when assisting clients to 
make modifications in their own behavior.
• Leader: The leadership role can be employed at different levels: individual 
client, family, groups of clients or colleagues, or the community.
• Manager: Every nurse manages the nursing care of individuals, families, or 
communities. The nurse manager, a formal leadership role, also delegates 
nursing activities to ancillary workers and other nurses, and supervises and 

evaluates their performance.

Self-assessment 6.1.1

1) Explain the difference between primary nursing and primary care
2) Explain importance of primary health care
3) Explain different role of the nurse in the primary health care
4) Which of the following statements best illustrates the difference between 
primary health care and primary care?
a. Primary health care is a theoretical approach to health care, whereas 
primary care is a system of delivering services.
b. Primary health care is illness focused, whereas primary care is health 
promotion focused.
c. Primary health care is a set of government standards for world health care, 
whereas primary care provides a set of principles for delivering care.
d. Primary health care is a philosophical approach to providing health care, 

whereas primary care provides an entry point to the health care system

6.1.2. History and Evolution of PHC.

Learning activity 6.1.2

Using the library books on “Primary Health Care” or internet, read on the 
evolution of primary health care. Focus on Alma-Ata Declarations and respond 
to the following questions;
1) Identify different issues that have pushed the World to establish primary 
health care?
2) Reading the information available on following link: https://www.euro.
who.int/en/health-topics/Health-systems/primary-health-care/primary
health-care/questions-and-answers-understanding-primary-health-care. 
What can be done to make quality PHC accessible and affordable for 

everyone, everywhere?

Deep concern for the health of the world’s population, specifically short life 
expectancies and high mortality rates among children, led to the formation of 
the global health strategy of primary health care. All members of the WHO were 
encouraged to take actions toward the attainment of “health for all by the year 
2000” through ensuring adequate food supply, safe water, adequate sanitation, 
maternal and child health care, immunization, prevention and control of endemic 
diseases, provision of essential drugs, health education, and treatment of common 
diseases and injuries.
a. Alma-Ata declarations
From September 6 to September 12, 1978, delegates from 134 countries and 
representatives from 67 nongovernmental organizations, agencies, and United 
Nations (UN) organizations gathered in the city of Alma-Ata at the invitation of the 
USSR under the aegis of the World Health Organization (WHO) and United Nations 
International Children’s Emergency Fund (UNICEF). The purpose of the conference 
was to exchange experience about something called primary health care.
The Declaration of Alma-Ata (WHO & UNICEF, 1978) emphasized health, or well
being, as a fundamental right and a worldwide social goal. It was an attempt 
to address inequality in the health status of persons in all countries and to target 
governments that needed to be responsible for policies that would promote economic, 
social, and health development, which were considered basic to the achievement 
of “health for all.” The following are declarations that have been agreed:
Declaration one: The Conference strongly reaffirms that health, which is a “state 

of complete physical, mental, and social well-being, and not merely the absence 

of disease or infirmity”, is a fundamental human right and that the attainment 
of the highest possible level of health is a most important worldwide social goal 
whose realization requires the action of many other social and economic sectors in 

addition to the health sector

Declaration two: The existing inequality in the health status of people particularly 
between developed and developing countries as well as within countries is politically, 
socially, and economically unacceptable and is, therefore, of common concern to 
all countries.
Declaration three: Economic and social development, based on a New International 
Economic Order, is of basic importance to the fullest attainment of health for all 
and to the reduction of the gap between the health status of the developing and 
developed countries. The promotion and protection of the health of the people is 
essential to sustained economic and social development and contributes to a better 
quality of life and to world peace
Declaration four: The people have the right and duty to participate individually and 
collectively in the planning and implementation of their health care.
Declaration five: Governments have a responsibility for the health of their people 
which can be fulfilled only by the provision of adequate health and social measures. 
A main social target of governments, international organizations, and the whole 
world community in the coming decades should be the attainment by all peoples of 
the world by the year 2000 of a level of health that will permit them to lead a socially 
and economically productive life. Primary health care is the key to attaining this 
target as part of development in the spirit of social justice.
Declaration Six: Primary health care is essential health care based on practical, 
scientifically sound, and socially acceptable methods and technology made 
universally accessible to individuals and families in the community through their full 
participation and at a cost that the community and country can afford to maintain at 
every stage of their development in the spirit of self-reliance and self-determination. 
It forms an integral part both of the country’s health system, of which it is the central 
function and main focus, and of the overall social and economic development of the 
community. It is the first level of contact of individuals, the family and community 
with the national health system bringing health care as close as possible to where 
the people live and work, and constitutes the first element of a continuing health 
care process. 
Declaration Seven: Primary health care:
1) reflects and evolves from the economic conditions and sociocultural and 
political characteristics of the country and its communities and is based 
on the applications of the relevant results of social, biomedical, and health 

services research and public health experience;

2) addresses the main health problems in the community, providing promotive, 
preventive, curative, and rehabilitative services accordingly; 
3) includes at least education concerning prevailing health problems and the 
methods of preventing and controlling them; promotion of food supply and 
proper nutrition; an adequate supply of safe water and basic sanitation; 
maternal and child health care, including family planning and immunization 
against the major infectious diseases; prevention and control of locally 
endemic diseases; appropriate treatment of common diseases and injuries; 
and provision of essential drugs
4) involves, in addition to the health sector, all related sectors and aspects 
of national and community development, in particular agriculture, animal 
husbandry, food, industry, education, housing, public works, communications, 
and other sectors, and demands the coordinated efforts of all those sectors;
5) requires and promotes maximum community and individual self-reliance and 
participation in the planning, organization, operation and control of primary 
health care, making the fullest use of local, national, and other available 
resources; and to this end develops through appropriate education the 
ability of communities to participate;
6) should be sustained and integrated, functional and mutually supportive 
referral systems, leading to the progressive improvement of comprehensive 
healthcare for all, and giving priority to those most in need;
7) relies, at local and referral levels, on health workers, including physicians, 
nurses, midwives, auxiliaries, and community workers as applicable, as 
well as traditional practitioners as needed, suitably trained socially and 
technically to work as a health team and to respond to the expressed health 
needs of the community.
Declaration Eight: All governments should formulate national policies, strategies, 
and plans of action to launch and sustain primary health care as part of a 
comprehensive national health system and in coordination with other sectors. 
To this end, it will be necessary to exercise political will, to mobilize the country’s 
resources and to use available external resources rationally.
Declaration Nine: All countries should cooperate in a spirit of partnership and 
service to ensure primary health care for all people since the attainment of health 
by people in any one country directly concerns and benefits every other country. In 
this context, the joint WHO/UNICEF report on primary health care constitutes a solid 
basis for the further development and operation of primary health care throughout 
the world.
Declaration Ten: An acceptable level of health for all people of the world by the 

year 2000 can be attained through a fuller and better use of the world’s resources,

a considerable part of which is now spent on armaments and military conflicts. 
A genuine policy of independence, peace, detente, and disarmament could and 
should release additional resources that could be devoted to peaceful aims and in 
particular to the acceleration of social and economic development of which primary 

health care, as an essential part, should be allotted its proper share

Self-assessment 6.1.2 

1) Summarize the declarations from the Alma-Ata

6.1.3. Characteristics of Primary Health Care

Learning activity 6.1.3

Using library books or internet, read on characteristics of primary health care 
and respond to the following question.
1) What do you think are the pillars of the primary health care?
2) What do you think as the primary health care being client (patient/Family) 

centered?

Good primary health care aims at safeguarding, promoting and restoring health. 
However, health is not an aim in its self, but a condition for human development 
and well-being. Health services should thus be developed in harmony with other 
aspects of society; education, social and economic infrastructure etc. and use only 
a reasonable share of the total financial and human resources available.

Indeed, “the possibility that the direct positive effects of health care on health may 
be outweighed by its negative effects through its competition for resources with 
other health-enhancing activities. A society which spends so much on health that 
it cannot or will not spend adequately on other health-enhancing activities may 
actually be reducing the health of its population through increased health spending”. 
To produce a maximum of health with these limited resources, health services must 
be rationalized to function in an effective and efficient way.
Characteristics of PHC include:
• Patient/family centeredness, self-reliance and participation: the 
involvement of the patient/Family makes the PHC interventions more effective 
and sustainable.
• Community engagement and participation: Community are engaged to 
take initiations in identifying their own health and social problems therefore, 
integration of promotive, preventive and curative health services are given in 

a unified way by the participation of the local population

• Health workers collaborating in inter-disciplinary teams: the primary 
health care approach does not only involve one profession. Multidisciplinary 
teams and multisectoral involvement is the key to achieve PHC objectives.
• Proactive Prevention Focus: the primary health care services includes 
promotion, prevention and restoring health, however, early intervention before 
the population health is endangered is the main focus.
• Accessibility: the services delivered within the primary health care should 
be easily available and meeting the primary health needs of the population
• Better Management of Chronic Conditions
• Localized set of choices, 
• Sustainability
• Multi-sector alignment and involvement: the PHC ideal require good 
planning and allocation of resources. Multisectoral involvement makes the 
PHC services more available, accessible and affordable but putting needed 

resources

a. Pillars of primary health care

Primary health care consists of an integrative group of health care professionals 
coordinating to provide basic health care services to a particular group of people 
or population. The Primary Health care outline is built on four key pillars which are 
reinforcement for the delivery of safe health care.
The four major pillars of primary health care are as follows: Community Participation, 
Inter-sectoral Coordination, Appropriate Technology and Support Mechanism Made 
Available.
• Community Participation: Community participation is a process in which 
community people are engaged and participated in making decisions about 
their own health. It is a social approach to point out the health care needs 
of the community people. Community participation involves participation of 
the community people from identifying the health needs of the community, 
planning, organizing, decision making and implementation of health programs. 
It also ensures effective and strategic planning and evaluation of health care 
services. In lack of community participation, the health programs cannot 
run smoothly and universal achievement by primary health care cannot be 
achieved.
• Inter-sectoral Coordination: Inter-sectoral coordination plays a vital role in 
performing different functions in attaining health services. The involvement of 
specialized agency, private sectors, and public sectors is important to achieve 
improved health facilities. Intersectoral coordination will ensure different 
sectors to collaborate and function interdependently to meet the health care 

needs of the people.

• It also refers to delivering health care services in an integrated way. Therefore, 
the departments like agriculture, animal husbandry, food, industry, education, 
housing, public works, communication, and other sectors need to be involved 
in achieving health for all.
• Appropriate Technology: Appropriate healthcare technologies are an 
important strategy for improving the availability and accessibility of healthcare 
services. It has been defined as ‘’technology that is scientifically sound, 
adaptable to local needs and acceptable to those who apply it and to whom it 
is applied and that can be maintained by people themselves in keeping with 
the principle of self-reliance with the resources the community and country 
can afford.’’
Appropriate technology refers to using cheaper, scientifically valid and 
acceptable equipment and techniques. It is also necessary to ensure that 
the technology is: Scientifically reliable and valid, Adapted to local needs, 
Acceptable to the community people and Accessible and affordable by the 
local resources.
• Support Mechanism Made Available: Support Mechanism is vital to health 
and quality of life. Support mechanism in primary health care is a well-known 
process focused to develop the quality of life. Support mechanism includes that 
the people are getting personal, physical, mental, spiritual and instrumental 
support to meet goals of primary health care. Primary health care depends on 
adequate number and distribution of trained physicians, nurses, community 
health workers, allied health professions and others working as a health team 

and supported at the local and referral levels.

Self-assessment 6.1.3

Read the following scenario and attempts questions asked:
Scenario 1: A dentist finds a suspicious white lesion while doing a routine check
up of a 72-year-old woman smoker and offers to refer her urgently to an oral 
surgeon.
Scenario 2: A multi-disciplinary community team including doctors, nurses, 
social workers and health advocates provides a ‘health bus’ offering a range of 
services to refugees and asylum seekers on an inner city estate
1) What primary health care does the scenarios above represent and why?
2) Among the following, one is not the component of the primary health care
a. Community participation
b. Support mechanism made available
c. Appropriate technology

d. Sustainability

6.1.4. Structure and Functioning of Health Care system

Learning activity 6.1.4

Using library books or other available resources on the health sector, Read on 
Health system organization and answer the following questions;

What do you think are the components of the health system and why?

a. Overview of the health system 
Health system consists of all the activities whose primary purpose is to promote, 
restore and maintain health. It is also defined as the people, institutions and 
resources, arranged together by established policies, to improve the health of the 
population they serve, while responding to people’s legitimate expectations and 
protecting them against the cost of ill-health through a variety of activities whose 
primary intent is to improve health. (WHO, 2017).
b. Principles of health system
The following are the principles of a health system:
• People-centered: when it is people centered, equity and fairness are ensured.
• Results-oriented: Quality management system for continual quality 
improvement.

• Evidence-based: Technocrats, academicians, politicians, community or local

context and change are key divers of the health system.
• Community-driven: Leadership, governance accountability, transparency 
and sustainability.
• Context-specific: context is synonymous with resource-constrained 
environment.
• Ethically sound: Human rights and dignity, safety for the client, community 
and environment
• Systems thinking: Holistic view of the health system
c. Components of health system
For the health system to work, it has components, these are: Service delivery, Health 
workforce, Information, Medical products, vaccines and technologies, Financing 
and Leadership and governance
Leadership and governance: Each country’s specific context and history shapes 
the way leadership and governance is exercised, but common ingredients of good 
practice in leadership and governance can be identified. These include:
• Ensuring that health authorities take responsibility for steering the entire 
health sector and for dealing with future challenges (including unanticipated 
events or disasters) as well as with current problems
• Defining, through transparent and inclusive processes, national health 
policies, strategy and plan that set a clear direction for the health sector
Health information systems: good governance is only possible with good 
information on health challenges, on the broader environment in which the health 
system operates, and on the performance of the health system. This specifically 
includes timely intelligence on:
• Progress in meeting health challenges and social objectives (particularly 
equity),including but not limited to household surveys, civil registration 
systems and epidemiological surveillance
• Health financing, including through national health accounts and an analysis 
of financial catastrophes and of financial and other barriers to health services 
for the poor and vulnerable
• Trends and needs for HRH; on consumption of and access to pharmaceuticals; 
on appropriateness and cost of technology; on distribution and adequacy of 
infrastructure
• Access to care and on the quality of services provided.
Health financing: Health financing can be a key policy instrument to improve 
health and reduce health inequalities if its primary objective is to facilitate universal 
coverage by removing financial barriers to access and preventing financial hardship 

and catastrophic expenditure. The following can facilitate these outcomes:

• A system to raise sufficient funds for health fairly
• A system to pool financial resources across population groups to share 
financial risks
• A financing governance system supported by relevant legislation, financial 
audit and public expenditure reviews, and clear operational rules to ensure 
efficient use of funds.
Human resources for health: The health workforce is central to achieving health. 
A well performing workforce is one that is responsive to the needs and expectations 
of people, is fair and efficient to achieve the best outcomes possible given available 
resources and circumstances. Countries are at different stages of development 
of their health workforce but common concerns include improving recruitment, 
education, training and distribution; enhancing productivity and performance; and 
improving retention.
Essential medical products and technologies: Universal access to health 
care is heavily dependent on access to affordable essential medicines, vaccines, 
diagnostics and health technologies of assured quality, which are used in a 
scientifically sound and cost-effective way. Economically, medical products are the 
second largest component of most health budgets (after salaries) and the largest 
component of private health expenditure in low- and middle-income countries
Service delivery: Health systems are only as effective as the services they provide. 
These critically depend on:
• Networks of close-to-client primary care, organized as health districts or 
local area networks with the back-up of specialized and hospital services, 
responsible for defined populations
• Provision of a package of benefits with a comprehensive and integrated 
range of clinical and public health interventions, that respond to the full 
range of health problems of their populations, including those targeted by the 
Millennium Development Goals 
• Standards, norms and guidance to ensure access and essential dimensions of 
quality: safety, effectiveness, integration, continuity, and people -centeredness 
• Mechanisms to hold providers accountable for access and quality and to 
ensure consumer voice
d. Institutional overview of the health sector in Rwanda 
The healthcare sector is a complex system made up of people, facilities, laws and 
regulations. It addresses current health, tries to ensure wellness, treats medical 
problems; creates new medication and medical devices; manages the health both 

individuals and populations; and helps determine regulations for safety, privacy, the 

environment, and healthcare delivery itself.
The Rwandan health sector is a pyramidal structure and consists of three levels: the 
central level, the intermediary level, and the peripheral level. (More details lesson 
6.1.7Levels of Healthcare Essential components of PHC.)
The Central Level: The central level comprises: Ministry of Health, Rwanda 
Biomedical Center and national referral and teaching hospitals.
The Intermediary Level: the intermediate level comprises of regional (within 
country) referral hospitals, provincial referral hospitals and other private practices.
The peripheral level: the peripheral level comprises of administrative offices at 
health district, the District hospitals, Health centers and health posts
e. Stakeholders of the health sector
There are many types of stakeholders in the healthcare sector. The space covers 
everyone from the general public – who have a stake in their own health and the 
health of those around them for issues like infectious disease – to the individual 
researchers who investigate current healthcare problems. The high-level groups of 
stakeholders include:
• The general public;
• Healthcare providers (such as doctors, nurses, clinics, and hospitals);
• Payers (such as insurance companies);
• Public health organizations;
• Researchers, scientists, and corporations in the pharmaceutical industry;
• Medical device manufacturers;
• Policy makers (particularly those with interest in public health, healthcare 
safety or privacy policies);
• Healthcare information technology technicians and organizations; and
• Professional organizations and societies relevant to the various aspects of 
the space

Self-assessment 6.1.4 

1) Explain the principals of the health system

6.1.5. Elements of PHC.

Learning activity 6.1.5

1) What are the elements of the primary health care?
The Alma Ata declaration put forward 8 essential components of primary healthcare. 
They are:
1) Education about prevailing health problems and methods of preventing 
and control them
Ill health inhibit access to opportunities in education, work, income earning, political 
and cultural participation and other value dimensions of human life. Health education 
is important element to communicate with the facts that help to promote the ways of 
healthy livings and solve basic health problems.
2) Prevention and control of Locally endemic diseases
The other aspect of the primary health care is to establish measures to prevent and 
control the diseases that may attack and spread rapidly throughout the community.
3) Provision of Essential drugs
PHC also emphasize on the availability of essential medicine such as drugs against 
diarrhea, fever, pain, malaria, etc. free of cost.

4) Maternal and child health, Family planning

With the world population increasing and women’s health in danger as they have to 
work for their families and still get pregnant; the primary health care also focuses 
on improvement of the maternal and child health by ensuring trained staffs to help 
mother while pregnant, giving birth and after birth and to care for the babies and 
also by availing the family planning methods to all people in need.
5) Expanded Immunization against major infectious diseases
Most people, especially in the developing world, due to lack of proper knowledge of 
health, poor economic status, lack of sophisticated curative health services are not 
in position to afford the costs of treatment, therefore, Immunization is the only major 
preventive measure against various communicable diseases such as Tuberculosis, 
tetanus, Diphteria, Whopping cough, etc.
6) Promotion of Food supply and proper Nutrition
A balanced diet is highly necessary to live healthy lives. Sufficient supply of food 
and management of proper nutrition is necessary to get balanced diet. People suffer 
from malnutrition due to lack of balance in diet and various related health problems 
emerge along with malnutrition. Therefore, food supply and proper nutrition is one 
of the important aspects of PHC.
7) Treatment of common infections
In the absence of proper and time treatment on communicable diseases various 
rural people have died immature death. Treatment of various such disease can be 
managed at the local level with short training preparation.
8) Adequate supply of safe water and basic Sanitation
Safe water supply and sanitation are close related: without water, the sanitary 
conditions are automatically affected. Without safe drinking water and poor 
sanitation, we are exposed to the gastrointestinal diseases such as diarrhea, 
cholera, typhoid, round worm, amoeba, dysentery, etc. therefore, good supply of 
safe drinking water is and ensuring good sanitation are critically important for our 

good health. 

Self-assessment 6.1.5

1) Explain the elements of the primary health care

6.1.6. Principles of PHC.

Learning activity 6.1.6

Look at the diagram above which represents the six primary principles. Reading 
the books that talk about the primary health. Respond to the following questions

1) Explain each of the above point in the above image

Attributes of primary health care
The following are attributes of primary health care: Essential healthcare, 
Universally accessible, Acceptable, Community bases, First point of contact, 
Affordability, Adaptability, Appropriateness, Community participation, Continuity, 
Comprehensiveness, Continuity, and coordination
a. Core principles of primary health care
The primary health care principles, are: 
Equitable distribution: inequitable access to the health care services is a major 
concern especially in the marginalized and poor community. One author Julian 
Tudor Hart described the health inequality as the “inverse care law” where by the 
care is mostly availed to those who are in need of it whilst the people in need 
cannot access. The first key principle in primary healthcare is that individuals with 
more compromised health should receive more health services. Commitment to 
health equity does not only focus only on ensuring program inputs but also reducing 
differences in health outcomes. Aspects of health and health care are: equity in 
access to healthcare, equity in health and effective coverage.
Community participation: refers to the involvement of individuals, families 
and community, determine the collective needs and priorities. Universal health 
coverage cannot be achieved without involving the local community. They are two 
types of community participation: Active community participation; this involves the 
cooperation of the community with the health administration with the community 
share the financial implications; and Passive community participation; the 
community and the administration are working cooperatively but community is not 
actually required to have certain financial involvement.
The following are advantages of community participation: increases program 
acceptance and leadership, ensures that the program meets the local needs, cost 
of implementing the program may be reduced by using the local resources, use 
local/familiar organizations and hence problem solving is efficient, commitments to 
the decisions is facilitated and the community is key to sustainability.
Intersectoral communication: primary health care involves in addition to the health 
sector, all related sectors and aspects of national and community development. 
It includes sustainable participation that combine inter-organizational cooperative 
working alliances. Here are the pre-requisites of the Intersectoral coordination: 
proper orientation of policies and program, formation of joint coordination committee 
at each level. Defining role and responsibilities of participatory agencies and 
participatory decision making.
Use of appropriate technology: the use of technology that is scientifically sound, 

adaptable to local needs and acceptable to those for whom it is used and is 

maintained by the people themselves in keeping with the principle of self-reliance 
with the resources the country and the community can afford. The technology 
should be designed to meet the specific health needs and it should be selected 
with reference to the magnitude of the population affected the health condition.
The use of technology is effective only when it is accompanied by the following: 
Knowledgeable and skilled users, clear practice guidelines and policies, effective 
financing and distribution to make them available, community efforts to bring clients 

into contact with health services in timely way.

Self-assessment 6.1.6

1) Explain the following principles of primary health care according to the 
Alma-Ata declarations
a. Bottom-up and community engaged
b. Priority to those in need

c. Involving many counterparts

6.1.7. Levels of Healthcare Essential components of PHC.

Learning activity 6.1.7

1) Illustrate the public health care service delivery in Rwanda
a. Back ground of health system in Rwanda 
Following the African regional committee of the World Health Organization held 
at Lusaka in 1985, Rwanda has adopted a health development strategy based 
on decentralized management and district-level care. The decentralization process 
began with the development of provincial-level health offices for health system 
management. Progress was made toward decentralizing management to the 
province and, ultimately, to the district level.
During the Genocide against Tutsi in 1994, the health system has been disrupted; 
infrastructures, equipment, personnel and the health system itself, have been 
destroyed. In February 1995, the government has issued a new policy for health 
system reconstruction; district health offices have been established and started to 
work as autonomous entities and providing services to a well-defined population.
b. Institutional overview of the health sector in Rwanda
The Rwandan health sector is a pyramidal structure and consists of three levels: 

the central level, the intermediary level, and the peripheral level.

The Central Level
The central level comprises (i) Ministry of Health (MOH), (ii) Rwanda Biomedical 
Center (RBC) and the (iii) national referral and teaching hospitals.
• The responsibility of the MOH at central level is to formulate policies and 
strategies, ensure monitoring and evaluation, facilitate capacity building and 
mobilization of resources. The central level organizes and coordinates the 
intermediary and peripheral levels of the health system and provides them 
with administrative, technical and logistical support.
• The RBC’s mission is to provide quality affordable and sustainable health 
care services to the population through innovative and evidence based 
interventions and practices, guided by ethics and professionalism. The core 
functions of the RBC include coordination and improvement of biomedical 
research activities, coordination of various activities geared towards the 
fight against communicable and non-communicable diseases, provide high 
level technical expertise in the health realm, ensure availability of medicines 
and medical supplies at all times in health facilities, and establish strategic 
relations with regional and international institutions, so as to achieve the 
strategic health goals.
• The mission of the national referral and teaching hospitals is to provide tertiary 
care to the population. These include King Faisal Hospital (KFH), Rwanda 
Military Hospital, Kigali University Hospital (CHUK), Butare University Hospital 
(CHUB) and Ndera Hospital for mental health and psychiatric care. King 
Faisal hospital was created to provide a higher level of technical expertise 
than that available in the national referral hospitals to both the private and 
public sector and to reduce the number of patients being referred abroad for 
complex medical interventions.
The Intermediary Level
To decrease the pressure of demand for services in the national referral hospitals, 
3 district hospitals were upgraded to referral hospital level (Ruhengeri, Kibuye 
and Kibungo hospitals) and four other district hospital were upgraded to provincial 
hospital level (Rwamagana, Bushenge, Ruhango and Kinihira) in order to form 
an intermediary level of referral hospitals. In addition, there are private practices 
operating in most of these cities.
The Peripheral Level: DHs, HCs and HPs
The peripheral level is represented by the health district and consists of an 
administrative office; District Health Unit (DHU), a district hospital (DH), and a 
network of health centers and health posts (HCs /HPs). As part of the decentralized 
structure of the GOR, the District Health Unit (DHU) is an administrative unit in 
charge of coordination of the provision of health services (including the private 

The Central Level
The central level comprises (i) Ministry of Health (MOH), (ii) Rwanda Biomedical 
Center (RBC) and the (iii) national referral and teaching hospitals.
• The responsibility of the MOH at central level is to formulate policies and 
strategies, ensure monitoring and evaluation, facilitate capacity building and 
mobilization of resources. The central level organizes and coordinates the 
intermediary and peripheral levels of the health system and provides them 
with administrative, technical and logistical support.
• The RBC’s mission is to provide quality affordable and sustainable health 
care services to the population through innovative and evidence based 
interventions and practices, guided by ethics and professionalism. The core 
functions of the RBC include coordination and improvement of biomedical 
research activities, coordination of various activities geared towards the 
fight against communicable and non-communicable diseases, provide high 
level technical expertise in the health realm, ensure availability of medicines 
and medical supplies at all times in health facilities, and establish strategic 
relations with regional and international institutions, so as to achieve the 
strategic health goals.
• The mission of the national referral and teaching hospitals is to provide tertiary 
care to the population. These include King Faisal Hospital (KFH), Rwanda 
Military Hospital, Kigali University Hospital (CHUK), Butare University Hospital 
(CHUB) and Ndera Hospital for mental health and psychiatric care. King 
Faisal hospital was created to provide a higher level of technical expertise 
than that available in the national referral hospitals to both the private and 
public sector and to reduce the number of patients being referred abroad for 
complex medical interventions.
The Intermediary Level
To decrease the pressure of demand for services in the national referral hospitals, 
3 district hospitals were upgraded to referral hospital level (Ruhengeri, Kibuye 
and Kibungo hospitals) and four other district hospital were upgraded to provincial 
hospital level (Rwamagana, Bushenge, Ruhango and Kinihira) in order to form 
an intermediary level of referral hospitals. In addition, there are private practices 
operating in most of these cities.
The Peripheral Level: DHs, HCs and HPs
The peripheral level is represented by the health district and consists of an 
administrative office; District Health Unit (DHU), a district hospital (DH), and a 
network of health centers and health posts (HCs /HPs). As part of the decentralized 
structure of the GOR, the District Health Unit (DHU) is an administrative unit in 

charge of coordination of the provision of health services (including the private 

sector) and responsible for planning, monitoring and supervision of the decentralized 
implementing agencies. The DHU is part of the DHMT and reports to the Vice 
Mayor in charge of social affairs.
The functions of the DHU include organization and coordination of health services 
in the Health Facilities (DH, HCs and HPs) and the Community. Health facilities 
deliver the approved healthcare packages (annex 6), provide administration, 
manage logistics supplies and supervise Community Health Workers (CHWs).
Generally, the service package at a district hospital (DH) includes inpatient / 
outpatient services, surgery, laboratory services, gynecology-obstetrics, radiology, 
mental health, dental and eye services. The HCs provide preventive services, 
primary health care, in-patient care, referrals, and basic maternity services, while 
the HPs provide services such as immunization, family planning, growth monitoring, 
and antenatal care.
At the village level, Community Health Workers (CHWs) provide prevention, 
promotion and some curative health services. Community health services are 
integrated into the community development services and administrative structures. 
There are 499 HCs spread-out all over the country.
c. Level of services provided within the public healthcare system in 
Rwanda
Regarding the healthcare services provision, it is offered into levels whereby each 
level works in complementarity to the other levels. It starts by the community health 
workers, working closely with the health posts and health centers. These are 
primary level. The secondary level is composed by the district hospitals located in 
each district. The tertiary level is composed by the provincial referral hospitals and 
the national referral hospitals and University teaching hospitals.

Table 6.1 1 Existing Administrative Structures and related health facilities (HSSP4 2018-

2024)

d. Package of the health services
Most common illnesses in Rwanda are transmissible diseases that are preventable 
through improved hygienic measures and changes in individual health behavior (cfr 
Rwanda Health statistics). A package of activities directed toward these, as well 
as common preventive interventions, has been defined for each level of the health 
system. Here below are different package of activities according to levels:
i. Health center level, the minimum package of activities (MPA)
• Promotional activities: including information, education, and communication 
(IEC); psychosocial support nutritional activities related to small farming and 
food preparation; community participation; management and financing of 

health services; home visits; and hygiene and sanitation in the catchment 

area around the health center
• Preventive activities: premarital consultation, Ante Natal Care (ANC) 
services, postpartum care for the mother and child, family planning counseling 
and services, school health, and epidemiologic surveillance activities
• Curative activities: including consultations, management of chronically 
ill patients, nutritional rehabilitation, curative care, observation before 
hospitalization, normal deliveries, minor surgical interventions, and laboratory 
testing
ii. District hospitals, complementary package of activities
The complementary package of activities (CPA) for district hospitals includes almost 
all activities of the MPA for the peripheral level, but emphasizes treating referred 
case. Additional activities under the CPA include the following:
• Prevention, including preventive consultations for referred cases and ANC 
consultations for at-risk pregnancies. Family planning, with the provision of all 
methods for referred cases, including female and male sterilization.
• Curative care, including management of referred cases, referrals for tertiary
level care, management of difficult labor, medical and surgical emergencies, 
minor and major surgical interventions, inpatient care, laboratory testing, and 
medical imaging;
• Management, including the training of paramedical personnel in district 
schools and collaboration with the district work group for continuing education 
and supervision activities.
iii. Complementary package of activities for national referral hospitals
Although the national referral hospitals provide the highest level of service and 
should function almost solely as referral centers from district hospitals, in reality, 
there is an overlap of the activities of the district and national referral hospitals.
This is because there is still an unclear delineation of responsibilities for the central
level national referral hospitals, and there are not enough functioning district 
hospitals, especially in urban areas. This results in national referral hospitals often 
assuming the responsibilities of district hospitals.
e. Standards of functioning health system
A well-functioning health system responds in a balanced way to a population‘s 
needs and expectations by: Improving the health status of individuals, families and 
communities, Defending the population against what threatens its health, Protecting 
people against the financial consequences of ill-health, Providing equitable access 
to people-centered care and Making it possible for people to participate in decisions 
affecting their health and health system
Self-evaluation 6.1.7
1) What are the levels of health care delivery in Rwanda?

2) What are the characteristics of the well-functioning health system?

6.2. Health Promotion

6.2.1. Background of health promotion

Learning activity 6.2.1

Read this link below about background of health promotion and briefly give an 
overview, strategy and focus of health promotion according to WHO.

https://www.who.int/health-topics/health-promotion#tab=tab_1 ;

The first International Conference on Health Promotion was held in Ottawa in 1986, 
and was primarily a response to growing expectations for a new public health 
movement around the world. It launched a series of actions among international 
organizations, national governments and local communities to achieve the goal 
of “Health For All” by the year 2000 and beyond. The basic strategies for health 
promotion identified in the Ottawa Charter were: advocate (to boost the factors 
which encourage health), enable (allowing all people to achieve health equity) and 
mediate (through collaboration across all sectors).
Since then, the WHO Global Health Promotion Conferences have established 
and developed the global principles and action areas for health promotion. Most 
recently, the 9th global conference (Shanghai 2016), titled ‘Promoting health in 
the Sustainable Development Goals: Health for all and all for health’, highlighted 
the critical links between promoting health and the 2030 Agenda for Sustainable 
Development. Whilst calling for bold political interventions to accelerate country 
action on the SDGs, the Shanghai Declaration provides a framework through which 
governments can utilize the transformational potential of health promotion.

Self-assessment 6.2.1

1) Where was the first International Conference on Health Promotion held?
2) Which was the goal of the first International Conference on Health 
Promotion?
3) What are the basic strategies for health promotion identified in the Ottawa 

Charter?

6.2.2. Concept definition of “Health promotion”

Learning activity 6.2.2

1) What is the relationship between these components (physical activity, 
health eating, stop smoking, community development, health schools, 

and health trainers) and health promotion?

The most well-known definition of health promotion is that of the World Health 
Organization’s Ottawa Charter (1986): Health promotion is the process of enabling 
people to increase control over, and to improve, their health. This definition was 
slightly modified in 2005, in WHO’s Bangkok Charter for Health Promotion in a 
Globalized World to: Health promotion is the process of enabling people to increase 
control over their health and its determinants, and thereby improve their health.
 To reach a state of complete physical, mental and social well-being, an individual 
or group must be able to identify and to realize aspirations, to satisfy needs, and to 
change or cope with the environment. Health is therefore, seen as a resource for 
everyday life, not the objective of living. Health is a positive concept emphasizing 
social and personal resources, as well as physical capacities. Therefore, health 
promotion is not just the responsibility of the health sector, but goes beyond healthy 
life-styles to well-being.
Health promotion is the process of enabling people to exert control over the 
determinants of health and thereby improve their health. (WHO, 2009)

Purpose of health promotion

The purpose of this activity is to strengthen the skills and capabilities of individuals 
to take action and the capacity of groups or communities to act collectively to exert 
control over the determinants of health and achieve positive change.
Health promotion and determinants of health.
Many factors combine together to affect the health of individuals and communities. 
Whether people are healthy or not, is determined by their circumstances and 
environment. 
To a large extent, factors such as where we live, the state of our environment, 
genetics, our income and education level, and our relationships with friends and 
family all have considerable impacts on health, whereas the more commonly 
considered factors such as access and use of health care services often have less 

of an impact

Self-assessment 6.2.2
1) What is health promotion according to WHO?
2) What must an individual/ group be able to do in order to reach a state of 
complete physical, mental and social well-being?
3) List five determinants of health.

6.2.3. The scope of health promotion.
Learning activity 6.2.3
Open one of the following links and read about the scope of health promotion, 
describe briefly five health promotion actions.
https://www.euro.who.int/__data/assets/pdf_file/0004/129532/Ottawa_Charter.
pdf 
https://bsahely.com/2018/09/12/the-ottawa-charter-for-health-promotionwho-1986/ 
a. Developing personal skills
Youth organizations, through the broad range of programmes and activates delivered 
to young people, including health education and health information, positively 
influence the development of personal skills, for example self-esteem, self-efficacy, 
communication, negotiation, life skills and motivation. The development of these 
skills has a positive impact on health.

b. Creating supportive environments

Through creating safe and secure physical and social environments, youth 
organizations provide young people and staff with opportunities to discuss and 
explore health issues and practice health-enhancing behaviors, thus supporting 
health education and ‘making the healthier choice the easier choice’; for example 
providing healthy food options in the tuck shop; providing healthy snacks for after 
schools clubs; providing a smoke free environment, implementing an anti-bullying 
policy, providing an adolescent friendly health service.
c. Strengthen community action
Through developing partnerships and alliances with other organizations and 
sectors in the community, youth organizations can build capacity and positively 
influence health within the wider community, which in turn, can continue to support 
the health of their target groups who live in the community, for example delivering 
parent programmes, working in partnership with healthy towns’ initiatives.
d. Delivering health public policy
Through the development of health-related policy internally, youth organizations 
demonstrate evidence-based practice indicating the importance of having policy in 
place to support practice, for example sexual health policy; substance use policy. 
Additionally, youth organizations have a key role to play in raising awareness and 
advocating for public policy development and change in order to support their 
health-related work and the health of their target groups, for example national 
alcohol policy.
e. Reorient the health services
Advocating for the development and provision of health services that can respond 
to the health needs of young people is a key role of youth organizations, for 
example youth organizations have a role in creating awareness and advocating for 

the provision of an adolescent friendly health service for young people.

Self-assessment 6.2.3

Consider each of the following activities and decide whether you think each is, 
or is not, health promotion.
1) Using TV advertisements to encourage people to more physically active.
2) Campaigning for smoking cessation programs such as ‘quit’ activities and 
‘brief interventions.
3) Explaining the mother how to breastfeed his child. 
4) Setting up a self-help group for people who have been sexually abused 

as children.

5) Providing schools with a crossing patrol to help children across the road 
outside schools.
6) Raising awareness on how poverty affect health.
7) Giving people information about the way their bodies work.
8) Immunizing children against infectious diseases such as measles. 
9) Protesting about a breach in the voluntary code of practice for alcohol 
advertising.
10) Running low-cost gentle exercise classes for older people at local leisure 
centres. 
11) Proving healthier menu choices at workplace canteens.
12) Teaching a programme of personal and social education in a secondary 
education.
13) Proving support to people with learning disabilities living in the community.
14) Using social marketing tools to ensure behavioral change in a group of 
smokers. 
15) Campaigning for increasing tax on tobacco.
What were your reasons for saying “yes” or “no”? Can you identify the criteria 

you are using for deciding whether an activity is “health promotion’?

6.2.4. Principles of health promotion

Learning activity 6.2.4

Open the link below and read about Principles of health promotion and briefly 
give an overview of health promotion principles.

https://www.youth.ie/articles/principles-of-health-promotion/

a. Principles of health promotion

Empowerment: a way of working to enable people to gain greater control over 
decisions and actions affecting their health.
Participative: where people take an active part in decision making.
Holistic: taking account of the separate influences on health and the interaction of 
these dimensions
Equitable: ensuring fairness of outcomes for service users.
Intersectoral: working in partnership with other relevant agencies/organizations.
Sustainable: ensuring that the outcomes of health promotion activities are 
sustainable in the long term.

Multi Strategy: working on a number of strategy areas such as programmes, policy

Self-assessment 6.2.4

6.2.5. Main approaches to health promotion.

Learning activity 6.2.5
Open the link below and read about approaches to health promotion and 
describe briefly each approach.
https://repository.canterbury.ac.uk/download/
e5b13fb82eb016e6c2bae128f962f54291a459571e774b8ec99c0b0d6d2
7f297/298377/Effective%20approaches%20to%20health%20promotion

%20in%20nursing%20-%20Nursing%20Standard%20Oct%202018.pdf

a. Medical or Preventive Approach 
The medical or preventive approach aims to reduce premature death by targeting 
the whole population or groups who are at higher risk of developing disease. This 
approach can operate at three levels: 
• Primary prevention – preventing the onset of disease 
• Secondary prevention – attempting to prevent disease progressing 
• Tertiary prevention level – seeking to mitigate harm in people who have 
already developed disease. Nurses who work within this approach to health 
promotion may be involved in immunization programmes, screening for 
diseases such as cancers, or administering medicine to patients in palliative 
care settings. 
b. Behavioral Approach 
The behavioral approach, also known as the behavior change approach, makes 
the fundamental assumption that healthy lifestyles are crucial to maintaining 
good health. Some behavior change attempts have been targeted at the whole 
population, for example, ‘Stoptober’, the annual 28-day stop smoking campaign that 
was initiated by the Department of Health in 2012. Healthcare professionals who 
adopt the behavioral approach in their practice seek to provide individual patients 
with information concerning their unhealthy lifestyle behaviors and motivate them 
to change. 
c. The Educational Approach 
The educational approach to health promotion assumes that increasing people’s 
knowledge about their health will lead to healthier behavior. Nurses who adopt an 
educational approach provide people with knowledge and information about their 
health. This differs from the behavior change approach in that it does not seek to 
attempt to motivate the individual to change their behavior in a specific direction 
decided by the professional, for example, to quit smoking, reduce alcohol intake or 
consume more fruit and vegetables. 
The focus of the educational approach is on learning and comprises three aspects 
• Cognitive -addresses people’s understanding concerning a health topic.
• Affective -considers an individual’s feelings and attitudes towards a health 
topic. 
• Behavioral -concerned with people’s skills, for example, their ability to cook. 
One important outcome of the educational approach is ‘health literacy’, which 
refers to “the personal, cognitive and social skills which determine the ability 
of individuals to gain access to, understand and use information to promote 
and maintain good health”
d. The Empowerment Approach 
Within the context of health promotion, empowerment can be understood as “a 
process through which people gain greater control over decisions and actions 
affecting their health” (WHO, 1998, p. 6). An empowerment approach seeks to 
enable individuals and social groups to express their health-related needs and 
have greater involvement in decision-making regarding their health. It can be used 
when working directly with individual patients or whole communities. Since nurses 
have an understanding of the needs and socio-cultural challenges within the local 
communities in which they work, it has been suggested that there is scope within 
some nursing roles, for example school nursing, to support whole families and 
collaborate with other healthcare professionals to achieve joint, local health goals.
One example of the empowerment approach being used to successfully promote 
patient health has been demonstrated within a hospice setting that specializes in 
cancer care. By improving open dialogue with patients and their families, nursing 
staff were able to elicit expressed needs and subsequently develop patient-centred 
care plans that promoted patients’ autonomy
e. The Social Change Approach 
The social change approach focuses on making changes to the physical, social and 
economic environment to increase their health promoting capacity. This approach 
assumes that if the healthier choice is made the easier choice, it will become 
increasingly realistic for individuals to make decisions to improve their health and 
wellbeing. Therefore, health promotion is therefore ‘a social and political process’ 
that regards health as a human right and considers the maintenance of population 

health to be a prerequisite for social progress. 

Self-assessment 6.2.5

1) List five approaches to health promotion.
2) With supportive examples, describe briefly the aims of each approach to 
health promotion listed in question 1.
3) This approach to health promotion is based on the assumption that 
humans are rational decision-makers, this approach relies heavily upon 
the provision of information about risks and benefits of certain behaviors.
a. behavior change approach
b. community development approach
c. biomedical approach
d. none of these 
4) This approach to health promotion is synonymous with health education 
as it aims to increase individuals’ knowledge about the causes of health 
and illness.
a. behavior change approach
b. community development approach
c. biomedical approach

d. none of these

6.2.6.Basic strategies of health promotion

Learning activity 6.2.6

Open the link below and read about basic strategies of health promotion, 
describe briefly each strategy. https://www.betterhealth.vic.gov.au/health/
servicesandsupport/ottawa-charter-for-health-promotion
Learning activity 6.2.6
The Ottawa Charter identifies three basic strategies for health promotion:
• Advocate – good health is a major resource for social, economic and personal 
development, and an important dimension of quality of life. Political, economic, 
social, cultural, environmental, behavioral and biological factors can all favour 
or harm health. Health promotion aims to make these conditions favorable, 
through advocacy for health.
• Enable – health promotion focuses on achieving equity in health. Health 
promotion action aims to reduce differences in current health status and 
to ensure the availability of equal opportunities and resources to enable all 
people to achieve their full health potential. This includes a secure foundation 
in a supportive environment, access to information, life skills and opportunities 
to make healthy choices. People cannot achieve their fullest health potential 
unless they are able to control those things that determine their health. This 
must apply equally to women and men.
• Mediate – the prerequisites and prospects for health cannot be ensured by 
the health sector alone. Health promotion demands coordinated action by 
all concerned, including governments, health and other social and economic 
sectors, non-government and voluntary organizations, local authorities, 

industry and the media.

Self-assessment 6.2.6 

1) Outline three basic strategies for health promotion.
6.3. Health Education
6.3.1. Concept definition of health education.

Learning activity 1.9

Look at the images above and attempt the following questions
1) What do you see in the image A and B? 
2) When observing carefully the image B, what should be going on?

3) Why do you think health education is important?

a. Definition of health education

Health education is defined as a process by which people learn about their health 
and more specifically, how to improve their health. It can also be defined as a 
development of individual, group, institutions, community and systemic strategies 
to improve health knowledge, attitudes, skills and behaviour.
The WHO defined health education as comprising of consciously constructed 
opportunities for learning involving some form of communication designed to 
improve health literacy, including improving knowledge, and developing life skills 
which are conducive to individual and community health.
Health education as a tool for health promotion is critical for improving the health of 
populations and promotes health capital.
Health literacy is the degree to which people are able to access, understand, 
appraise and communicate information to engage with the demands of different 
health contexts in order to promote and maintain good health across the life-course.
b. Relationship between health education and health promotion 
Health promotion and health education are easily confused because both concepts 
are closely related and work together to help people make wise decisions about 
their health. Health education is one aspect of promoting a healthy lifestyle and it 
only aims to inform people and give them knowledge about health. Health promotion 
is more general and broader of an area and it involves government policy-making in 
addition to education. Health promotion also includes areas such as cultural, social 

and political factors, in addition to education.

Table 6.3 1 Table comparing health promotion and health education

Self-assessment 6.3.1

1) Define the term ‘Health education’.

2) Is health education important in the community? Justify your answer

6.3.2. Objectives of health education

Learning activity 6.3.2

Referring to the definition of Health education as a process by which people 
learn about their health and more specifically, how to improve their health; and 
also considering the above topics, answer the following questions:
1) What should be the relationship between health education and nutrition? 

2) Give at least 2 objectives of health education.

Health education programs help empower individuals and communities to live 
healthier lives by improving their physical, mental, emotional and social health by 
increasing their knowledge and influencing their attitudes about caring for their wellbeing.
Health education focuses on prevention, increasing health equity, and decreasing 
negative health outcomes such as availability and accessibility of health services, 
benefiting all stakeholders.

The following are the some of the main objectives of health education:

• To provide information about health and its value as community asset:
Health education aims at acquainting the etchers with the rules of health and 
hygiene. Functioning of Precautionary measures to ward off diseases and to 
provide good disease-free working conditions.
• To maintain norms of good health: The authorities should provide hygienic 
environment in the form of adequate ventilation proper temperature, good 
sanitation and all-round cleanliness. It helps the authorities to keep certain 
norms of health.
• To take precautionary and preventive measures against communicable
diseases. Its aim is to take adequate precautions against contamination 
and spread of diseases. Thus, good sanitary arrangements are made. 
Precautionary and preventive measures. If they are properly adopted can 
help in improving the health standards of society.
• To render assistance to the school going children an understanding 
of the nature and purpose of health services and facilities – It aims 
at discovering physical defects and other abnormalities in the child and 
promoting their reduction if they are easily curable.
• To develop and promote mental and emotional health – Mental and 
emotional health are also equally important along with physical health. While 
physically health makes a pupil physically fit mental and emotional health 
enables him to maintain an even temper and a happy disposition.
• To develop a sense of civic responsibility. School is a miniature society 
Responsibility of skill health does not lie on any one’s shoulders. Even some 
cause of skill health has their origin in social conditions which require action 
on the part of community as a whole in order to eradicate them. It aims at 
realizing the people to make combined efforts and work for community health.
Factors affecting learning
The nurse should be aware of the following factors that can facilitate or hinder 
optimal learning by a client:
• Age and developmental stage: three major developmental stage factors 
associated with clients’ readiness to learn include physical, cognitive, and 
psychosocial maturation.
• Motivation: Motivation to learn is the desire to learn. Motivation is generally 
greatest when a person experiences a need and believes the need will be 
met through learning
• Readiness: Readiness to learn refers to demonstrated behaviors that reflect 
not only the client’s willingness to learn but also his or her ability to learn at 
a specific time. For example, a client may want to learn self-care during a

dressing change, but when experiencing pain he may not be able or ready to 
learn.
• Active involvement: When the learner is actively involved in the process of 
learning, learning becomes more meaningful and faster, and retention is better. 
Active learning promotes more effective problem solving and application of 
learning to the clients’ own situations
• Relevance: The client can learn more easily if he or she can connect or relate 
the new knowledge or skills to what he or she already knows.
• Feedback: Feedback is information regarding a person’s performance 
in meeting a desired goal; it needs to be meaningful and given in a timely 
manner. Feedback that accompanies the practice of psychomotor skills helps 
the person learn those skills.
• Nonjudgmental support: People learn best when they believe they 
are accepted and not being judged. Once learners have succeeded in 
accomplishing a task or understanding a concept, they gain self-confidence 
in their ability to learn. This confidence reduces their anxiety about failure and 
can motivate further learning.
• Simple to complex: Learning is facilitated by material that is logically 
organized and proceeds from the simple to the complex. Such organization 
enables the learner to comprehend new information, assimilate it with previous 
learning, and form new understandings
• Repetition: Repetition of key concepts and facts facilitates retention of newly 
learned material
• Timing People retain information and psychomotor skills best when the time 
between learning and active use of the learning is short; the longer the time 
interval, the higher the chances of the learning being forgotten
• Environment An optimal learning environment with reduced distractions 
facilitates learning. Noise can distract the learner and interfere with listening 
and thinking.
• Emotions: Emotions, such as high anxiety, fear, anger, and depression, can 
impede learning. Clients or families who are experiencing extreme emotional 
states may retain only part of the communication.
• Physiological events Physiological events, such as a critical illness, pain, or 
sensory deficits, inhibit learning
• Cultural barriers Cultural barriers to learning include language, beliefs, 
and values. Western medicine may conflict with cultural healing beliefs and 
practices. Nurses need to be competent in providing culturally safe and 
sensitive care; otherwise, the client may be partially or totally noncompliant 
with recommended treatments
• Psychomotor ability Nurses must be aware of a client’s psychomotor skills 

when planning teaching. Motor abilities can be affected by health status.

Self-assessment 6.3.2 

1) List the main objectives of health education.

2) List factors that can affect learning during health education

6.3.3. Principles of Health education.

Learning activity 6.3.3

1) Read through the link below and list the principles of health education

http://nursingexercise.com/health-health-education-overview/

The following are principles of health education: Credibility, Interest, Participation, 
Motivation, Comprehension, Reinforcement, Learning by doing, Known to unknown, 
Setting an example, Good human relations, Feedback and Leaders. They are 
discussed below: 
1. Interest: Health teaching should be related to the interests of the people. 
Health programmers should be based on the “FELT NEEDS”, so that it 
becomes “people’s programme. Felt needs are the real health needs of the 
people that is needs the people feel about themselves.
2. Participation: A high degree of participation tends to create a sense of 
involvement, personal acceptance and decision –making and provides 
maximum feedback. The Alma- Ata Declaration states “The people have a 
right and duty to participate individually and collectively in the planning and 
implementation of their health care”. Health programmers are unlikely to 
succeed if community participation is not an integral part. Health educators 
should include clients from the identification of the problems, planning, 
implementation, and evaluation.
3. Known to unknown: We must proceed “from the concrete to the abstract”, 
“from the particular to the general”, “from the simple to the more complicated”, 
“from the easy to more difficult” and “from the known to unknown” Here 
health communicator uses the existing knowledge of the people as pegs on 
which to hang new knowledge
4. Reinforcement: Repetition of message at intervals is necessary; if the 
message is repeated in different ways, people are more likely to remember 
it.
5. Motivation: In every person, there is a fundamental desire to learn. 
Awakening this desire is called motivation. Two types of motives are: primary 
motives-are driving forces initiating people into action; and secondary 
motives –are created by outside forces or incentives. Need for incentives is 
a first step in learning to change and incentives may be positive or negative. 
Main aim of motivation is to change behavior and motivation is contagious: 
one motivated person may spread motivation throughout a group.
6. Comprehension: Health educator must know the level of understanding, 
education and literacy of people to whom the teaching is directed. Always 
communicate in the language people understand and consider the mental 
capacity of the audience when
7. Communication: Communication is very important. Health educator should 
know any barrier to communication like language, cultural background of the 
community. Health educator has to know the group for whom he/she has to 
give health education.
8. Needed-based: Any health-related education should focus on community 
health needs. It should be purposeful, ascertain, specific and relevant to the 
problems and available solutions.
9. Change behavior: Health educator should know the prior behavior of the 
community to educate. The purpose of health education is to change their 
behavior and adopt a healthier one. Therefore, multidisciplinary approach is 
necessary to understand human behavior as well as for an effective teaching 
process.
10. Scientific based knowledge: Health-related education must be scientific 
and current knowledge-based. Therefore, a health educator should have the 
recent scientific knowledge to provide health education.
11. Rapport relationship: The health educators are not teachers; they are 
facilitators, enablers. They need to be accepted by the community members; 
they have to win the confidence of their clients.
12. Compare and upgrade knowledge: It must be remembered that people 
have no information or ideas about health. The health educators are not only 
passing information but also allow clients to analyses old ideas with new 
ones, compare with experience, and take decisions that are found favorable 
and beneficial.
Targets people for health education: 
• Individuals such as clients of services, patients, healthy individuals.
• Groups E.g. groups of students in a class, youth club.
• Community e.g. people living in a village.
Self-assessment 6.3.3
1) List at least five principles of health education

2) Who are the target people for health education?

6.3.4. Process of Health education

Learning activity 6.3.4

Referring to the books that talks about the health education and using the link 
below, give the steps that are involved in the teaching-learning process
Books on teaching content for a variety of health care conditions
• Nurse’s Handbook of Patient Education, by Shirin F. Pestonjee (2000, 
Springhouse).
• Mosby’s Handbook of Patient Teaching, by Mary Conobbio (2000, Harcourt 
Health Services).
Link: 
https://www.euromedinfo.eu/process-of-patient-education-introduction.
html/#:~:text=Developing%20learning%20objectives,Documenting%20
patient%20teaching%20and%20learning
Learning activity 6.3.4
The process of patient teaching refers to the steps you follow to provide teaching 
and to measure learning. The steps involved in the teaching-learning process are:
• Assessing learning needs
• Developing learning objectives
• Planning and implementing patient teaching
• Evaluating patient learning
• Documenting patient teaching and learning
a. Assessing learning needs
The first step in the process of patient teaching is assessing the patient’s learning 
needs, learning style, and readiness to learn. Assessment includes finding out what 
patients already know, what they want and need to learn, what they are capable of 
learning, and what would be the best way to teach them.
Begin the process by interviewing the patient. First, find out more about the patient 
as an individual and what his life is like. Questions you might ask include:

• Tell me what an average day is like for you

• How has your average day changed since you’ve been sick?
• What do you like to do in your spare time?
• Tell me about your family
• Tell me about your work
Second, start assessing the patient’s learning needs. Questions you might ask 
include:
• What are you most concerned about?
• What are your goals for learning how to take care of yourself?
• What do you feel you need to know to achieve your goals?
• What specific problems are you having?
• What do you know about your condition?
• What are you most interested in learning about?
• How will you manage your care at home?
Third, find out what the patient’s learning style is so you can match teaching 
strategies as closely as possible to the patient’s preferred learning style. Questions 
you might ask to determine the patient’s learning style are:
• What time of day do you learn best?
• Do you like to read/what types of books or magazines do you enjoy reading?
• Would you prefer to read something first, or would you rather have me explain 
information to you?
• Do you learn something better if you read it, hear it, or do it hands on yourself?
Forth, gather information about the patient’s readiness to learn. Questions you 
might ask include:
– How do you feel about making the changes we’ve discussed?
– What changes would you like to work on now?
– Are there any problems that would prevent you from learning right now?
Forth, gather information about the patient’s readiness to learn. Questions you 
might ask include:
• How do you feel about making the changes we’ve discussed?
• What changes would you like to work on now?
• Are there any problems that would prevent you from learning right now?
After you’ve talked with the patient, interview the family. Conversations with the 
patient’s family can fill in missing information, change your understanding of what
 you’ve heard from the patient, or affect your view of what the patient’s home situation might be. Do family members ask to be present during teaching, and when teaching 
occurs, do they actively participate? Do they seem supportive of the patient’s need 
to change health behaviors and to learn new tasks and skills?
You can also consider using checklists and questionnaires to obtain information 
about learning needs, learning style, and learning readiness. Written materials 
also help you determine the patient’s literacy level and ability to understand written 
information. Confer with other health care team members. Each health care team 
member has valuable information about the patient and his or her learning needs 
and abilities. Collaborating with others who care for the patient can give you-and 
them-a better picture, allowing all of you to design more effective teaching strategies.
In some instances, there are differences between the patient’s and the health 
professional’s view of the need to know. The health professional may perceive the 
need for information when the patient does not. For example, a pharmacist tries 
to give the patient information when filling a prescription. The patient’s response 
is: „Oh, I don’t need to know that-I trust my doctor. Whatever he ordered is fine. 
There’s no reason I should know all the details. “ In this example, the best approach 
may be for the pharmacist to start with why the information is important and explain 
that the physician depends on the patient to know the information.
Determining learning style involves assessing how patients learn best, when 
they learn best, and how able they are to learn what they need to know. Finding 
out whether the patient learns best by hearing, reading, or hands-on learning is 
relatively straightforward. However, factors such as the patient’s educational and 
literacy levels also need to be considered. Sometimes patients and families may 
seem uninterested in learning because they don’t know what to ask or don’t yet 
realize that they will need information. For example, family members of a patient 
with a stroke may have never known anyone else with a stroke and thus may have 
no idea of what to plan for or what to ask. In some instances, nurses and other health 
professionals may take it for granted that patients have a better understanding of 
their condition and treatment than they actually do.
During the acute phase of an illness, patients are dependent on health care 
professionals. Dependency may be a realistic and necessary condition because 
of physical and psychosocial demands caused by the illness. Available energy is 
invested in coping with the physiological and psychosocial demands of the illness 
and the person’s focus may be on survival. Readiness to learn, therefore, is limited. 
Not only is energy diminished, but other distractors such as pain and fatigue are 
usually present. Learning needs at this time usually focus on diagnostic tests and 
treatments. These needs are considered short-term learning-the material being 
learned relates to the present situation and once the situation is over, it is usually no 
longer necessary to retain it. As the person recovers and independence increases, 
he or she progresses to the post-acute or resolution stage of illness. For most 
patients, an improving physical condition and the desire to return to normalcy acts 
as an incentive to learn how to recognize, prevent, and manage complications. Due 
to short hospital stays, much of the patient’s learning readiness for management 
and prevention of further problems will take place in an out-patient or a home setting.
b. Developing learning objectives
To develop objectives, you need to define the outcomes you and the patient expect 
from the teaching-learning process. Unlike goals, which are general and long
term, learning objectives are specific, attainable, measurable, and short-term. For 
example, for a newly diagnosed diabetic patient, the overall learning goal may be to 
learn how to maintain blood glucose levels between 70 and 150 mg/dl at all times. 
Reaching such a goal may be overwhelming unless it’s broken down into specific, 
short-term behavioral objectives that lead up to the overall goal. For this patient, an 
objective such as „After this session, the patient will be able to list five symptoms of 
hypoglycemia “is one step on the way to the larger goal.
A simple and practical way of developing learning objectives is to start with the 
words WHO, DOES, WHAT, HOW, and WHEN. For example, the objective “The 
patient will list five signs of hyperglycemia by time of discharge” could be broken 
down this way:
• WHO-the patient
• DOES-will list
• WHAT-five signs of hyperglycemia
• HOW-accurately or by stating out loud
• WHEN-by discharge
Make sure in writing objectives that you use action words that are measurable such 
as list, state, explain, and demonstrate. Avoid using terms that cannot be measured 
or observed easily, such as understand or appreciate.
c. Planning and implementing teaching
The next step in the process is to plan and implement an individualized teaching 
plan. Your teaching plan should include what will be taught, when teaching will 
occur, where teaching will take place, who will teach and learn, and how teaching 
will occur. 
Patient/clients should be involved in what will be taught/learnt from the beginning 
up to the end. Nurse as educator should identify the needs of the client and engage 
the client in the whole learning process.
Plan when and where the teaching/learning will take place considering what is best 
for the client; ensure that the clients inform you what works for them and offer as 
many as possible realistic options available. Consider the time and the length and 
depth of the session that is good for the client.
d. Evaluating teaching and learning
Evaluation, the last phase of the teaching process, is the ongoing appraisal of the 
patient’s learning progress during and after teaching. The goal of evaluation is to 
find out if the patient has learned what you taught.
Here are some ways you can evaluate learning:
• Observe return demonstrations to see whether the patient has learned the 
necessary psychomotor skills for a task
• Ask the patient to restate instructions in his or her own words
• Ask the patient questions to see whether there are areas of instruction that 
need reinforcing or re-teaching,
• Give simple written tests or questionnaires before, during, and after teaching 
to measure cognitive learning
• Talk with the patient’s family and other health care team members to get 
their opinions on how well the patient is performing tasks he or she has been 
taught
• Assess physiological measurements, such as weight and blood pressure, 
to see whether the patient has been able to follow a modified diet plan, 
participate in prescribed exercise, or take antihypertensive medication
• Review the patient’s own record of self-monitored blood glucose levels, blood 
pressure, or daily weights
• Ask the patient to problem solve in a hypothetical situation
e. Documenting patient teaching
Your documentation of patient teaching should take place throughout the entire 
teaching process. Documentation is done for several purposes. Documentation 
promotes communication about the patient’s progress in learning among all health 
care team members. Good documentation helps maintain continuity of care and 
avoids duplication of teaching. Documentation also serves as evidence of the 
fulfillment of teaching requirements for regulatory and accrediting organizations 
such as the JCAHO, provides a legal record of teaching, and is mandatory for 
obtaining reimbursement from third party payers. Documentation of patient teaching 
can be done via flow-charts, checklists, care plans, traditional progress notes, or 
computerized documentation. Whatever the method, the information must become 
a part of the patient’s permanent medical record. Table 6 shows suggestions on 

what to document and how

Sample Teaching Plan: Wound Care
Assessment of Learner: A 24-year-old male university student suffered a 7-cm 
laceration on the lower anterior part of the left leg during a hockey game. 
The laceration was cleaned, sutured, and bandaged. The client was given an 
appointment to return to the health clinic in 7 days for suture removal. Client 
states that he lives in the university dormitory and is able to care for the wound if 
given instructions. Client is able to understand and read English.
• Nursing diagnosis: Lack of knowledge of wound and suture care
• Long-term goals: Client’s wound will heal completely without infection or 
other complications.
• Intermediate goal: At clinic appointment, client’s wound will be healing 
without signs of infection, loss of function, or other complication.
• Short-term goals: Client will (a) correctly list three signs and symptoms of 
wound infection and (b) correctly perform a return demonstration of wound 
cleansing and bandaging.
Behavioral outcomes.
On completion of the instructional session, the client will do the following:
• Describe normal wound healing
• Describe signs and symptoms of wound infection
• Demonstrate wound cleansing and bandaging 
Content outline
• Normal wound healing
• Infection:
– Signs and symptoms
– Signs of systemic infection.
• Wound care equipment
– Cleansing solution
– Dressing materials
• Demonstration of wound cleansing and bandaging on the client’s wound
• Resources available for client’s questions

• Follow-up treatment plan

Teaching methods
• Describe normal wound healing with the use of audiovisuals.
• Discuss the mechanism of wound infection. Use audiovisuals to 
demonstrate infected wound appearance.
• Demonstrate the equipment needed for cleansing and bandaging wound.
• Demonstrate wound cleansing and bandaging on the client’s wound.
• Discuss available resources.
• Provide a handout of the procedure and frequently asked questions (FAQs)
Evaluation
The client will do the following:
• Correctly describe normal wound healing and signs and symptoms of 
wound infection
• Return demonstration of wound cleansing and bandaging
• State contact person and telephone number to obtain assistance

• State date, time, and location of follow-up appointment

Documenting Patient Teaching
What to document
• The patient’s learning needs
• The patient’s preferred learning style and readiness to learn
• The patient’s current knowledge about his or her condition and health care 
management
• Learning objectives and goals as determined by both you and the patient
• Information and skills you have taught
• Teaching methods you have used, such as demonstration, brochures, and 
videos.
• Objective reports of patient and family responses to teaching
• Evaluation of what the patient has learned and how learning was observed 
to occur
How to document
• Record the patient’s name on every page of your documentation.
• Include the time and date on all entries.
• Sign each entry.
• Write in black or blue ink, for legal and reproduction purposes.
• Write legibly.
• Be accurate and truthful when discussing facts and events.
• Be objective-don’t show personal bias or let others influence what you 
write.
• Be specific.
• Be concise-record information succinctly, without compromising accuracy.
• Be comprehensive-include all pertinent information.
• Record events in chronological order.
Source: Rankin, S.H., & Stallings, K.D. (1996). Patient Education: Issues, 

Principles, Practices, 3rd ed. Philadelphia: Lippincott-Raven, 233-236

Self-assessment 6.3.4

1) List the steps used in the teaching learning process

2) What to document in patient teaching

End unit assessment 6

1) Selective Public Health Care is:
a. Client is a passive recipient
b. Service provision is not holistic, equitable or sustainable
c. Health achieved through medical interventions
d. All of the above
2) Comprehensive PHC is?
a. Holistic understanding and implementation of healthcare and wellbeing 
that is equitable, empowering and sustainable.
b. Health achieved through medical interventions
c. Client is a passive recipient and Service provision is not holistic, equitable 
or sustainable
d. All of the above
3) Health is best described as a resource that allows a person to have
a. A social and spiritual life
b. A productive social and economic life
c. Economic well being
d. Physical capacity
4) What distinguishes primary healthcare from primary care
a. A focus on primary, secondary, and tertiary intervention
b. Provision of interventions specific to the health need
c. Works within a multidisciplinary framework
d. Planning and operation of services is centralized
5) Primary prevention is concerned with
a. Preventing disease or illness occurring
b. Delaying the progress of an existing disease or illness
c. Maintaining current health status
d. Treatment of existing disease or illness
6) Which of the following approaches to health promotion aims to reduce 
premature death by targeting the whole population or groups who are at 
higher risk of developing disease?
a. Medical/preventive
b. Behavioural
c. Educational
d. Empowerment
7) A home health nurse who provides skin care and repositioning of a client 
on bedrest is conducting activities in:
a. Health promotion 
b. Health protection
c. Health prevention 
d. Rehabilitation
8) The public health nurse who does Blood Pressure screening and related 
health education is conducting activities in the level of :
a. Primary prevention 
b. Secondary prevention
c. Tertiary prevention
d. Focused prevention
9) The major goal of health promotion includes all of the following Except:
a. optimizing health
b. focusing on subacute diseases
c. staying health
d. creating new health environment
10) Which of the following is the core principle of health promotion?
a. one or two strategies
b. inequity
c. sustainability 
d. disempowerment
11) A person’s health and wellbeing are dependent on a good, good future, 
good care, and support. These influences, social, economic, physical, 
and environmental factors, are known as:
a. Health care
b. Health promotion
c. Public health
d. Determinants of health.
12) The scope of health promotion in which developing partnerships and 
alliances with other organizations and sectors in the community to build 
capacity and positively influence health within the wider community is ….
a. Developing personal skills
b. Creating supportive environments
c. Strengthen community action
d. Delivering health public policy
13) The principle of health promotion where people take an active part in 
decision making is:
a. Empowerment 
b. Participative 
c. Holistic 
d. Equitable 
14) 14) Which audience comment best demonstrates self-efficacy?
a. I believe I can learn to do this. 
b. I think the nurse is a real expert in this stuff.
c. Those computer graphics really make it clear how people can do this. 
d. Wow. The nurse really expects us to do this
15) Which of the following would be the best question for a nurse to ask to 
determine whether an educational intervention had any effect?
a. Are you interested in any other topics for me to teach? 
b. Did you find this program useful to you? 
c. Do you understand the material I presented? 
d. How are you going to apply these ideas at home?
16) In preparing to give a presentation on breast self-examination, a nurse 
went to the Rwandan Cancer Center and obtained a variety of handouts 
to use during the presentation. Which possibly erroneous assumption is 
the nurse make?
a. Handouts are the best technique for emphasizing important points.
b. Handouts will be easily read by people in the audience.
c. People will appreciate the brochures and freebies such as shower hook 
reminders.
d. People will use the reminders and put them in their bathrooms
17) Principles of health education includes all except:
a. Participation 
b. Motivation 
c. Reinforcement 
d. Punishment 
18) What are the key elements of health promotion?
19) What is the Purpose of health promotion?