Impacto e prevalência do assédio no trabalho no contexto de enfermagem em Portugal / Impact and prevalence of workplace bullying in Portuguese nursing settings / Impacto y prevalencia del acoso laboral en el contexto de la enfermería en Portugal

Resumo Enquadramento: O assédio no trabalho é caracterizado pela repetição prolongada de condutas de agressão, efetuadas por um ou mais trabalhadores. Objetivos: Avaliar a prevalência de assédio no trabalho, as causas e o impacto no bem-estar físico, mental, emocional e desempenho dos enfermeiros. Metodologia: Estudo quantitativo, descritivo e correlacional com questionário online divulgado na newsletter da Ordem dos Enfermeiros. Utilizou-se a escala NAQ-R (Negative Act Questionnaire Revised) e obteve-se uma amostra de 2015 enfermeiros de instituições de saúde portuguesas. Resultados: A prevalência de assédio no trabalho mediante os 3 critérios de avaliação foi de 46,40%, 28,88% e 22,53% subsequentemente. As principais causas de assédio identificadas foram: não ceder nem se deixar influenciar por chantagem ou servilismo e o solidarizar-se com os colegas de trabalho e o não ignorar a injustiça. O desempenho laboral de 73,33%, dos enfermeiros que percecionaram ser vítimas, foi comprometido. Conclusão: O assédio afeta saúde física e mental de trabalhadores e organizações laborais, levando a absentismo, desempenho diminuído, relações deterioradas, perda de interesse e motivação.

Abstract Background: Workplace bullying is characterized by the prolonged repetition of aggressive conduct, carried out by one or more workers. Objectives: To assess the prevalence of workplace bullying and the impact on the physical, mental, emotional well-being and performance of nurses. Methodology: Quantitative, descriptive and correlational study with online questionnaire shared in the newsletter of the Ordem dos Enfermeiros. The NAQ-R (Negative Act Questionnaire Revised) scale was used and a sample of 2015 nurses from Portuguese health institutions was obtained. Results: The prevalence of workplace bullying using the 3 evaluation criteria was 46,40%, 28,88% and 22,53% subsequently. The main causes of bullying identified were not giving in or letting oneself be influenced by blackmail or servility and showing solidarity with co-workers and not ignoring injustice. The work performance of 73,33% of nurses who perceived themselves to be victims was compromised. Conclusion: Bullying affects the physical and mental health of workers and labor organizations, leading to absenteeism, decreased work performance, deterioration in the quality of relationships, loss of interest and motivation.

Resumen Marco contextual: El acoso laboral se caracteriza por la repetición prolongada de conductas agresivas, realizadas por uno o más trabajadores. Objetivos: Evaluar la prevalencia del acoso en el trabajo y el impacto en el bienestar físico, mental, emocional y desempeño de los enfermeros. Metodología: Estudio cuantitativo, descriptivo y correlacional con cuestionario online publicado en el boletín de la Ordem dos Enfermeiros. Se utilizó la escala NAQ-R (Negative Act Questionnaire Revised) y se obtuvo una muestra de 2015 enfermeras de instituciones de salud portuguesas. Resultados: La prevalencia de acoso laboral utilizando los 3 criterios de evaluación fue de 46,40%, 28,88% y posteriormente 22,53%. Las principales causas de acoso identificadas fueron: no ceder o dejarse influenciar por chantajes o servilismos y ser solidario con los compañeros de trabajo y no ignorar las injusticias. El desempeño laboral del 73,33% de los enfermeros que se percibieron como víctimas fue comprometido. Conclusión: El acoso afecta a la salud física y mental de los trabajadores y las organizaciones laborales, provocando absentismo, disminución del rendimiento, deterioro de las relaciones, pérdida de interés y motivación.

Scale for the Environment Evaluation of Professional Nursing Practice: Construct validation.

AIM: Testing the validity and reliability of the Scale for the Environments Evaluation of Professional Nursing Practice (SEE-Nursing Practice). BACKGROUND: The environment of professional nursing practice is key to achieve better results for clients, nurses and institutions. Therefore, instruments enabling the assessment of all its attributes are required. METHOD: Cross-sectional methodological study. The SEE-Nursing Practice, based on a previous qualitative study and literature review, was applied as a questionnaire. Exploratory and confirmatory factor analyses were used to assess construct validity. RESULTS: A total of 752 nurses participated in the study. Exploratory factor analysis of the SEE-Nursing Practice led to a factor solution with 93 items and three subscales. The Structure, Process and Outcome subscales, respectively, have 43, 37 and 13 items, loaded in 6 factors, 6 factors and 2 factors and explaining 62.6%, 59.2% and 67.4% of the total variance. Cronbach's alpha of the overall scale and of the 3 subscales was greater than 0.90. Confirmatory factor analysis showed a good fit. CONCLUSION: SEE-Nursing Practice is a good valid and reliable instrument. IMPLICATIONS FOR NURSING MANAGEMENT: The SEE-Nursing Practice enables assessing practice environments and is a tool for nursing managers in the definition of strategies ensuring favourable environments for nursing care quality.

Programas de promoção de estilo de vida saudável em contexto de saúde escolar: scoping review / Programas que promueven un estilo de vida saludable en el contexto de la salud escolar: scoping review / Programs for promoting a healthy lifestyle in the context of school health: a scoping review

INTRODUÇÃO: A adoção de estilos de vida saudável (EVS) nas crianças é estimulada na escola mas a educação para a saúde orienta-se maioritariamente para as crianças, descurando a família. OBJETIVO: Mapear e examinar programas escolares de promoção de EVS nas crianças (3-10anos) que abordem 3 ou mais temáticas. MÉTODO: Scoping Review de 1992-2020 com metodologia do Institute Joanna Briggs e recurso à plataforma Rayyan QCRI. Resultados: De 4952 artigos, selecionaram-se 19 programas de promoção de EVS, de 13 países, com temas: alimentação saudável, atividade física e educação parental, mas também intervenções na dependência de ecrã, sono e higiene. DISCUSSÃO: Apesar de a maioria dos programas encontrados serem eficientes, não há consenso sobre técnicas de monitorização das dimensões dos EVS, nem intervenções holísticas de promoção de EVS. CONCLUSÃO: Programas que envolvem pais tornam-se mais eficientes. As evidências científicas encontradas podem aprimorar intervenções em saúde.

INTODUCCIÓN: En la escuela se fomenta la adopción de estilos de vida saludables (EVS) en los niños, pero la educación para la salud se orienta principalmente a los niños, descuidando a la familia. OBJETIVO: Mapear y examinar programas escolares para promover el EVS en niños (de 3 a 10 años) que aborden 3 o más temas. MÉTODO: Scoping Review de 1992-2020 siguiendo la metodología del Joanna Briggs Institute y utilizando la plataforma Rayyan QCRI. RESULTADOS: De 4952 artículos, se seleccionaron 19 programas de promoción del EVS de 13 países, con temas: alimentación saludable, actividad física y educación de los padres, pero también intervenciones sobre dependencia de la pantalla, sueño e higiene. DISCUSIÓN: Aunque la mayoría de los programas encontrados son eficientes, no hay consenso sobre técnicas para monitorear las dimensiones del EVS y sobre intervenciones holísticas para promover el EVS. CONCLUSIÓN: Los programas que involucran a los padres se vuelven más eficientes. La evidencia científica encontrada puede mejorar las intervenciones en salud.

INTRODUCTION: The adoption of healthy lifestyles (HLs) in children is encouraged at school, but health education is mainly oriented towards children, neglecting the family. OBJECTIVE: To map and examine school programs to promote HLs in children (3-10 years old) that address 3 or more topics. METHOD: A Scoping Review from 1992-2020 with the Joanna Briggs Institute methodology and using the Rayyan QCRI platform. RESULTS: Out of 4,952 articles, 19 HL promotion programs from 13 countries were selected, with the following themes: healthy eating, physical activity and parental education, but also interventions on screen dependence, sleep and hygiene.DISCUSSION: Although most of the programs found are efficient, there is no consensus on techniques for monitoring the dimensions of HLs, nor holistic interventions to promote Hls. CONCLUSION: Programs that involve parents become more efficient. The scientific evidence found can improve health interventions.

Instruments for assessing professional nursing practice environments: An integrative review.

OBJECTIVE: To identify the instruments used to evaluate the professional nursing practice environments in the hospital context. METHOD: An integrative review, whose research process was conducted independently by two researchers in the period from July to August 2019 in the CINHAL, PubMed and SciELO databases. RESULTS: Based on the inclusion and exclusion criteria, 53 studies published between 2009 and 2019 were considered for analysis. Ten instruments and three thematic areas were identified: instruments for the assessment of the nursing professional practice environments; implications of the use of instruments for the assessment of nursing professional practice environments; limitations of the instruments for the assessment of nursing professional practice environments. CONCLUSION: Despite the relevance of the instruments identified, this integrative review provides contributions that support the need to use specific tools to assess the nursing practice environments that include the structure, process and outcome components.

Instruments for assessing professional nursing practice environments: An integrative review / Instrumentos para la evaluación de los entornos de la práctica profesional de enfermería: revisión integradora / Instrumentos para avaliação dos ambientes da prática profissional de enfermagem: revisão integrativa

ABSTRACT Objective: To identify the instruments used to evaluate the professional nursing practice environments in the hospital context. Method: An integrative review, whose research process was conducted independently by two researchers in the period from July to August 2019 in the CINHAL, PubMed and SciELO databases. Results: Based on the inclusion and exclusion criteria, 53 studies published between 2009 and 2019 were considered for analysis. Ten instruments and three thematic areas were identified: instruments for the assessment of the nursing professional practice environments; implications of the use of instruments for the assessment of nursing professional practice environments; limitations of the instruments for the assessment of nursing professional practice environments. Conclusion: Despite the relevance of the instruments identified, this integrative review provides contributions that support the need to use specific tools to assess the nursing practice environments that include the structure, process and outcome components.

RESUMEN Objetivo: Identificar los instrumentos utilizados para evaluar los entornos de la práctica profesional de enfermería en el contexto hospitalario. Método: Revisión integradora, cuyo proceso de investigación se realizó de manera independiente por dos investigadores en el período de julio a agosto de 2019 en las bases de datos CINHAL, PubMed y SciELO. Resultados: En función de los criterios de inclusión y exclusión, se consideraron para el análisis 53 estudios publicados entre 2009 y 2019. Se identificaron diez instrumentos y tres áreas temáticas: instrumentos para la evaluación de los entornos de la práctica profesional de enfermería; implicaciones del uso de instrumentos para la evaluación de los entornos de la práctica profesional de enfermería; limitaciones de los instrumentos para la evaluación de los entornos de la práctica profesional de enfermería. Conclusión: A pesar de la relevancia de los instrumentos identificados, esta revisión integradora ayuda a respaldar la necesidad de utilizar herramientas específicas para evaluar los entornos de la práctica de enfermería que incluyen componentes de estructura, proceso y resultados.

RESUMO Objetivo: Identificar os instrumentos utilizados para avaliar os ambientes da prática profissional de enfermagem no contexto hospitalar. Método: Revisão integrativa, cujo processo de pesquisa, foi conduzido de forma independente por dois investigadores, no período de julho e agosto de 2019 nas bases de dados CINHAL, PubMed e SciELO. Resultados: Com base nos critérios de inclusão e exclusão, consideraram-se para análise 53 estudos, publicados entre 2009 e 2019. Foram identificados dez instrumentos e três áreas temáticas: instrumentos de avaliação dos ambientes da prática profissional de enfermagem; implicações do uso dos instrumentos de avaliação dos ambientes da prática profissional de enfermagem; limitações dos instrumentos de avaliação dos ambientes da prática profissional de enfermagem. Conclusão: Apesar da relevância dos instrumentos identificados, essa revisão integrativa fornece contribuições que sustentam a necessidade de utilização de ferramentas específicas para avaliação dos ambientes da prática profissional de enfermagem que incluam os componentes estrutura, processo e resultado.

Escala de avaliação dos ambientes da prática profissional de enfermagem: Construção e validação de conteúdo / Escala de evaluación de los ambientes de la práctica profesional de enfermería: construcción y validación de contenido / Scale of evaluation of the environments of professional nursing practice: construction and content validation

Objetivo construir e validar o conteúdo da Escala de Avaliação dos Ambientes da Prática Profissional de Enfermagem. Método estudo metodológico realizado de janeiro a maio de 2020. A construção da Escala foi antecedida de pesquisa qualitativa prévia e de revisão de literatura. A validação de conteúdo foi efetuada por 22 peritos. Resultados inicialmente a Escala tinha 128 itens agrupados nas dimensões estrutura, processo e resultado. Decorrente da avaliação dos peritos, na estrutura dos 65 itens iniciais, foram excluídos 20, reformulados 10 e adicionado um. No processo, dos 49 itens iniciais, excluíram-se 8 e reformularam-se 2. No resultado, dos 14 itens iniciais, foram excluídos 2, reformulados 2 e adicionado 1. A versão final ficou com 100 itens, cujo Índice de Validade de Conteúdo de cada item oscilou entre 0,86 e 1. Conclusão a construção e posterior validação dos itens pelos peritos foi uma etapa fundamental, dando segurança à continuidade dos procedimentos psicométricos.

Objetivo construir y validar el contenido de la Escala de Evaluación de Ambientes de Práctica Profesional de Enfermería. Método estudio metodológico realizado de enero a mayo de 2020. La construcción de la Escala ocurrió después de investigaciones cualitativas previas y revisión de la literatura. La validación del contenido fue realizada por 22 expertos. Resultados inicialmente, la Escala tenía 128 elementos agrupados en las dimensiones estructura, proceso y resultado. Debido a la evaluación de los expertos, en la dimensión estructura, de los 65 puntos iniciales, se excluyeron 20, 10 fueron reformulados y uno añadido. En la dimensión proceso, de los 49 puntos iniciales, se excluyeron 8 y se reformularon 2. En la dimensión resultado, de los 14 elementos iniciales, 2 fueron excluidos, 2 reformulados y añadidos 1. La versión final fue de 100 elementos, cuyo Índice de Validez de Contenido de cada elemento fluctuó entre 0,86 y 1. Conclusión la construcción y posterior validación de los elementos por parte de los expertos fue un paso fundamental, dando seguridad a la continuidad de los procedimientos psicométricos.

Objective to construct and validate the content of the Assessment Scale of Nursing Professional Practice Environments. Method methodological study conducted from January to May 2020. The construction of the Scale after a previous qualitative research and literature review. Content validation was performed by 22 experts. Results initially, the Scale had 128 items grouped in the dimensions structure, process and outcome. Due to the experts' evaluation, in the structure dimension, the 65 initial items, 20 were excluded, 10 were reformulated and one, added. In the process dimension, of the 49 initial items, 8 were excluded and 2 were reformulated. In the outcome dimension, of the 14 initial items, 2 were excluded, 2 reformulated and added 1. The final version contained 100 items, in which the Content Validity Index of each item fluctuated between 0.86 and 1. Conclusion the construction and subsequent validation of the items by the experts was a fundamental step, giving security to the continuity of psychometric procedures.

On ciprofloxacin concentration in chronic rhinosinusitis / Acerca de la concentración de ciprofloxacino en la rinosinusitis crónica

Objective: Considering that all the evidence indicates that chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are distinct entities, the aim of this study was to compare the concentrations obtained in plasma and in sinonasal mucosa with oral and nasal topical ciprofloxacin, in patients with and without nasal polyps, without evaluating the effectiveness of the use of an antibiotic. Methods: Prospective clinical study with single-blind randomization. The population consisted of patients with chronic rhinosinusitis with eligible for endonasal surgery, over 18 years old. It took place between January 2010 and December 2014. A single preoperative dose of ciprofloxacin (oral or nasal topic- spray, gel or drops) was given and samples of plasma and nasal mucosa (inferior turbinate, middle turbinate, ethmoid and maxillary sinus) were collected prior to surgery. The plasma and mucosal ciprofloxacin concentrations were assayed with high performance liquid chromatography (HPLC) with fluorescence detection (FD). Results: The oral ciprofloxacin achieved better mucosal concentrations but had a significant plasmatic expression in all patients. None of the topical formulations achieved measurable ciprofloxacin plasmatic levels. Among the topical formulations, the gel had the best mucosal results, despite the existence of polyposis (AU)

Objetivo: Considerando todas las evidencias de que la rinosinusitis crónica sin poliposis nasal (RSCsPN) y la rinosinusitis crónica con poliposis nasal (RSCcPN) son entidades distintas, el objetivo de este estudio fue comparar las concentraciones obtenidas en el plasma y en la mucosa nasal con ciprofloxacino oral y tópico nasal en pacientes con y sin pólipos nasales, sin evaluar la efectividad del uso del antibiótico. Métodos: Estudio clínico prospectivo con asignación aleatoria. La población se componía de pacientes con rinosinusitis crónica propuestos para cirugía endonasal, mayores de 18 años. Se desarrolló entre enero de 2010 y diciembre de 2014. Se administró una dosis única preoperatoria de ciprofloxacino (oral o tópico nasal, en aerosol, gel o gotas) y se recogieron muestras de plasma y mucosa nasal (cornetes, etmoides y seno maxilar) antes de la cirugía. La concentración de ciprofloxacino en el plasma y en la mucosa se ensayó mediante cromatografía líquida de alto rendimiento con detección de fluorescencia. Resultados: El ciprofloxacino oral logró las concentraciones mucosas más altas pero tuvo una expresión plasmática significativa en todos los pacientes. Ninguna de las formulaciones tópicas ha generado niveles plasmáticos de ciprofloxacino medibles. Entre las formulaciones tópicas, el gel fue el que presentó mejores resultados mucosos, a pesar de la existencia de poliposis (AU)

On ciprofloxacin concentration in chronic rhinosinusitis.

OBJECTIVE: Considering that all the evidence indicates that chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are distinct entities, the aim of this study was to compare the concentrations obtained in plasma and in sinonasal mucosa with oral and nasal topical ciprofloxacin, in patients with and without nasal polyps, without evaluating the effectiveness of the use of an antibiotic. METHODS: Prospective clinical study with single-blind randomization. The population consisted of patients with chronic rhinosinusitis with eligible for endonasal surgery, over 18 years old. It took place between January 2010 and December 2014. A single preoperative dose of ciprofloxacin (oral or nasal topic- spray, gel or drops) was given and samples of plasma and nasal mucosa (inferior turbinate, middle turbinate, ethmoid and maxillary sinus) were collected prior to surgery. The plasma and mucosal ciprofloxacin concentrations were assayed with high performance liquid chromatography (HPLC) with fluorescence detection (FD). RESULTS: The oral ciprofloxacin achieved better mucosal concentrations but had a significant plasmatic expression in all patients. None of the topical formulations achieved measurable ciprofloxacin plasmatic levels. Among the topical formulations, the gel had the best mucosal results, despite the existence of polyposis.

Cardiac venous arterialization in acute myocardial infarction: how great is the benefit?

OBJECTIVES: Cardiac venous arterialization has been proposed as an alternative approach for myocardial revascularization in ischaemic heart disease. It is based on using the cardiac venous system to transport arterial blood from a systemic artery to infarcted myocardial areas. Our goal was to evaluate its benefit in reducing acute myocardial infarct size and its effects on cardiac performance. METHODS: In a group of pigs, the left internal mammary artery was anastomosed to the left anterior descending vein; this vein was ligated proximally. The left anterior descending coronary artery was also occluded. Over 5 days, several diagnostic procedures were used to characterize and measure the extent of myocardial infarct, namely ECG, echocardiography, cardiac biomarkers and histopathology. Data were compared with those from a control group of pigs, which were submitted to ligation of only the left anterior descending coronary artery. RESULTS: In the experimental group, echocardiography revealed that the ejection fraction and thickness of the ventricular walls remained unchanged 4 days after surgery, in contrast to the major alterations in the control group. In fact, the ejection fraction in the control group decreased by 21% (P < 0.001), with a reduction of 31% (P < 0.004) in the thickness of the interventricular septum at end systole and enlargement of the left ventricular lumen by 28% (P < 0.001). In the experimental group, the sum for ST segment shift was 50% lower (P = 0.038) and the total ventricular histological lesion size was 50% smaller (P < 0.001). Within this lesion, the area of necrotic tissue was 70% smaller (P < 0.001). Cardiac biomarkers were not different between the two groups (P > 0.2). CONCLUSIONS: This study reveals that selective cardiac venous arterialization can nourish the myocardium and is able to reduce infarct size by more than 50%, while protecting cardiac performance. We believe, therefore, that further investigation should be carried out into this technique in order for it to be considered as an option in coronary surgery.

Immunohistochemical evaluation of MMP-2 and TIMP-2 in canine mammary tumours: a survival study.

Canine mammary tumours (CMTs) are a very heterogeneous group of neoplasms with variable prognosis. Their aggressiveness is mainly due to their ability to invade locally and to metastasize. The degradation of extracellular matrix components is an important determinant of the invasive phenotype. The aims of this study were to analyse by immunohistochemistry and double immunofluorescence the expression of metalloproteinase 2 (MMP-2) and tissue inhibitor of metalloproteinase 2 (TIMP-2) in eight normal canine mammary glands and 118 CMTs (24 benign, 94 malignant) and to investigate relationships with metastatic disease and survival. MMP-2 and TIMP-2 expression was higher in malignant tumours than in normal canine mammary tissue and benign tumours. The main difference between benign and malignant CMTs was the pattern of expression of both molecules: benign tumours presented TIMP-2 and MMP-2 immunoreactivity in the myoepithelial cells lining the basement membrane of tubuloalveolar structures, while malignant tumours showed mainly diffuse expression in neoplastic cells. In malignant tumours, increased TIMP-2 expression was significantly associated with the development of distant metastases, lower overall survival and lower disease-free survival. MMP-2 expression was not significantly associated to any of these parameters. These results suggest that the immunohistochemical expression of TIMP-2 is a useful prognostic factor in CMTs.

Immunohistochemical analysis of urokinase plasminogen activator and its prognostic value in canine mammary tumours.

Urokinase plasminogen activator (uPA) has been associated with aggressive behaviour and poor prognosis in human breast cancer, but there is no information on its expression in canine mammary tumours (CMT). uPA immunohistochemical expression was studied in 119 CMT (24 benign, 95 malignant) to investigate its relationship with clinical and histopathological parameters. Dogs with malignant mammary tumours (MMT) underwent a 2-year follow-up evaluation. MMT expressed significantly more uPA than benign tumours. In MMT, high uPA stromal expression was significantly associated with larger tumour size, high Ki-67 expression, invasive growth, high histological grade, regional lymph node metastases, development of distant metastases, and lower overall survival (OS) and disease-free survival (DFS). On the basis of these results, uPA could be considered a useful prognostic factor in dogs with MMT.

Awareness of chronic diseases in the rapidly developing community of Chon Buri, Thailand.

This study investigated the contributing behaviors to chronic diseases in rapidly developing communities. An exploratory cross-sectional design and focus group discussions were employed for data collection from March, 2003 - April, 2005. Five representative communities located in the rapidly growing industrial region of Chon Buri, Thailand were included. Four hundred twenty-two respondents stratified into various community groups were interviewed. The interview data were analyzed and followed-up by focus group discussions in each community with representative community members. The findings indicate diabetes and hypertension were frequent complaints. Older age groups more often reported chronic disease. Most people, especially those who had no chronic diseases (66.2%), were unconcerned about eating healthy food. These people were little concerned about annual routine health checkups and self-care. Most people had hurried lifestyles with limited time, were stressed, were unconcerned about health or quality of life, and had little information regarding chronic diseases. Dietary habits, age groups, and annual routine health checkups were significantly related to self-reported chronic diseases (p=0.005, 0.002, and 0.002, respectively). Based on our findings, we recommend the government provide education regarding a healthy life style to prevent chronic diseases. Diet trends should be monitored and appropriate strategies should be developed at the community level.

Strengthening health development at the community level in Thailand: what events should be managed?

Community action for health development is important for sustaining community health. This study aimed to identify the components and processes for strengthening the community health development process. We used an exploratory, cross-sectional design and focus group discussions in Chonburi, Thailand, between March 2003 and April 2005. We interviewed 422 respondents selected by stratified sampling from various groups involved with community health activities. Interview data was analyzed and then clarified by focus group discussions with representatives of the communities and stakeholders. Results indicated that both study components, namely, community experience in health activities and appearance of health conditions in the community, as well as all of their subcomponents, influence community action for health development. The most influential subcomponent of the community experience in health activities was perception of health information and policy (p < .001; r = .546). The most influential subcomponent of the appearance of health conditions in the community was the impact of health information (p < .001; r = .439). Focus group discussions indicated the communities' potential, ideas and need to activate health development by community mobilization. We recommend that the government encourage and support community action for health development with the subcomponents identified by this study. The process of community empowerment and network of implementation should encourage successful and sustainable health development by the community.