Introduction to Community Health PDF

**Introduction to Community Health** Before we can understand community health nursing, we must define health, community, and population.  The World Health Organization defines health as a \"state of complete physical, mental, and social well-being and not merely the absence of disease or infirmit...

**Introduction to Community Health** Before we can understand community health nursing, we must define health, community, and population.  The World Health Organization defines health as a \"state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity\" (Nies & McEwen, 2019). The word \"social\" in this definition is essential. Social health indicates community strength resulting from group collaboration to prevent illness and promote health. Considering this social context, health depends on the goals and performance of individuals, families, communities, and societies. ​ Public health is the science of protecting and improving the health of communities through organized community effort. This is achieved by:​ - promoting healthy lifestyles through education, outreach, and policy recommendations - researching disease and injury prevention​ - detecting, preventing, and responding to infectious disease Community is a group of individuals that share a geographic location, common interests, characteristics, values, or goals Population is used to define a group of people with common personal or environmental characteristics or a group within a defined community (Nies & McEwen, 2019). Aggregates are subpopulations or subgroups with some shared characteristics or concerns.​ Community and public health nursing can be traced as far back as Florence Nightingale, as she used a community assessment to implement a statistical method to meet the needs of the community (Nies & McEwen, 2019). This holistic approach to caring for communities was not formally established until the late nineteenth and early twentieth centuries (Nies & McEwen, 2019), so Nightingale's work was truly visionary. District nursing was established in England where nursing care was delivered to disadvantaged families, and public health in the United States was developed from this model. ​ Social determinants of health such as access to healthcare, socioeconomic status, environmental issues, and cultural practices greatly influence today's community health nursing practice. In order to provide effective care, the nurse must understand the factors that affect an individual's health. Community health nursing is population-focused, quality-driven, and science-based way to inform, prevent, and protect the population served. "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: ​ - sanitation of the environment,​ - control of communicable infections​, - education of the individual in personal hygiene, ​ - organization of medical and nursing services for the early diagnosis and preventative treatment of disease, and ​ - 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" (Nies & McEwen, p. 6). - The health status of the community depends on many factors, including individual determinants, social determinants, economic and cultural conditions, and health services and policy. The nurse must understand determinants of health and recognize the influence of these factors on disease, death, and disability. - Annually, approximately one million Americans die prematurely from the five leading causes of death: heart disease, cancer, chronic lower respiratory diseases​, stroke, and unintentional injuries (Centers for Disease Control and Prevention, 2014). However, according to the Centers for Disease Control and Prevention, up to 40% of these deaths could be prevented (CDC, 2014). Biology and behaviors work together to influence health, but modifiable risk factors are largely responsible for each of the leading causes of death. ​ - Personal behavioral changes could minimize many of these risks. Others are due to disparities attributed to social, demographic, environmental, economic, and geographic conditions of the community. If health disparities were mitigated or eliminated, all states would be closer to achieving the lowest rates possible for the leading causes of death (CDC, 2014). According to the Office of Disease Prevention and Health Promotion, Healthy People 2030 represents a tangible, measurable plan for all people to achieve health and well-being by 2030 (n.d.). Determinants of Health - Individual Determinants - age  - gender - diet - physical activity - substance use - family health history - Social Determinants - social norms and attitudes - exposure to media and emerging technologies - socioeconomic conditions - quality schools - transportation options - public safety - residential segregation - General Socioeconomic, Cultural, and Environment Conditions - agriculture and food production - education - work environment - unemployment - water and sanitation - healthcare services - housing, homes, and neighborhoods - exposure to toxic substances - Health Services - lack of available healthcare - High cost of healthcare - Lack of insurance coverage - limited language access - inability to receive preventative services - Policy - policies at the local, state, and federal levels that affect the health of the individual, population, or community The overarching goals of Healthy People 2030, and community health nursing, include those listed below (Nies & McEwen, 2019). **Healthy People Goals​** Attain high quality, longer lives -- free of preventable disease, disability, injury & 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 Public and community health includes a wide range of organizations that work collaboratively to meet the needs of clients. Regardless of the level of involvement, public health nurses play a valuable role in ensuring clients receive access to the services they need. - World Health Organization (global)​ - Department of Health and Human Services (federal)​ - Centers for Disease Control and Prevention (federal)​ -     State Departments of Health (local)​ - County Health Departments (local)​ - Communities within the county (local)​ - Individual clients ​​​ Public health nurses focus on assessment of the community and clients, involvement in policy development, and assurance that all clients have access to resources needed to prevent illness and promote health. ​ - Assessment - Assess and monitor population health - Investigate, diagnose, and address health hazards and root causes - Policy Development - Strengthen, support, and mobilize communities and partnerships - Create, champion, and implement policies, plans, and laws - Utilize legal and regulatory actions - Assurance - Enable equitable access - Build a diverse and skilled workforce - Improve and innovate through evaluation, research, and quality improvement - Build and maintain a strong organizational infrastructure for public health The roles of community health nurses have developed and changed over recent years to allow for specialization in this vast area of nursing. Many areas can be chosen, and each has its own area of expertise and focus: - Clinical ​ - Population health​ - Meaningful metrics​ - Shaping health policy​ - Telenursing​ - Public health career track​ - Nurse epidemiologist​ - Nurse researcher​ - Nurse educator  Public health focuses on the preventative aspect of healthcare. Health promotion and disease prevention activities are the core components. There are three levels of prevention: primary, secondary, and tertiary (Nies & McEwen, 2019). **Primary Prevention Activities** - Prevent problems before they occur (for example, immunizations)​ - General health promotion -- enhance resiliency ​ - Specific protection -- target well populations to reduce or eliminate risk factors **Secondary Prevention Activities** - Early detection and intervention (for example, screening for sexually transmitted infection)​ - Implemented after a problem has begun but before signs and symptoms appear - **Tertiary Prevention Activities** - Correction and prevention of deterioration of disease (for example, teaching insulin administration at home) - Examples of Clients Served - Individual​s - Families - Groups or aggregate​s - Communities - According to the Office of Disease Prevention and Health Promotion, Healthy People 2030 is a set of 355 data-driven objectives to improve the health and well-being of Americans over the next 10 years (n.d.). Core objectives reflect high-priority public health issues associated with evidence-based interventions, and most measure progress towards a goal over time. Developmental objectives are still high-priority but do not have reliable baseline data. Research objectives represent a high health or economic burden but are not associated with evidence-based interventions. ​ - Throughout the ten-year data collection period, progress is tracked and reported at varied intervals. **Healthy People Objectives** - Target Met​ - Target set at the beginning of the decade has been achieved or exceeded.​ - Improving - Progress is being made toward the target.​ - Little or No Detectable Change​ - Progress is not being made toward the target. ​ - Baseline Only​ - No data beyond the initial baseline is available so unsure if progress has been made. ​ - Getting Worse​ - Target is farther from achievement than at the beginning of the decade.  - Upstream thinking is a term used in community health to refer to the guiding principle of the discipline: prevention. Current medical models treat the illness after it has developed, the equivalent of rescuing someone when they are "downstream" after falling into a river. Therefore, upstream thinking means thinking ahead, planning before the illness, and attempting to prevent it. This analogy is quite appropriate for the work done in public health, since the focus is not on curative methods. - The community health nurse works collaboratively with other disciplines to provide care for the client. The client can be an individual, family, or an entire community. Community health nursing focuses on providing preventative care for the client and ensuring equality for all populations. **Population Health** Public health seeks to improve the health of communities through policy recommendations, health education, disease and injury prevention, health promotion, and community outreach. As a specialty, "population health provides an opportunity for health care systems, agencies, and organizations to work together in order to improve the health outcomes of the communities they serve" (Centers for Disease Control and Prevention, 2020). It is a collaborative and interdisciplinary approach to identify and manage outcomes for a population of individuals despite geographic location. In population health, the focus changes from episodic healthcare to management of groups of people with a focus on primary and preventative care. Additionally, the goal is to maintain health while improving quality and lowering costs (Ariosto et al., 2018).​ Specifically, population-focused practice focuses on the entire population, is based on assessment of the population's health status, considers broad descriptors of health, emphasizes all levels of prevention, and intervenes with communities, systems, individuals, and families (Nies & McEwen, 2019).​ For an additional description of population health, please listen to this interview (Sabin & Hunt, 2021). In acute care, the focus is often on the current symptoms and a simple diagnosis to define the problem and identify treatment. In population health, the determinants of health are reviewed and considered in determining the cause of a particular problem. These determinants include individual, social, general socioeconomic, cultural and environmental factors, health services, and policies. ​ Population health nurses are interested in the aggregate outcomes that drive improvement in healthcare delivery. This is an upstream approach that focuses on prevention at all three levels: primary, secondary, and tertiary. Population-focused health can take place within the public health system or within a clinical setting where clients are served.  **Determinants of Health** - Individual Determinants - age  - gender - diet - physical activity - substance use - family health history - Social Determinants - social norms and attitudes - exposure to media and emerging technologies - socioeconomic conditions - quality schools - transportation options - public safety - residential segregation - General Socioeconomic, Cultural, and Environment Conditions - agriculture and food production - education - work environment - unemployment - water and sanitation - healthcare services - housing, homes, and neighborhoods - exposure to toxic substances - Health Services - lack of available healthcare - High cost of healthcare - Lack of insurance coverage - limited language access - inability to receive preventative services - Policy - policies at the local, state, and federal levels that affect the health of the individual, population, or community There are three pillars of population health. Review each one below. **Three Pillars of Population Health** **Clinical health** care encompasses direct patient care delivered to individuals. For example, clinical healthcare services might include care for individuals who experience illness, injury, or disability, as well as individuals who are well.​ **Public health** services focus on the health of the population or community. For example, prevention and control of communicable disease, food safety, and mitigation of environmental health hazards are well-established functions within the public health system.​ **Public policy **includes efforts aimed at issues that impact the health status of individuals and communities. Policy efforts might directly target a health issue, such as provision of healthcare coverage. In other cases, policy efforts address issues that are not directly related to health, but which influence the health of individuals and populations, such as policies which support education, affordable housing, or transportation. Population health is often used to describe an interdisciplinary approach to care that focuses on collaborative practice and innovative partnerships with community stakeholders to promote aggregate-level health outcomes. To successfully navigate intersectoral initiatives, system-focused thinking and leadership are essential. Population health initiatives involve coordinated efforts from clinical healthcare systems, public health systems, and public policy to improve health outcomes. These initiatives involve a systems approach to collaborating with community partners and addressing variables that shape health status, such as the physical, social, and environmental determinants of health. In 2013, the Institute of Medicine (IOM) published a report which demonstrated the health disparities that exist within the United States as compared to other developed countries. The United States spends the most annually on healthcare per person and has large financial resources within the country, but the population health statistics demonstrate a significant disparity in length of life and poor health status (IOM, 2013). ​ The IOM report suggests explanations for significant health disparities that include unaffordable or inaccessible care. The U.S. has chronic diseases, health risks, socioeconomic conditions, and physical environments which foster more sedentary lifestyles instead of those that encourage physical activity (IOM, 2013). Examples of Key Health Indicators in which the United States is scoring lower compared to other industrialized nations despite higher spending include: ​​ - infant mortality and low birthweight​​ - injuries and homicides​​ - adolescent pregnancy and sexually transmitted infections​​ - HIV and AIDS​​ - drug-related deaths ​​ - obesity and diabetes​​ - heart disease​​ - chronic lung disease ​​ - disability​ - As is evident from the Institute of Medicine (IOM) (2013) report, many countries share similar concerns about population health. While efforts to promote and sustain health are underway within the United States, a shared focus on determinants that shape population health is occurring on a global level as well.​ - The World Health Organization (WHO) established specific goals to address key determinants impacting population health. These goals were initiated in 2000 as the Millennium Development Goals, and in 2015 a focus on Sustainable Development Goals has been asserted (Savage et al., 2016). Efforts of the WHO center on eradication of poverty and hunger, education, equality, decreased mortality, disease prevention, access to healthcare resources, and environmental sustainability. National and globally-focused health organizations use this information to direct programs using a collaborative approach to maximize efforts and funding. The IOM report shows that even developed countries, such as the United States, face disparities noted within the WHO initiatives.  - No poverty - Zero hunger - Good health and well-being - Quality education - Gender equality - Clean water and sanitation - Affordable and clean energy - Decent work and economic growth - Industry, innovation, and infrastructure - Reduced inequalities - Sustainable cities and communities - Responsible consumption and production - Climate action - Life below water - Life on land - Peace and justice - Partnerships for the goals Through support from the Robert Wood Johnson Foundation, Storjfell et al. (2017) published a white paper highlighting the role of the community health nurse in improving population health in the United States.​  Knowledge and skills were identified to support the role. These included competencies in clinical healthcare systems, school health, data analytics, chronic disease management, care coordination, and leadership of population-focused community initiatives.   Skills must include practice, education, research, and policy development to build and sustain a capacity for population health nursing (Storjfell et al., 2017). Population-focused health initiatives often address disease prevention. The classic model used is the levels of prevention model, which describes the primary, secondary, and tertiary levels of prevention. Each level of prevention correlates with the natural history of disease. **Primary Prevention** -- involves both health promotion and specific health protective measures. The focus of primary prevention is on the prevention of disease or disability before it occurs. Health promotion at this level encourages healthy individuals to strengthen and further support their good health status. Specific protection is aimed at the healthy individual, but the focus is on prevention of specific diseases or injuries. Examples include vaccinations and promoting wearing seatbelts when riding in a vehicle.​ **Secondary prevention **-- includes both screening for an early detection of a health problem and early treatment to mitigate disability. Note that with secondary levels of prevention, the disease or health problem is present, even if signs and symptoms are not yet evident. An example is a screening for elevated cholesterol levels or hearing and vision screenings. ​ **Tertiary prevention **-- aimed at limiting complications from the disease or disability that is present. Tertiary prevention also includes rehabilitation with the intent to return to optimal health and functioning. Cardiac rehabilitation or palliative care for terminal illness are two examples.  Just as the nursing process is used to develop the care and treatment of patients, a framework helps to support the care of individuals, communities, and systems on a larger level. The Intervention Wheel was originally developed by the Minnesota Department of Health, Section of Public Nursing in 1998 to provide a systematic approach to improving population health (Minnesota Department of Health Division of Community Health Services Public Health Nursing Section, 2001).​ One unique characteristic of this model is its applicability to nursing and other professions that strive to promote the health of individuals and populations across different levels of care. The model includes a wide array of approaches, from individual and relationship-level strategies to community and societal-level interventions.​ - 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 - Advocacy - Social marketing - Policy development and enforcement Population-focused care involves the use of scientific data collected through epidemiological methods. Epidemiology is the study of the \"distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems\" (Centers for Disease Control and Prevention \[CDC\], 2012, para. 2). Epidemiology serves as a critical underpinning of public health and clinical healthcare systems, and provides important data to direct health policy efforts. A systematic approach is used in the collection of information, analysis of the data, and during the evaluation process. Principles of epidemiology are based on quantitative approaches that borrow from the fields of biology, biostatistics, economics, and social and behavioral sciences to draw inferences about patterns and frequency of diseases (CDC, 2012). Population health uses the six core functions of epidemiology in planning population-specific care. **Surveillance** Perhaps one of the most well-known functions of epidemiology is the surveillance of disease and health conditions. Public health surveillance involves the ongoing collection, interpretation, and dissemination of health data to determine health needs and direct action steps to address those needs. Effective surveillance relies upon timely reporting of health data regarding morbidity and mortality statistics, disease registries, health surveys, and individual reporting from providers, laboratories, and healthcare systems. Surveillance efforts provide assessment data to determine health concerns within the population and to shape efforts to address those needs effectively. **Field Investigation** Based upon data gathered through surveillance efforts, field investigation is frequently the next step when a health concern is noted. Field investigation is generally conducted by the public health system and involves, literally, a \"feet on the ground\" approach within the community to learn more about the individuals exposed, clinical progression, risk factors, and other characteristics of the disease to determine etiology and to take action to control further spread of disease. **Analytic Studies** In cases where field investigation falls short of providing a clear root cause, analytic studies are conducted to determine the cause of disease and mode of transmission. Analytic studies in epidemiology involve more rigorous research methods, including a comparison group to substantiate findings. Through such studies, the public health and clinical healthcare systems can better understand the health concern or outbreak and effectively intervene to promote and protect the health of individuals and populations. **Evaluation** The practice of epidemiology also contributes to the evaluation of public health interventions and services provided. For example, epidemiological data plays an important role in demonstrating the effectiveness of specific programs to reduce incidents and the prevalence of disease or the usefulness of surveillance systems. **Linkages** Interprofessional practice is fundamental to effective epidemiology, providing linkage and collaborative engagement across health systems, disciplines, and geographic jurisdictions. Much like our earlier discussion of systems theory, epidemiological systems share connections to public health and clinical healthcare, collectively working to improve health outcomes. **Policy Development** Similar to the inherent connection to public health and clinical healthcare systems, epidemiology plays a critical role in informing public and health-related policy. A core function of epidemiology is to contribute to policy regarding the prevention and control of disease, as well as regulations regarding disease surveillance. **Community Assessment** The nature of a community is described by various features including the aggregate of people, the location in space and time, and the social system. Select each tab below for details. Aggregate of People: - a group of people who have common characteristics​ - may belong to the same church, be similar age or ethnic background, or share a health-trait (for example, a support group for people with cancer) - geographic or physical location may define a community​ - boundaries may include a city, county, state, voting precinct, school district, or census tract​ - a community may change over time; for example, the presence of a younger workforce may attract different industries - relationships of community members​ - a community is a complex social system built of various subsystems in the community​ - a health care system is an example of a complex system that is composed of smaller subsystems​ - many subsystems are impacted by changes made to a larger system; for example, if a health department cuts programs, the community must react and readjust  - **define the community​** - collect data​ - analyze data​ - establish community diagnosis​ - plan programs​ - implement programs​ - evaluate outcomes The primary concern of a community health nurse is to improve the health of a community. The community health nurse must be familiar with the features of the community, make observations about the community, and utilize data to prioritize and formulate a community diagnosis and plan. The nurse then implements programs and evaluates the outcomes.​ A comprehensive assessment requires several methods of data collection. Beginning the data collection by interviewing formal or informal leaders with knowledge of the community (key informants) provides insights and information used to plan and collect a comprehensive community assessment. Below are some methods the community nurse may use to **collect data**.​ - interviews with key informants​ (formal or informal leaders with knowledge about or experience with the community) - community forums​ - secondary data (existing data such as census data, vital statistics, or mortality and morbidity data)​ - observation of community activities​ - focus groups​ - surveys​ - windshield survey - A windshield survey is completed by driving or walking through a community and making organized observations to provide a descriptive overview of a community environment. The nurse is looking to gain an understanding of the community's health, strengths, and potential health problems. - Go through the presentation to the right, using the arrows below the images, for the components of such surveys and example questions. Social Functioning - Who are the people?​ - What is their ethnicity or race?​ - What are the people doing? ​ - What is their general appearance?​ - Are there different subgroups?​ - Is there evidence of substance use, violence, or disease?​ - Are there children or pregnant women?  Economic Conditions - Is housing acceptable quality?​ - Are there single family or multifamily dwellings?​ - Are the homes in good repair?​ - Is it rural?​ - What form of transportation is being used? Is public transit available?​ - What kind of schools or day cares are available?​ - Are there indicators of the type of work available?​ - Are there homeless people? Health Resources - Are there hospitals or clinics?​ - Are there nursing homes, mental health clinics, substance abuse centers, urgent care centers, or pharmacies?​ - Are there adequate resources to address the health needs of the community?  Environmental Conditions - Is there handicapped access to buildings, sidewalks, and streets?​ - Are there restaurants?​ - Is there evidence of nuisances such as bugs, rodents, or stray animals?​ - Are there recreational facilities or playgrounds?​ - What is the condition of the roads? Attitude Toward Healthcare - Is there evidence of preventative or wellness care?​ - Are the health resources being utilized?​ - Is there evidence of alternative medicine?​ - Is there evidence of efforts to improve the neighborhood's health (health fairs, health-related events)? - The U.S. Census Bureau undertakes a massive survey of all American families every 10 years. The census data includes demographic variables, including population size and the distribution of age, sex, race, and ethnicity. - The American Community Survey (ACS) is collected annually and includes social data such as income, poverty, and occupational factors. This data may be useful to community health nurses familiarizing themselves with a new community. For example, if the nurse recognizes that a community includes a large population of elderly people, the nurse may further assess resources needed for that population. - census survey​ - age​ - sex​ - race​ - ethnicity​ - community survey​ - income​ - poverty​ - occupation Every year, health departments aggregate and report official records of births, deaths, marriages, divorces, and adoptions from the previous year. These vital statistics provide information about the growth or reduction of the population, morbidity and mortality trends, and trends of congenital defects.​ Community health nurses can access a broad range of local, regional, and state government reports to use in a comprehensive assessment of a community and the social determinants of health. Local agencies, chambers of commerce, hospitals, school nurses, newspapers, libraries, and the internet can provide various information about the following topics.  - crime ​ - housing​ - prevalence of disability, illness, and other health-related variables​ - geography​ - population size and density​ - environment: water, sewage and waste disposal, air quality, housing, animal control​ - employment and income levels​ - education: types of education, schools, literacy rates, special education, school lunch programs, after-school programs, daycare​ - recreation: parks, libraries, public and private recreation​ - religion: churches and synagogues, denominations, community organizations​ - communication: newspapers, news, radio, internet availability, hotlines​ - transportation​ - public services: fire, police, emergency medical services​ - political organization​ - community development​ - disaster programs​ - community health services​ - health literacy The nurse analyzes the data collected and then creates a list of actual and potential problems. The nurse should work with community members and local health professionals to establish priorities and desired outcomes.​ The types of nursing diagnoses are actual (problem-focused), risk, and health promotion. As an example, a community nursing diagnosis is written in the following format:​ Increased risk of **\[disability, disease\]** among **\[community or population\]** related to **\[etiological statement\]** as demonstrated in **\[health indicators\]**. Community Nursing Risk Diagnosis Example Increased risk of **\[undetected testicular cancer\]** among **\[young men\]** related to **\[insufficient knowledge about the disease and the methods for preventing and detecting it at an early stage\], **as demonstrated by **\[high rates of late initiation of treatment\]**. **Care for the Community** Community-based nursing practice focuses on the community as the client and also includes nursing care focused on other levels, such as the individual and family levels. The nurse should be mindful that these clients are also members of various groups and they may be influenced by their environment. Alternatively, the nurse may also utilize knowledge of the community to help understand the individual or family health problems. - An individual is one person​. - A family is a family system​. - A group is a group of people with common interests or needs​. - A population group is an unorganized group of people with common interests or problems​. - An organization is an organized group of people in a common location with shared goals​. - A community is an aggregate of people in a common location. The Health Planning Model is used to apply the nursing process to a larger aggregate within a systems framework. 1. Assessment: the aggregate characteristics are described; a literature review is completed to compare the aggregate to the health status of similar aggregates; identify and prioritize the health needs/problems​ 2. Planning: identify the goal of the intervention and specific objectives; consider interventions at each system level as appropriate​ 3. Intervention: interventions are implemented​ 4. Evaluation: the project is evaluated based on the objectives, plan, and outcomes; include the aggregate's evaluation of the project; make recommendations for further action The community health nurse must first establish a relationship with the selected aggregate by meeting with the group leaders, clarifying the role of the nurse, and establishing mutual expectations. There are several components to the assessment of an aggregate. Go through the presentation below using the arrows under the images. - Gather information about sociodemographic characteristics by observing, interviewing key informants, reviewing available records​. - Assess the overall health status by considering both positive and negative factors; the specific aggregate will determine the health status measures. For example, common immunization rates may be appropriate for children, but rates of influenza or pneumonia vaccines would be more appropriate for adults.​ - Conduct a systems analysis of the subsystem (individuals of a group), aggregate system (selected group), and suprasystem (larger system the group belongs to)​. - Complete a literature review to compare the aggregate with the norm​. - Identify and prioritize the aggregate's health problems and needs; this should also reflect the aggregate's perception of need​. - Assess types of needs:​ - expressed: need expressed or need expressed by behavior​ - normative: lack, deficit, or inadequacy determined by expert health professionals​ - perceived: aggregate's expressed needs, wants, and preferences​ - relative: gap of health disparities between advantaged and disadvantaged populations​ - Prioritize the identified problems and needs to create a plan; consider utilizing a framework to refine priorities such as Maslow's hierarchy of needs or Leavell and Clark's levels of prevention (primary, secondary, tertiary)​ - Primary Prevention​ - Health promotion and activities that protect the client from illness or dysfunction​ - Secondary Prevention​ - Early diagnosis and treatment to reduce the duration and severity of disease or dysfunction​ - Tertiary Prevention​ - Rehabilitating and restoring to an optimal level of functioning An essential component of health planning is to have a strong level of community involvement. Empowering the community shifts the power from health care providers to the community members. The nurse should also be sure to meet the people where they are (assess their knowledge and start from there). Select each option to learn more. **Planning Community Interventions** - Determine the intervention level(s): subsystem, aggregate system, and/or suprasystem​. - Plan interventions for each system level, which may center on the primary, secondary, or tertiary level of prevention​. - Validate the feasibility of the planned interventions based on available personal resources​. - Consider potential interventions (education, counseling, policy change, community service development); seek input from other disciplines or community agencies​. - Coordinate the interventions with the aggregate's input to maximize participation. **Development of Goals and Objectives ** - The goal is where the community wants to be; objectives are the steps to get there​. - Measurable objectives are the specific measures used to determine whether the nurse is successful in achieving the goal; may be used to measure outcomes. Thoughtful assessment and planning should contribute to a positive response to the intervention. Generally, implementation should follow the initial plan, but the nurse should prepare for unexpected problems such as bad weather, poor attendance, or competing events. A variety of resources should be used to promote the intervention and distribute information, such as mass media, use of pamphlets or posters, use of electronic formats such as websites or tweets, and public forums such as focus groups or town meetings. Evaluation of the success or failure of a project includes feedback from the participants, evaluation of the plan (process evaluation), and evaluation of whether the outcomes were achieved (product evaluation). Evaluation should include adequacy, efficiency, appropriateness, and cost--benefit analysis. The nurse should also include follow-up recommendations upon completion of the project. Unsuccessful projects are often caused by problems with one or more steps in the nursing process.​ Questions used to evaluate the outcomes may include: ​ - Was the assessment adequate?​ - Were the plans based on an incomplete assessment?​ - Did the plan allow adequate client involvement?​ - Were the interventions realistic or unrealistic in terms of available resources?​ - Did the plan consider all levels of prevention?​ - Did the plan advance the knowledge levels of the aggregate and the nurse?​ - Were the participants satisfied with the interventions?​ - Were the stated goals and objectives accomplished? There are several systematic methods available for health planning in public health. These models provide a structured approach to planning. - Planning Approach to Community Health (PATCH): encourages the idea that health promotion is a process that enables the population to control its' health; community participation is an essential component​. - Assessment Protocol for Excellence in Public Health (APEC-PH): voluntary process for organizational and community self-assessment, planned interventions, continuing evaluation, and reassessment​. - Mobilizing for Action Through Planning and Partnerships (MAPP Model): helps public leaders mobilize the community, guide the community toward a shared vision, and conduct assessments to identify community strengths, local health systems, health status, and forces of change in the community.