NURS 4530 Chapter 1 Summary PDF

1: Health A Community View Melanie McEwen, and Mary A. Nies CHAPTER OUTLINE Definitions of Health and Community Health Community Determinants of Health and Disease Indicators of Health and Illness Definition and Focus of Public Health and Community Health Preventive Approach to Health Health Promotion and Levels of Prevention Thinking Upstream Prevention Versus Cure Healthy People 2030 Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing Public and Community Health Nursing Community-Based Nursing Community and Public Health Nursing Practice Population-Focused Practice and Community/Public Health Nursing Interventions Public Health Interventions The Public Health Intervention Wheel Public Health Nursing, Managed Care, and Health Reform Bibliography OBJECTIVES Upon completion of this chapter, the reader will be able to do the following: 1. Compare and contrast definitions of health from a public health nursing perspective. 2. Define and discuss the focus of public health. 3. Discuss determinates of health and indicators of health and illness from a population perspective. 4. List the three levels of prevention and give examples of each. 5. Explain the difference between public/community health nursing practice and community-based nursing practice. 6. Describe the purpose of Healthy People 2030 and give examples of the leading health indicators, social determinants of health and topic areas for the national health objectives. 7. Discuss public/community health nursing practice in terms of public health's core functions and essential services. 8. Discuss public/community health nursing interventions as explained by the Intervention Wheel. KEY TERMS aggregates community community health community health nursing disease prevention health health promotion health-related quality-of-life (HRQOL) Healthy People 2030 population population-focused nursing primary prevention public health public health nursing secondary prevention tertiary prevention As a result of recent and anticipated changes related to healthcare reform and the long-term consequences of the COVID-19 pandemic, community/public health nurses are in a position to assist the US healthcare system in the transition from a disease-oriented system to a health-oriented system. Costs of caring for the sick account for the majority of escalating healthcare dollars, which increased from 5.7% of the gross domestic product in 1965 to almost 18% in 2018 (National Center for Health Statistics [NCHS], 2019). Alarmingly, national annual healthcare expenditures reached nearly $3 trillion in 2017, or an astonishing $10,700 per person. Healthy People 2030 Major Topic Areas and Selected Subtopics Health Conditions Arthritis Cancer Dementias Diabetes Heart Disease Sexually Transmitted Infections Health Behaviors Child and Adolescent Development Drug and Alcohol Use Emergency Preparedness Family Planning Nutrition and Healthy Eating Tobacco Use Vaccination Populations Adolescents Children LGBT Older Adults People with Disabilities Settings and Systems Environmental Health Healthcare Health Insurance Health Policy Hospital and Emergency Services Schools From US Department of Health and Human Services: Healthy People 2030: browse objectives. Available from: https://health.gov/healthypeople/objectives-and-data/browse-objectives. Health expenditures in the United States reflect a focus on the care of the sick. In 2017, $0.39 of each healthcare dollar supported hospital care, $0.23 supported physician/professional services, and $0.11 was spent on prescription drugs (more than double the proportion since 1980). The vast majority of these funds were spent providing care for the sick, and less than $0.03 of every healthcare dollar was directed toward preventive public health activities (NCHS, 2018). Despite high hospital and physician expenditures, US health indicators such as life expectancy and infant mortality rate remain considerably below the health indicators of many other countries. This situation reflects a relatively severe disproportion of funding for preventive services and social and economic opportunities. Furthermore, the health status of the population within the United States varies markedly across areas of the country and among different cohorts. For example, it is widely recognized that the economically disadvantaged and many cultural and ethnic groups have poorer overall health status compared with middle-class Caucasians. Nurses constitute the largest segment of healthcare workers; therefore, they are instrumental in creating a healthcare delivery system that will meet the health-oriented needs of the people. According to a survey of registered nurses (RNs) conducted by the National Council of State Boards of Nursing (NCSBN, 2018), about 55.7% of approximately 2.8 million RNs employed full-time in the United States worked in hospitals during 2017 (down from about 66.5% in 1992). This survey also found that about 11%, of all RNs worked in home, hospice, school, public/community health, or correctional facilities; 9.4% worked in ambulatory care settings; and 5.3% worked in nursing homes or other extended care or assisted living facilities (NCSBN, 2018). Between 1980 and 2018, the number of nurses employed in community, health, and ambulatory care settings more than doubled (NCSBN, 2018; US Department of Health and Human Services [USDHHS], Health Resources and Services Administration [HRSA], 2010). The decline in the percentage of nurses employed in hospitals and the subsequent increase in nurses employed in community settings suggests a shift in focus from illness and institution-based care to health promotion and preventive care. This shift will likely continue into the future as alternative delivery systems, such as ambulatory, home care, and hospice employ more nurses (American Nurses Association (ANA), 2016; Institute of Medicine (IOM), 2011; Rosenfeld & Russell, 2012). Community/public health nursing is the synthesis of nursing practice and public health practice. The major goal of community/public health nursing is to preserve the health of the community and surrounding populations by focusing on health promotion and health maintenance of individuals, families, and groups within the community. Thus, community/public health nursing is associated with health and the identification of populations at risk rather than with an episodic response to patient demand. Public health is often described as the art and science of preventing disease, prolonging life and promoting health through organized community efforts to benefit each citizen (Winslow, 1920). The mission of public health is social justice, which entitles all people to basic necessities such as adequate income and health protection and accepts collective burdens to make it possible. Public health, with its egalitarian tradition and vision, often conflicts with the predominant US model of market justice that largely entitles people to what they have gained through individual efforts. Although market justice respects individual rights, collective action and obligations are minimal. An emphasis on technology and curative medical services within the market justice system has limited the evolution of a health system designed to protect and preserve the health of the population. Public health assumes that it is society's responsibility to meet the basic needs of the people. Thus, there is a greater need for public funding of prevention efforts to enhance the health of our population. Current US health policies advocate changes in personal behaviors that might predispose individuals to chronic disease or accidents. These policies promote exercise, healthy eating, tobacco use cessation, and moderate consumption of alcohol. However, simply encouraging the individual to overcome the effects of unhealthy activities lessens focus on collective behaviors necessary to change the determinants of health stemming from such factors as poor air and water quality, workplace hazards, unsafe neighborhoods, and unequal access to healthcare. Because living arrangements, work/school environment, and other sociocultural constraints affect health and well-being, public policy must address societal and environmental changes, in addition to lifestyle changes, which will positively influence the health of the entire population. With ongoing and very significant changes in the healthcare system and increased employment in community settings, there will be greater demands on community and public health nurses to broaden their population health perspective. The Code of Ethics of the ANA (2015) promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of healthcare. Community and public health nurses therefore must align themselves with public health programs that promote and preserve the health of populations by influencing sociocultural issues such as human rights, homelessness, violence, disability, and stigma of illness. This principle allows nurses to be positioned to promote the health, welfare, and safety of all individuals. This chapter examines health from a population-focused, community-based perspective. Therefore, it requires understanding of how people identify, define, and describe related concepts. The following section explores six major ideas: 1. Definitions of “health” and “community” 2. Determinants of health and disease 3. Indicators of health and disease 4. Definition and focus of public and community health 5. Description of a preventive approach to health 6. Definition and focus of “public health nursing,” “community health nursing,” and “community- based nursing” Definitions of Health and Community Health The definition of health is evolving. The early, classic definition of health by the World Health Organization (WHO) set a trend toward describing health in social terms rather than in medical terms. Indeed, the WHO (1958, p. 1) defined health as “a state of complete physical, mental, and social well- being and not merely the absence of disease or infirmity.” Social means “of or relating to living together in organized groups or similar close aggregates” (American Heritage College Dictionary, 1997, p. 1291) and refers to units of people in communities who interact with one another. “Social health” connotes community vitality and is a result of positive interaction among groups within the community, with an emphasis on health promotion and illness prevention. For example, community groups may sponsor food banks in churches and civic organizations to help alleviate problems of hunger and nutrition. Other community groups may form to address problems of violence and lack of opportunity, which can negatively affect social health. In the mid-1980s, the WHO expanded the definition of health to emphasize recognition of the social implications of health. Thus, health is the extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living; it is a positive concept emphasizing social and personal resources, and physical capacities. WHO (1986, p. 73) The WHO definition considers several dimensions of health. These include physical (structure/function), social, role, mental (emotional and intellectual), and general perceptions of health status. It also conceptualizes health from a macroperspective, as a resource to be used rather than a goal in and of itself (Saylor, 2004). The nursing literature contains many varied definitions of health. For example, health has been defined as “a state of well-being in which the person is able to use purposeful, adaptive responses and processes physically, mentally, emotionally, spiritually, and socially” (Murray et al., 2009, p. 53); “the individual's total well-being, the regular patterns of people and their environments that result in maintaining wholeness and human integrity” (Roy, 2009, p. 3); “realization of human potential through goal-directed behavior, competent self-care, and satisfying relationships with others, while adapting to meet the demands of everyday life within one's social and physical environment” (Murdaugh et al., 2019, p. 14); and a “state of physical, mental, spiritual and social functioning that realizes a person's potential and is experienced within a developmental context” (Ross & Kleman, 2018, p. 5). The variety of characterizations of the word illustrates the difficulty in standardizing the conceptualization of health. Commonalities involve description of “goal-directed” or “purposeful” actions, processes, responses, functioning, or behaviors and the possession of “integrity,” “wholeness,” and/or “well-being.” Problems can arise when the definition involves a unit of analysis. For example, some writers use the individual or “person” as the unit of analysis and exclude the community. Others may include additional concepts, such as adaptation and environment, in health definitions, and then present the environment as static and requiring human adaptation rather than as changing and enabling human modification. For many years, community and public health nurses have favored Dunn's (1961) classic concept of wellness, in which family, community, society, and environment are interrelated and have an impact on health. From his viewpoint, illness, health, and peak wellness are on a continuum; health is fluid and changing. Consequently, within a social context or environment, the state of health depends on the goals, potentials, and performance of individuals, families, communities, and societies. Active Learning Exercise Interview several community/public health nurses and several clients regarding their definitions of health. Share the results with your classmates. Do you agree with their definitions? Why or why not? Community The definitions of community are also numerous and variable. Baldwin and colleagues (1998) outlined the evolution of the definition of community by examining community health nursing textbooks. They determined that, before 1996, definitions of community focused on geographic boundaries combined with social attributes of people. Citing several sources from the later part of the decade, the authors observed that geographic location became a secondary characteristic in the discussion of what defines a community. In recent nursing literature, community has been defined as “a collection of people who interact with one another and whose common interests or characteristics form the basis for a sense of unity or belonging” (Rector, 2018, p. 6); “a group of people who share something in common and interact with one another, who may exhibit a commitment with one another and may share a geographic boundary” (Lundy & Janes, 2016, p. 13); and “a locality-based entity, composed of systems of formal organizations reflecting society's institutions, informal groups and aggregates” (Shuster, 2012, p. 398). Maurer and Smith (2013) further addressed the concept of community and identified three defining attributes: people; place; and social interaction or common characteristics, interests, or goals. Combining ideas and concepts, in this text, community is seen as a group or collection of individuals interacting in social units and sharing common interests, characteristics, values, and goals. Maurer and Smith (2013) noted that there are two main types of communities: geopolitical communities and phenomenological communities. Geopolitical communities are those most traditionally recognized or imagined when the term community is considered. Geopolitical communities are defined or formed by natural and/or human-made boundaries and include cities, counties, states, and nations. Other commonly recognized geopolitical communities are school districts, census tracts, zip codes, and neighborhoods. Phenomenological communities, on the other hand, refer to relational, interactive groups. In phenomenological communities, the place or setting is more abstract, and people share a group perspective or identity based on culture, values, history, interests, and goals. Examples of phenomenological communities are schools, colleges, and universities; churches, synagogues, and mosques; and various groups and organizations, such as social networks. A community of solution is a type of phenomenological community. A community of solution is a collection of people who form a group specifically to address a common need or concern. The Sierra Club, whose members lobby for the preservation of natural resource lands, and a group of disabled people who challenge the owners of an office building to obtain equal access to public buildings, education, jobs, and transportation are examples. These groups or social units work together to promote optimal “health” and to address identified actual and potential health threats and health needs. Population and aggregate are related terms that are often used in public health and community health nursing. Population is typically used to denote a group of people with common personal or environmental characteristics. It can also refer to all of the people in a defined community (Williams, 2020). Aggregates are subgroups or subpopulations that have some common characteristics or concerns (Gibson & Thatcher, 2020). Depending on the situation, needs, and practice parameters, community health nursing interventions may be directed toward a community (e.g., residents of a small town), a population (e.g., all elders in a rural region), or an aggregate (e.g., pregnant teens within a school district). Determinants of Health and Disease The health status of a community is associated with a number of factors, such as healthcare access, economic conditions, social and environmental issues, and cultural practices, and it is essential for the community health nurse to understand the determinants of health and recognize the interaction of the factors that lead to disease, death, and disability. It has been estimated that individual behaviors are responsible for about 50% of all premature deaths in the United States (Elbel et al., 2019). Indeed, individual biology and behaviors influence health through their interaction with each other and with the individual's social and physical environments. Thus, policies and interventions can improve health by targeting detrimental or harmful factors related to individuals and their environment. Fig. 1.1 shows the model developed for Healthy People 2020. This model depicts the interaction of these determinants and shows how they influence health. In a seminal work, McGinnis and Foege (1993) described what they termed “actual causes of death” in the United States, explaining how lifestyle choices contribute markedly to early deaths. Their work was updated a decade later (Mokdad et al., 2004). Leading the list of “actual causes of death” was tobacco, which was implicated in almost 20% of the annual deaths in the United States—approximately 435,000 individuals. Poor diet and physical inactivity were deemed to account for about 16.6% of deaths (about 400,000 per year), and alcohol consumption was implicated in about 85,000 deaths because of its association with accidents, suicides, homicides, and cirrhosis and chronic liver disease. Other leading causes of death were microbial agents (75,000), toxic agents (55,000), motor vehicle crashes (43,000), firearms (29,000), sexual behaviors (20,000), and illicit use of drugs (17,000). FIG. 1.1 Model: Healthy People 2020. From US Department of Health and Human Services: Healthy People 2030: browse objectives. Available from: https://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf. A chart for model of healthy people 2020: A society in which all people live long, healthy lives. Determinants for health outcomes are as follows: Physical environment, social environment, individual behavior, biology and genetics, and health services. Overarching goals: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development and healthy behaviors across all life stages. Although all of these causes of mortality are related to individual lifestyle choices, they can also be strongly influenced by population-focused policy efforts and education. For example, the prevalence of smoking has fallen dramatically during the past two decades, largely because of legal efforts (e.g., laws prohibiting sale of tobacco to minors and much higher taxes), organizational policy (e.g., smoke-free workplaces), and education. Likewise, concerns about the widespread increase in incidence of overweight and obesity have led to population-based measures to address the issue (e.g., removal of soft drink and candy machines from schools, regulations prohibiting the use of certain types of fats in processed foods). Public health experts have observed that health has improved over the past 100 years largely because people become ill less often (McKeown, 2003; Russo & Gourevitch, 2019). Indeed, at the population level, better health can be attributed to higher standards of living, good nutrition, a healthier environment, and having fewer children. Furthermore, public health efforts, such as immunization and clean air and water, and medical care, including management of acute episodic illnesses (e.g., pneumonia, tuberculosis) and chronic disease (e.g., cancer, heart disease), have also contributed significantly to the increase in life expectancy. Community and public health nurses should understand these concepts and appreciate that health and illness are influenced by a web of factors, some that can be changed (e.g., individual behaviors such as tobacco use, diet, physical activity) and some that cannot (e.g., genetics, age, gender). Other factors (e.g., physical and social environment) may require changes that will need to be accomplished from a policy perspective. Public health nurses must work with policy-makers and community leaders to identify patterns of disease and death and to advocate for activities and policies that promote health at the individual, family, aggregate, and population levels. Indicators of Health and Illness A variety of health indicators are used by health providers, policy-makers, and community health nurses to measure the health of the community. Local or state health departments, the Centers for Disease Control and Prevention (CDC), and the National Center for Health Statistics (NCHS) provide morbidity, mortality, and other health status–related data. State and local health departments are responsible for collecting morbidity and mortality data and forwarding the information to the appropriate federal-level agency, which is often the CDC. Some of the more commonly reported indicators are life expectancy, infant mortality, age-adjusted death rates, and cancer incidence rates. Indicators of mortality in particular illustrate the health status of a community and/or population because changes in mortality reflect a number of social, economic, health service, and related trends (Shi & Singh, 2019). These data may be useful in analyzing health patterns over time, comparing communities from different geographic regions, or comparing different aggregates within a community. When the national health objectives for Healthy People 2030 were being revised, a total of 23 “leading health indicators” (LHIs) were identified that reflected the major public health concerns in the United States (see Healthy People 2030 box). The LHIs are noted to be a subset of “high-priority” HP 2030 objectives that were selected to direct provider and population responses to improve health and well- being. Among the LHIs are individual behaviors (e.g., cigarette smoking, consumption of calories from added sugars, annual vaccination against influenza), physical and social environmental factors (e.g., household food insecurity and hunger, exposure to unhealthy air, homicides), and health systems issues (e.g., persons with medical insurance). In addition, there are population or group specific indicators (e.g., infant mortality, children and adolescents with obesity, maternal mortality, new cases of diagnosed diabetes). Each of these indicators can affect the health of individuals and communities and can be correlated with leading causes of morbidity and mortality. For example, tobacco use is linked to heart disease, stroke, and cancer; substance abuse is linked to accidents, injuries, and violence; irresponsible sexual behaviors can lead to unwanted pregnancy as well as sexually transmitted diseases, including human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS); and lack of health insurance can contribute to poor pregnancy outcomes, untreated illness, and disability. Healthy People 2030 Selected Leading Health Indicator Topics All Ages Children, adolescents, and adults who use the oral healthcare system Drug overdose deaths Exposure to unhealthy air Homicides Household food insecurity and hunger Infants Infant deaths Children and adolescents Adolescents with major depressive episodes who receive treatment Children and adolescent with obesity Adults and older adults Adults engaging in binge drinking of alcoholic beverages during the past 30 days Adults who receive a colorectal cancer screening based on the most recent guidelines Adults with hypertension whose blood pressure is under control Cigarette smoking in adults Maternal deaths From US Department of Health and Human Services: Healthy People 2030 leading health indicators. Available from: https://health.gov/healthypeople/objectives-and-data/leading-health-indicators. Public health nurses should be aware of health patterns and health indicators within their practice. Each nurse should ask relevant questions, including the following: What are the leading causes of death and disease among various groups served? Which groups have been most affected by COVID-19? How do infant mortality rates and teenage pregnancy rates in my community compare with regional, state, and national rates? What are the most serious health threats in my neighborhood? What are the most serious environmental risks in my city? The public health nurse may identify areas for further investigation and intervention through an understanding of health, disease, and mortality patterns. For example, if a school nurse learns that the teenage pregnancy rate in their community is higher than regional and state averages, the nurse should address the problem with school officials, parents, and students. Likewise, if an occupational health nurse discovers an apparent high rate of chronic lung disease in an industrial facility, the nurse should work with company management, employees, and state and federal officials to identify potential harmful sources. Finally, if a public health nurse works in a state-sponsored AIDS clinic and recognizes an increase in the number of women testing positive for HIV, the nurse should report all findings to the designated agencies. The nurse should then participate in investigative efforts to determine what is precipitating the increase and work to remedy the identified threats or risks. Definition and Focus of Public Health and Community Health C. E. A. Winslow is known for the following classic definition of public health: Public health is the Science and Art of (1) preventing disease, (2) prolonging life, and (3) promoting health and efficiency through organized community effort for: (a) sanitation of the environment, (b) control of communicable infections, (c) education of the individual in personal hygiene, (d) organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and (e) development of the social machinery to ensure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity. Hanlon (1960, p. 23) A key phrase in this definition of public health is “through organized community effort.” The term public health connotes organized, legislated, and tax-supported efforts that serve all people through health departments or related governmental agencies. The public health nursing tradition, begun in the late 1800s by Lillian Wald and her associates, clearly illustrates this phenomenon (Wald, 1971; see Chapter 2). After moving into the immigrant community in New York City to provide care for individuals and families, these early public health nurses saw that neither administering bedside clinical nursing nor teaching family members to deliver care in the home adequately addressed the true determinants of health and disease. They resolved that collective political activity should focus on advancing the health of aggregates and improving social and environmental conditions by addressing the social and environmental determinants of health, such as child labor, pollution, and poverty. Wald and her colleagues affected the health of the community by organizing the community, establishing school nursing, and taking impoverished mothers to testify in Washington, DC (Wald, 1971). Box 1.1 Core Public Health Functions Assessment: Regular collection, analysis, and information sharing about health conditions, risks, and resources in a community. Policy development: Use of information gathered during assessment to develop local and state health policies and to direct resources toward those policies. Assurance: Focuses on the availability of necessary health services throughout the community. It includes maintaining the ability of both public health agencies and private providers to manage day-to- day operations and the capacity to respond to critical situations and emergencies. From Institute of Medicine: The future of public health, Washington, DC, 1988, National Academy Press. In a key action, the National Academy of Medicine (NAM), formerly called the IOM (1988), identified the following three primary functions of public health: assessment, assurance, and policy development. Box 1.1 lists each of the three primary functions and describes them briefly. All nurses working in community settings should develop knowledge and skills related to each of these primary functions. The term community health extends the realm of public health to include organized health efforts at the community level through both government and private efforts. Participants include privately funded agencies such as the American Heart Association and the American Red Cross. A variety of private and public structures serves community health efforts. Public health efforts focus on prevention and promotion of population health at the federal, state, and local levels. These efforts at the federal and state levels concentrate on providing support and advisory services to public health structures at the local level. The local-level structures provide direct services to communities through two avenues: Community health services, which protect the public from hazards such as polluted water and air, tainted food, and unsafe housing Personal healthcare services, such as immunization and family planning services, well-infant care, and sexually transmitted disease (STD) treatment Personal health services may be part of the public health effort and often target the populations most at risk and in need of services. Public health efforts are multidisciplinary because they require people with many different skills. Community health nurses work with a diverse team of public health professionals, including epidemiologists, local health officers, and health educators. Public health science methods that assess biostatistics, epidemiology, and population needs provide a method of measuring characteristics and health indicators and disease patterns within a community. In 1994, the American Public Health Association drafted a list of 10 essential public health services, which the US Department of Health and Human Services later adopted. The updated list of essential services (CDC, 2020) appears in Box 1.2. Preventive Approach to Health Health Promotion and Levels of Prevention Contrasting with “medical care,” which focuses on disease management and “cure,” public health efforts focus on health promotion and disease prevention. Health promotion activities enhance resources directed at improving well-being, whereas disease prevention activities protect people from disease and the effects of disease. Leavell and Clark (1958) identified three levels of prevention commonly described in nursing practice: primary prevention, secondary prevention, and tertiary prevention (Fig. 1.2 and Table 1.1). Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Examples include promotion of good nutrition, provision of adequate shelter, and encouraging regular exercise. Specific protection efforts reduce or eliminate risk factors and include such measures as immunization, seat belt use, and water purification. Box 1.2 Essential Public Health Services Assessment Assess and monitor population health status, factors that influence health, and community needs and assets. Investigate, diagnose, and address health problems and hazards affecting the population. Policy Development Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it. Strengthen, support, and mobilize communities and partnerships to improve health. Create, champion, and implement policies, plans, and laws that impact health. Utilize legal and regulatory actions designed to improve and protect the public's health. Assurance Assure an effective system that enables equitable access to the individual services and care needed to be healthy. Build and support a diverse and skilled public health workforce. Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement. Build and maintain a strong organizational infrastructure for public health. From Centers for Disease Control and Prevention, Public Health Professionals Gateway: Available from: https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html. FIG. 1.2 The three levels of prevention. A pyramid for three levels of prevention shows level 1 through 3 from top to bottom as follows: Level 1: Primary prevention activities: Prevention of problems before they occur. Example: Immunization. Level 2: Secondary prevention activities: Early detection and intervention. Example: Screening for sexually transmitted disease. Level 3: Tertiary prevention activities: Correction and prevention of deterioration of a disease state. Example: Teaching insulin administration in the home. Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Secondary prevention is implemented after a problem has begun, but before signs and symptoms appear, and targets those populations that have risk factors. Mammography, blood pressure screening, COVID-19 testing, and prostate-specific antigen (PSA) tests are examples of secondary prevention. Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Aims of tertiary prevention are to keep health problems from getting worse, to reduce the effects of disease and injury, and to restore individuals to their optimal level of functioning. Examples include teaching how to perform insulin injections and disease management to a patient with diabetes, referral of a patient with spinal cord injury for occupational and physical therapy, and leading a support group for grieving parents. Much of public health nursing practice is directed toward preventing the progression of disease at the earliest period or phase feasible using the appropriate level(s) of prevention. For example, when applying “levels of prevention” to a client with HIV/AIDS, a nurse might perform the following interventions: Educate students on the practice of sexual abstinence or “safer sex” by using barrier methods (primary prevention). Encourage testing and counseling for clients with known exposure or who are in high-risk groups; provide referrals for follow-up for clients who test positive for HIV (secondary prevention). Table 1.1 Examples of Levels of Prevention and Clients Served in the Community Definition of Client Served a Level of Prevention Primary (Health Promotion and Specific Prevention) Secondary (Early Diagnosis and Treatment) Tertiary (Limitation of Disability and Rehabilitation) Individual Dietary teaching during pregnancy Immunizations HIV testing Screening for cervical cancer Teaching new clients with diabetes how to administer insulin Exercise therapy after stroke Skin care for incontinent patients Family (two or more individuals bound by kinship, law, or living arrangement and with common emotional ties and obligations [see Chapter 20]) Education or counseling regarding smoking, dental care, or nutrition Adequate housing Dental examinations COVID-19 testing for family potentially exposed Mental health counseling or referral for family in crisis (e.g., grieving or experiencing a divorce) Dietary instructions and monitoring for family with overweight members Group or aggregate (interacting people with a common purpose or purposes) Birthing classes for pregnant teenage mothers AIDS and other STI education for high school students Vision screening of a first-grade class Mammography van for screening of women in a low-income neighborhood Hearing tests at a senior center Group counseling for grade-school children with asthma Swim therapy for physically disabled elders at a senior center Alcoholics anonymous and other self-help groups Mental health services for military veterans Community and populations (aggregate of people sharing space over time within a social system [see Chapter 6]; population groups or aggregates with power relations and common needs or purposes) Fluoride water supplementation Environmental sanitation Removal of environmental hazards Organized screening programs for communities (e.g., health fairs) Lead screening for children by school district Shelter and relocation centers for fire or earthquake victims Emergency medical services Community mental health services for chronically mentally ill Home care services for chronically ill a Note that terms are used differently in literature of various disciplines. There are not any clear-cut definitions; for example, families may be referred to as an aggregate, and a population and subpopulations may exist within a community. AIDS, Acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; STI, sexually transmitted infection. Provide education on management of HIV infection, advocacy, case management, and other interventions for those who are HIV positive (tertiary prevention). Thinking Upstream The concepts of prevention and population-focused care figure prominently in a conceptual orientation to nursing practice referred to as thinking upstream. This orientation is derived from an analogy of patients falling into a river upstream and being rescued downstream by health providers overwhelmed with the struggle of responding to disease and illness. The river as an analogy for the natural history of illness was first coined by McKinlay (1979), with a charge to health providers to refocus their efforts toward preventive and “upstream” activities. In a description of the daily challenges of providers to address health from a preventive versus curative focus, McKinlay differentiates the consequences of illness (downstream endeavors) from its precursors (upstream endeavors). The author then charges health providers to critically examine the relative weights of their activities toward illness response versus the prevention of illness. A population-based perspective on health and health determinants is critical to understanding and formulating nursing actions to prevent disease. By examining the origins of disease, nurses identify social, political, environmental, and economic factors that often lead to poor health options for both individuals and populations. The call to refocus the efforts of nurses “upstream, where the real problems lie” (McKinlay, 1979) has been welcomed by community health nurses in a variety of practice settings. For these nurses, this theme provides affirmation of their daily efforts to prevent disease in populations at risk in schools, work sites, and clinics throughout their local communities and in the larger world. Ethical Insights Inequities: Distribution of Resources In the United States, it has been established that inequities in the distribution of resources pose a threat to the common good and a challenge for community and public health nurses. Factors that contribute to wide variations in health disparities include education, income, and occupation. Lack of health insurance is a key factor in this issue and a major rationale for healthcare reform efforts. Lack of health insurance is damaging to population health, as low-income, uninsured individuals are much less likely than insured individuals to receive timely primary healthcare and preventive dental care. Public health nurses are regularly confronted with the consequences of the fragmented healthcare delivery system. They diligently work to improve the circumstances for populations who have not had adequate access to resources largely because of who they are and where they live. Ethical questions commonly encountered in community and public health nursing practice include the following: Should resources (e.g., free or low-cost immunizations) be offered to all, even those who have insurance that will pay for the care? Should public health nurses serve anyone who meets financial need guidelines, regardless of medical need? Should the health department provide flu shots to persons of all ages or just those most likely to be affected by the disease? Should nonresidents in the United States illegally or persons working on “green cards” receive the same level of healthcare services that are available to citizens? Who should have free or reduced-cost access to extremely expensive drugs such as those that treat hepatitis C, multiple sclerosis, or many forms of cancer, and who should bear the financial burden? Access to healthcare is a goal for all. To this end, community and public health nurses must face the challenges and dilemmas related to these and other questions, as they assist individuals, families, and communities dealing with the uneven distribution of health resources and the associated costs of healthcare. Prevention Versus Cure Spending additional dollars for cure in the form of healthcare services does little to improve the health of a population, whereas spending money on prevention does a great deal to improve health. Getzen (2013) and others (Russo & Gourevitch, 2019; Shi & Singh, 2019) note that there is an absence of convincing evidence that the amount of money expended for healthcare improves the health of a population. The real determinants of health, as mentioned, are prevention efforts that provide education, housing, food, a decent minimal income, and safe social and physical environments, as well as encouraging positive lifestyle choices. The United States spends more than one-sixth of its wealth on healthcare or “cure” for individuals, likely diverting money away from the needed resources and services that would make a greater impact on health (NCHS, 2019; Shi & Singh, 2019). US policy-makers must become committed to achieving improved health outcomes for the poor and vulnerable populations. With a limited health workforce and monetary resources, the United States cannot continue to spend vast amounts on healthcare services when the investment fails to improve health outcomes. In industrialized countries, life expectancy at birth is not related to the level of healthcare expenditures; in developing countries, longevity is closely related to the level of economic development and the education of the population (Russo & Gourevitch, 2019; Shi & Singh, 2019). The current healthcare system is currently in a flux following implementation of the Affordable Care Act (ACA) and subsequent efforts to “repeal and replace” it. Some of these endeavors have actually been detrimental to the health of the population, as the focus on obtaining health insurance for more people has deferred a large investment of the country's wealth from education and other developmental efforts that would positively affect the health of the population as a whole. Managed care organizations (MCOs) focus on prevention and have determined that the rate of healthcare cost increases has slowed among employees of large firms (Kongstvedt, 2020). Prevention programs may help reduce costs for those enrolled in MCOs, but it remains unclear who will provide services for those who are required to purchase insurance, those who are currently uninsured and may remain so, the poor, and other vulnerable populations. In addition, still to be determined is who will provide adequate schooling, housing, meals, wages, and a safe environment for the disadvantaged. Increasing healthcare spending may negatively affect efforts to address economic disparities by reducing investments in sufficient housing, employment, education, nutrition, and safe environments. Healthy People 2030 In 1979, the US Department of Health and Human Services (USDHHS) published a national prevention initiative titled Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. The 1979 version established goals that would reduce mortality among infants, children, adolescents and young adults, and adults and increase independence among older adults. In 1990, the mortality of infants, children, and adults declined sufficiently to meet the goal. Adolescent mortality did not reach the 1990 target, and data systems were unable to adequately track the target for older adults (USDHHS, 2000). Published in 1989, Healthy People 2000 built on the first surgeon general's report. Healthy People 2000 contained the following broad goals (USDHHS, 1989): 1. Increase the span of healthy life for Americans. 2. Reduce health disparities among Americans. 3. Achieve access to preventive services for all Americans. The purpose of Healthy People 2000 was to provide direction for individuals wanting to change personal behaviors and to improve health in communities through health promotion policies. The report assimilated the broad approaches of health promotion, health protection, and preventive services and contained more than 300 objectives organized into 22 priority areas. Although many of the objectives fell short, the initiative was extremely successful in raising providers' awareness of health behaviors and health promotional activities. States, local health departments, and private sector health workers used the objectives to determine the relative health of their communities and to set goals for the future. Healthy People 2010 emerged in January 2000. It expanded on the objectives from Healthy People 2000 through a broadened prevention science base, an improved surveillance and data system, and a heightened awareness of and demand for preventive health services. This reflects changes in demographics, science, technology, and disease. Healthy People 2010 listed two broad goals: Goal 1: Increase quality and years of healthy life. Goal 2: Eliminate health disparities. The first goal moved beyond the idea of increasing life expectancy to incorporate the concept of health- related quality-of-life (HRQOL). This concept of health includes aspects of physical and mental health and their determinants and measures functional status, participation, and well-being. HRQOL expands the definition of health—beyond simply opposing the negative concepts of disease and death—by integrating mental and physical health concepts (USDHHS, 2000). The final review and analysis of the Healthy People 2010 objectives showed decidedly mixed progress for the nation. Some 23% of the objectives were met or exceeded, and another 48% “moved toward target.” Conversely, 24% of the objectives “moved away from target” (i.e., the indicators were worse than in the previous decade), and another 5% showed no change. Particularly concerning were the poor responses in two of the focus areas: arthritis, osteoporosis and chronic back conditions (focus area 2) and nutrition and overweight (focus area 19) “moved toward” or “achieved” less than 25% of their targets (USDHHS, 2012). The fourth version of the nation's health objectives, Healthy People 2020, was published in 2010. Healthy People 2020 was divided into 42 topic areas and contained numerous new objectives and updates for hundreds of objectives from the previous editions (USDHHS, 2017). Per the 2020 midcourse review (CDC/NCHS, 2017), more than 20% of the objectives set in 2010 had met or exceeded their 2020 targets. Furthermore, almost 20% were “improving,” 27.3% showed “little or no detectable change,” 11% were “worse,” and 18% had baseline data only. Among the target areas meeting or exceeding the most goals were genomics, heart disease and stroke, medical product safety, occupational health and safety, and oral health. Among the target area in which progress for objectives was “worse” were early and middle childhood, mental health and mental disorders, older adults, and sleep health. The latest iteration of the national health objectives—Healthy People 2030—was launched in August of 2020. Healthy People 2030 consists five “overarching goals.” These are as follows: Attain healthy, thriving lives, and well-being free of preventable disease, disability, injury, and premature death. Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all. Promote healthy development, healthy behaviors, and well-being across all life stages. Engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all. To help achieve these goals, there are 355 “data-driven” objectives, which are intended “to improve health and well-being over the next decade” (USDHHS, 2020). Furthermore, the initiative provides a wealth of resources and information designed to help health professionals address health priorities and monitor progress. All healthcare practitioners, particularly those working in the community, should review the Healthy People 2030 objectives and focus on the relevant areas in their practice. Practitioners should incorporate these objectives into programs, events, and publications whenever possible and should use them as a framework to promote healthy cities and communities. Selected relevant objectives are presented throughout this book to acquaint future community health nurses with the scope of the Healthy People 2030 initiative and to enhance awareness of current health indicators and national goals (see www.healthypeople.gov for more information). Active Learning Exercise Become familiar with Healthy People 2030 (www.healthypeople.gov). Review objectives from several of the topics covered. How does your community compare with the groups, aggregates, and populations described? What objectives should be targeted for your community? Definition and Focus of Public Health Nursing, Community Health Nursing, and Community-Based Nursing The terms community health nursing and public health nursing are often used synonymously or interchangeably. Like the practice of community/public health nursing, the terms are evolving. In past debates and discussions, definitions of “community health nursing” and “public health nursing” have indicated similar yet distinctive ideologies, visions, or philosophies of nursing. These concepts and a third related term—community-based nursing—are discussed in this section. Public and Community Health Nursing Public health nursing has frequently been described as the synthesis of public health and nursing practice. Freeman (1963) provided a classic definition of public health nursing: Public health nursing may be defined as a field of professional practice in nursing and in public health in which technical nursing, interpersonal, analytical, and organizational skills are applied to problems of health as they affect the community. These skills are applied in concert with those of other persons engaged in health care, through comprehensive nursing care of families and other groups and through measures for evaluation or control of threats to health, for health education of the public, and for mobilization of the public for health action (p. 34). Through the 1980s and 1990s, most nurses were taught that there was a distinction between “community health nursing” and “public health nursing.” Indeed, “public health nursing” was seen as a subspecialty nursing practice generally delivered within “official” or governmental agencies. In contrast, “community health nursing” was considered to be a broader and more general specialty area that encompassed many additional subspecialties (e.g., school nursing, occupational health nursing, forensic nursing, home health). In 1980, the ANA defined community health nursing as “the synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations” (ANA, 1980, p. 2). This viewpoint noted that a community health nurse directs care to individuals, families, or groups; this care, in turn, contributes to the health of the total population. The ANA has revised the standards of practice for this specialty area (ANA, 2013). In the updated standards, the designation was again “public health nursing,” and the ANA used the definition presented by the American Public Health Association (APHA) Committee on Public Health Nursing (1996). Thus, public health nursing is defined as “the practice of promoting and protecting the health of populations using knowledge from nursing, social, and public health sciences” (APHA, 1996, p. 5). The ANA (2013) elaborated by explaining that public health nursing practice “is population-focused, with the goals of promoting health and preventing disease and disability for all people through the creation of conditions in which people can be healthy” (p. 5). Some nursing writers will continue to use community health nursing as a global or umbrella term and public health nursing as a component or subset. Others, as stated, use the terms interchangeably. This book uses the terms interchangeably. Active Learning Exercise Ask several neighbors or consumers of healthcare about their views of the role of public health and community health nursing. Share your results with your classmates. Research Highlights Public Health Nursing Research Agenda A national conference was held to set a research agenda that would advance the science of public health nursing (PHN). The conference employed a multistage, multimethod, and participatory developmental approach, involving many influential PHN leaders. Following numerous meetings and discussions, an agenda was proposed. The agenda was structured around four “High Priority Themes”: (1) public health nursing interventions models, (2) quality of population-focused practice, (3) metrics of/for public health nursing, and (4) comparative effectiveness and public health nursing outcomes. The aim of the agenda is to help PHN scholars contribute to an understanding of how to improve health and reduce population health disparities by advancing the evidence base regarding the outcomes of practice and by influencing related health policy. The group encouraged the agenda's use to guide and inform programs of research, to influence funding priorities, and to be incorporated into doctoral PHN education through course and curriculum development. Ultimately, it is anticipated that PHN research will proactively contribute to the effectiveness of the public health system and create healthier communities. Data from Issel LM, Bekemeier B, Kneipp S: A public health nursing research agenda, Public Health Nurs 29:330–342, 2012. Community-Based Nursing The term community-based nursing has been identified and defined in recent years to differentiate it from what has traditionally been seen as community and public health nursing practice. Community- based nursing practice refers to “application of the nursing process in caring for individuals, families and groups where they live, work or go to school or as they move through the healthcare system” (McEwen & Pullis, 2009, p. 6). Community-based nursing is setting specific, and the emphasis is on acute and chronic care and includes such practice areas as home health nursing and nursing in outpatient or ambulatory settings. Zotti, Brown, and Stotts (1996) compared community-based nursing and community health nursing and explained that the goals of the two are different. Community health nursing emphasizes preservation and protection of health, and community-based nursing emphasizes managing acute or chronic conditions. In community health nursing, the primary client is the community; in community-based nursing, the primary clients are the individual and the family. Finally, services in community-based nursing are largely direct, but in community health nursing, services are both direct and indirect (Williams, 2020). Community and Public Health Nursing Practice Community and public health nurses practice disease prevention and health promotion. It is important to note that public health nursing practice is collaborative and is based in research and theory. It applies the nursing process to the care of individuals, families, aggregates, and the community. Box 1.3 provides an overview of the Standards for Public Health Nursing (ANA, 2013). As discussed, the core functions of public health are assessment, policy development, and assurance. In 2003, the Quad Council of Public Health Nursing Organizations (Quad Council) closely examined the core functions and used them to develop a set of public health nursing competencies. These competencies were updated in 2018 and are summarized in Table 1.2 (Quad Council Coalition Competency Review Task Force, 2018). Current and future community health nurses should study these competencies to understand the practice parameters and skills required for public health nursing practice. Active Learning Exercise Interview several community/public health nurses regarding their opinions on the focus of community/public health nursing. Do you agree? Box 1.3 The Scope and Standards of Practice for Public Health Nursing The Scope and Standards of Practice for Public Health Nursing is the result of the collaborative effort between the American Nurses Association and the Quad Council of Public Health Nursing Organizations. The standards were originally developed in 1999 and were updated in 2013. The Scope and Standards of Practice, which are divided into Standards of Practice and Standards of Professional Performance, describe specific competencies relevant to the public health nurse and the public health nurse in advanced practice. The Standards of Practice include six standards that are based on the critical thinking model of the nursing process, with competencies addressing each nursing process step. The implementation step is further broken down into specific public health areas, including coordination of services, health education and health promotion, consultation, and regulatory activities. The Standards of Professional Performance include the leadership competencies necessary in the professional practice of all registered nurses, but with additional standards specific to the public health nurse and advanced public health nurse roles. These standards include evidence-based practice and research, collaboration, resource utilization, and advocacy, with competencies specific to public health, such as building coalitions and achieving consensus in public health issues, assessing available health resources within a population, and advocating for equitable access to care and services. Data from American Nurses Association: Public health nursing: scope and standards of practice, ed 2, Silver Spring, MD, 2013, Author. The standards can be purchased at: http://www.nursesbooks.org/Homepage/Hot-off-the-Press/Public-Health-Nursing-2nd.aspx. Population-Focused Practice and Community/Public Health Nursing Interventions Community/public health nurses must use a population-focused approach to move beyond providing direct care to individuals and families. Population-focused nursing concentrates on specific groups of people and focuses on health promotion and disease prevention, regardless of geographic location (Baldwin et al., 1998). The goal of population-focused nursing is “to provide evidence-based care to targeted groups of people with similar needs in order to improve outcomes” (Curley, 2020, p. 6). In short, population-focused practice (Minnesota Department of Health, 2003): Focuses on the entire population Is based on assessment of the population's health status Considers the broad determinants of health Emphasizes all levels of prevention Intervenes with communities, systems, individuals, and families Whereas community and public health nurses may be responsible for a specific subpopulation in the community (e.g., a school nurse may be responsible for the school's pregnant teenagers), population- focused practice is concerned with many distinct and overlapping community subpopulations. The goal of population-focused nursing is to promote healthy communities. Population-focused public health nurses would not have exclusive interest in one or two subpopulations, but instead would focus on the many subpopulations that make up the entire community. A population focus involves concern for those who do, and for those who do not, receive health services. A population focus also involves a scientific approach to community health nursing. Thus, a thorough, systematic assessment of the community or population is necessary and basic to planning, intervention, and evaluation for the individual, family, aggregate, and population levels. Public health nursing practice requires the following types of data for scientific approach and population focus: (1) the epidemiology, or body of knowledge, of a particular problem and its solution and (2) information about the community. Each type of knowledge and its source appear in Table 1.3. To determine the overall patterns of health in a population, data collection for assessment and management decisions within a community should be ongoing, not episodic. Public Health Interventions Public health nurses focus on the care of individuals, groups, aggregates, and populations in many settings, including homes, clinics, worksites, and schools. In addition to interviewing clients and assessing individual and family health, public health nurses must be able to assess a population's health needs and resources and identify its values. Public health nurses must also work with the community to identify and implement programs that meet health needs and to evaluate the effectiveness of programs after implementation. For example, school nurses were once responsible only for running first aid stations and monitoring immunization compliance. Now they are actively involved in assessing the needs of their population and defining programs to meet those needs through activities such as health screening and group health education and promotion. The activities of school nurses may be as varied as designing health curricula with a school and community advisory group, leading support groups for elementary school children with chronic illness, advocating for emergency equipment (e.g., automatic external defibrillators) in gyms and athletic fields, and monitoring the health status of teenage mothers. Table 1.2 Selected Tier 1 Public Health Nursing (PHN) Competencies (Generalist Public Health Nurses) Domain Community and Public Health Nursing Competencies 1. Assessment and analytic skills Assess the health status and health literacy of individuals and families, including determinants of health, using multiple sources of data. Use an ecological perspective and epidemiological data to identify health risks for a population. Select variables that measure health and public health conditions. Interpret valid and reliable data that impacts the health of individuals, families and communities to make comparisons that are understandable to all who were involved in the assessment process. Applies ethical, legal, and policy guidelines and principles in the collection, maintenance, use, and dissemination of data and information. Use evidence-based strategies of promising practices from across disciplines to promote health in communities and populations. 2. Policy development/program planning skills Identify local, state, national, and international policy issues relevant to the health of individuals, families, and groups. Describe the implications and potential impacts of public health programs and policies on individuals, families, and groups within a population. Identify outcomes of health policy relevant to public health nursing practice for individuals, families, and groups. Provide information that will inform policy decisions. Function as a team member in developing organizational plans while assuring compliance with established policies and program implementation guidelines. Participate in quality improvement teams by using quality indicators and core measures to identify and address opportunities for improvement in services for individuals, families, and groups. 3. Communication skills Determine the health, literacy, and the health literacy of the population served to guide health promotion and disease prevention activities. Apply critical thinking and cultural awareness to all communication modes (i.e., verbal, nonverbal, written, and electronic) with individuals, the community, and stakeholders. Use input from individuals, families, and groups when planning and delivering healthcare programs and services. Use a variety of methods to disseminate public health information to individuals, families, and groups within a population. Create a presentation of targeted health information. 4. Cultural competency skills Use determinants of health effectively when working with divers individuals, families, and groups. Use data, evidence, and information technology to understand the impact of determinants of health on individuals, families, and groups. Deliver culturally responsive public health nursing services for individuals, families, and groups practice. Explain the benefits of a diverse public health workforce that supports a just and civil culture. 5. Community dimensions of practice skills Use assessments, develop plans, and implement and evaluate interventions for public health services for individuals, families, and groups. Use formal and informal relational networks among community organizations and systems conducive to improving the health of individuals, families, and groups within communities. Select stakeholders needed to address public health issues impacting the health of individuals, families, and groups within the community. Use community assets and resources including the government, private, and nonprofit sectors to promote health and to deliver services to individuals, families, and groups. Identify evidence of the effectiveness of community engagement strategies on individuals, families, and groups. 6. Public health sciences skills Use the determinants of health and evidence-based practices from public health and nursing science when planning health promotion and disease prevention interventions for individuals, families, and groups. Determine the relationship between access to clean, sustainable water, sanitation, food, air, and energy quality on individual, family, and population health. Use evidence-based practice in population-level programs to contribute to meeting core public health functions and the 10 essential public health services. Participate in research activities impacting the health of populations. Use a wide variety of sources and methods to access public health information (i.e., GIS, mapping, community health assessment, local/state/ national sources). Demonstrate compliance with the requirements of patient confidentially and human subject protection. Table Continued Domain Community and Public Health Nursing Competencies 7. Financial planning, evaluation, and management skills Explain the interrelationships among local, state, tribal, and federal public health and healthcare systems. Explain the public health nurse's role in emergency preparedness and disaster response during public health events (i.e., infectious disease outbreak, natural or human-made disasters). Implement operational procedures for public health programs and services. Interpret the impact of budget constraints on the delivery of public health nursing services to individuals, families, and groups. Explain implications of organizational budget priorities on individuals, groups. and communities. Deliver public health nursing services to individuals, families, and groups based on reported evaluation results. Use public health informatics skills pertaining to public health nursing services of individuals, families, and groups. 8. Leadership and systems thinking skills Identify internal and external factors affecting public health nursing practice and opportunities for interprofessional collaboration. Use individual, team, and organizational learning opportunities for personal and professional development as a public health nurse. Identify organizational quality improvement initiatives that provide opportunities for improvement in public health nursing practice. Interpret organization dynamics of collaborating agencies. Select advocacy strategies to address the needs of diverse and underserved populations. Identify organizational policies and procedures that meet practice and public health accreditation requirements. Modified from Quad Council Coalition Competency Review Task Force: Community/public health nursing competencies, 2018. Available at: https://www.cphno.org/wp-content/uploads/2020/08/QCC-C- PHN-COMPETENCIES-Approved_2018.05.04_Final-002.pdf. Table 1.3 Information Useful for Population Focus Type of Information Examples Sources Demographic data Age, gender, race/ethnicity, socioeconomic status, education level Vital statistic data (national, state, county, local); census Groups at high risk Health status and health indicators of various subpopulations in the community (e.g., children, elders, those with disabilities) Health statistics (morbidity, mortality, natality); disease statistics (incidence and prevalence) Services/providers available Official (public) health departments; healthcare providers for low-income individuals and families; community service agencies and organizations (e.g., Red Cross, Meals on wheels) City directories; phone books; local or regional social workers; low-income providers' lists; local community health nurses (e.g., school nurses) Similarly, occupational health nurses are no longer required to simply maintain an office or dispensary. They are involved in many different types of activities. These activities might include maintaining records of workers exposed to physical or chemical risks, monitoring compliance with Occupational Safety and Health Administration standards, teaching classes on health issues, acting as case managers for workers with chronic health conditions, and leading support group discussions for workers with health-related problems. Private associations, such as the American Diabetes Association or the Red Cross, employ public health nurses for their organizational ability and health-related skills. Other public health nurses work with multidisciplinary groups of professionals, serve on boards of voluntary health associations such as the American Heart Association, work as case managers for insurance companies, and are members of health planning agencies and councils. Genetics in Public Health Community-Based Research for the Prevention of Cardiovascular Disease Cardiovascular disease (CVD) is the leading cause of death among Americans, and prevention of CVD should be a priority for all nurses. It has been established that CVD results from a complex interaction among modifiable factors including lifestyle choices and environmental influences, and nonmodifiable factors such as age and race/ethnicity or genetics. A group of nurse researchers led by Fletcher (2011) presented a “call to action for nursing” to promote community-based research that focuses on the genetic factors that contribute to CVD. The team described the need to build capacity for participation in genetics research within communities through community engagement, particularly among vulnerable ethnic minority groups. The importance of identifying the genetic–environmental interactions that may lead to clinical manifestation of CVD was stressed, and a number of community- based interventions to prevent CVD were described. Fletcher BJ, Himmelfarb CD, Lira MT, Meininger JC, Pradhan SR, Sikkema J: Global cardiovascular disease prevention: a call to action for nursing, J Cardiovasc Nurs 26(45): 535–545, 2011. The Public Health Intervention Wheel The Public Health Intervention Model was initially proposed in the late 1990s by nurses from the Minnesota Department of Health to describe the breadth and scope of public health nursing practice (Keller et al., 1998). This model was later revised and termed the Intervention Wheel (Fig. 1.3) (Keller et al., 2004a; Keller et al., 2004b), and it has become increasingly recognized as a framework for community and public health nursing practice. The Intervention Wheel contains three important elements: (1) it is population based; (2) it contains three levels of practice (community, systems, and individual/family); and (3) it identifies and defines 17 public health interventions. The levels of practice and interventions are directed at improving population health (Keller et al., 2004a). Within the Intervention Wheel, the 17 health interventions are grouped into five “wedges.” These interventions are actions taken on behalf of communities, systems, individuals, and families to improve or protect health status. Table 1.4 provides definitions. The Intervention Wheel is further dissected into levels of practice, in which the interventions may be directed at an entire population within a community, a system that would affect the health of a population, and/or the individuals and families within the population. Thus, each intervention can and should be applied at each level. For example, a systems-level intervention within “disease investigation” might be the community health nurse working with the state health department and federal vaccine program to coordinate a response to an outbreak of measles in a migrant population. An example of a population- or community-level intervention for “screening” would be public health nurses working with area high schools to give each student a profile of his or her health to promote nutritional and physical activity lifestyle changes to improve the student's health. FIG. 1.3 Public health intervention wheel. Modified from Minnesota Department of Health: Public health interventions 2019. Available from: https://www.health.state.mn.us/communities/practice/research/phncouncil/docs/ PHInterventionsHandout.pdf. A public health intervention wheel is as follows: The inner 3 rings from inside to outside are individual focused (population based), community focused (population based), and systems focused (population based). The outer ring shows following factors in clockwise direction: Surveillance, disease and health event investigation, outreach, screening, referral and follow-up, case management, delegated functions, health teaching, counseling, consultation, collaboration, coalition building, community organizing, accuracy, social marketing, and policy development and enforcement. Case findings include following factors: Surveillance, disease and health event investigation, outreach, and screening. Table 1.4 Public Health Interventions and Definitions Public Health Intervention Definition Surveillance Describes and monitors health events through ongoing and systematic collection, analysis, and interpretation of health data for the purpose of planning, implementing, and evaluating public health interventions Disease and other health event investigation Systematically gathers and analyzes data regarding threats to the health of populations, ascertains the source of the threat, identifies cases and others at risk, and determines control measures Outreach Locates populations of interest or populations at risk and provides information about the nature of the concern, what can be done about it, and how services can be obtained Screening Identifies individuals with unrecognized health risk factors or asymptomatic disease conditions Case finding Locates individuals and families with identified risk factors and connects them with resources Referral and follow-up Assists individuals, families, groups, organizations, and/or communities to identify and access necessary resources to prevent or resolve problems or concerns Case management Optimizes self-care capabilities of individuals and families and the capacity of systems and communities to coordinate and provide services Delegated functions Carries out direct care tasks under the authority of a healthcare practitioner as allowed by law Health teaching Communicates facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices of individuals, families, systems, and/or communities Counseling Establishes an interpersonal relationship with a community, a system, and a family or individual, with the intention of increasing or enhancing their capacity for self-care and coping Consultation Seeks information and generates optional solutions to perceived problems or issues through interactive problem solving with a community system and family or individual Collaboration Commits two or more persons or organizations to achieve a common goal by enhancing the capacity of one or more of the members to promote and protect health Coalition building Promotes and develops alliances among organizations or constituencies for a common purpose Community organizing Helps community groups to identify common problems or goals, mobilize resources, and develop and implement strategies for realizing the goals they collectively have set Advocacy Pleads someone's cause or acts on someone's behalf, with a focus on developing the community, system, and individual or family's capacity to plead their own cause or act on their own behalf Social marketing Utilizes commercial marketing principles and technologies for programs designed to influence the knowledge, attitudes, values, beliefs, behaviors, and practices of the population of interest Policy development and enforcement Places health issues on decision-makers' agendas, acquires a plan of resolution, and determines needed resources, resulting in laws, rules, regulations, ordinances, and policies. Policy enforcement compels others to comply with laws, rules, regulations, ordinances, and policies Modified from Keller LO, Strohschein S, Lia-Hoagberg B, Schaffer MA: Population-based public health interventions: practice-based and evidence-supported. Part I, St. Paul, MN, 2004, Minnesota Department of Health, Center for Public Health Nursing. Finally, an individual-level implementation of the intervention “referral and follow-up” would occur when a nurse receives a referral to care for an individual with a diagnosed mental illness who would require regular monitoring of his or her medication compliance to prevent rehospitalization (Keller et al., 2004b). Public Health Nursing, Managed Care, and Health Reform Shifts in reimbursement, the growth of managed care, and implementation and revision of the ACA have revitalized the notion of population-based care. Health insurance companies, governmental financing entities (e.g., Medicare, Medicaid), and MCOs use financial incentives and organizational structures in an attempt to increase efficiency and decrease healthcare costs. The foundation for managed care is management of healthcare for an enrolled group of individuals. This group of enrollees is the population covered by the plan who receive health services from managed care plan providers (Kongstvedt, 2020). An understanding of enrolled populations and healthcare patterns is essential for managing healthcare services and resources effectively. Most MCOs have become sophisticated in identifying key subgroups within the population of enrollees at risk for health problems. Typically, managed care systems target subgroups according to characteristics associated with risk or use of expensive services, such as selected clinical conditions, functional status, and past service use patterns. In March 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) (PL 111-148) into law. The ACA served to expand insurance coverage for those uninsured and to help control healthcare costs. Expansion of coverage was accomplished by requiring individuals to purchase health insurance for themselves and their families, implementation of “exchanges” to increase options for individuals to purchase health insurance, and requiring more employers to offer health insurance to employees. Public programs (e.g., Medicaid and State Children's Health Insurance Program) were expanded to cover healthcare for those who could not afford to buy their own insurance. With the change of administration in 2021, significant revisions of the ACA are likely to be implemented with new federal- and state-sponsored initiatives. Public health nurses must stay informed of these changes and work with groups and organizations to support legislation that will promote population health, reduce disparities, and better manage the costs of care. The purpose of public health is to improve the health of the public by promoting healthy lifestyles, preventing disease and injury, and protecting the health of communities. In the past, shrinking public health resources have supported personal health services over community health promotion. In public health practice, the community is the population of interest. With the proposed changes to healthcare financing, the personal healthcare system will be under increasing pressure to provide the services that health departments previously provided. Traditionally served by public health, the most vulnerable populations will pose tremendous challenges for private healthcare providers. Public health agencies and providers will be responsible for partnering with private providers to care for these populations. Providing population-based care requires a dramatic shift in thinking from individual-based care. Some of the practical demands of population-based care are the following: 1. It must be recognized that populations are not homogeneous; therefore, it is necessary to address the needs of special subpopulations within populations. 2. High-risk and vulnerable subpopulations must be identified early in the care delivery cycle. 3. Nonusers of services often become high-cost users; therefore, it is essential to develop outreach strategies. 4. Quality and cost of all healthcare services are linked together across the healthcare continuum (Kaiser Family Foundation, 2013a,b). Nurses in community and public health have an opportunity to share their expertise regarding population-based approaches to healthcare for groups of individuals across healthcare settings. Today, healthcare practitioners require additional skills in assessment, policy development, and assurance to provide community public health practice and population-based service. Healthcare professionals should focus attention on promoting healthy lifestyles, providing preventive and primary care, expanding and ensuring access to cost-effective and technologically appropriate care, participating in coordinated and interdisciplinary care, and involving patients and families in the decision-making process. Public health nurses must work in partnership with colleagues in managed care settings to improve community health. Partnerships may address information management, cultural values, healthcare system improvement, and the physical environment roles in health and may require complex negotiations to share data. The partners may need to develop new community assessment strategies to augment epidemiological methods that often mask the context or meaning of the human experience of vulnerable populations.

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